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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 16 | Biofeedback Treatment of Fecal Incontinence [2001년 5월 DCR] | 2011-11-12 | 3224 |
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A Critical Review
Steve Heymen, M.S., Kenneth R. Jones, Ph.D., Yehuda Ringel, M.D., Yolanda Scarlett, M.D., William E. Whitehead, Ph.D.
From the Center for Functional Gastrointestinal and Motility Disorder& Department of Medicine, The
University of North Carolina, Chapel Hill, North Carolina PURPOSE: The aims of this review are 1) to critically evaluate the literature on the efficacy of biofeedback treatment for fecal incontinence, 2) to compare different types of biofeedback, and 3) to identify patient characteristics which predict a successful outcome.
METHODS: The MEDLINE database was searched for articles published between 1973 and 1999 which included the terms "biofeedback" and "fecal incontinence." Pediatric and adult articles in any language were screened. Inclusion for review required that the study be prospective, have five or more subjects, and have a description of the treatment protocol.
RESULTS: Thirty-five studies were reviewed. Only six studies used a parallel treatment design and just three of those randomized subjects to treatment groups. A meta-analysis (weighted by subjects) was performed to compare the results of two treatment protocols that dominate the literature. The mean
success rate of studies using Coordination training (i.e.,coordinating pelvic floor muscle contraction with the sensation of rectal filling) was 67 percent, while the mean success rate for studies using Strength training (i.e., pelvic floor muscle contraction) was 70 percent. Furthermore, the mean success rate for those Strength training studies using electromyographic biofeedback was 74 percent, while the mean success rate for studies using anal canal pressure biofeedback Strength training was 64 percent. However, these conclusions are limited by the absence of clearly identified criteria for determining success. There are also inconsistencies in the literature regarding the patient selection criteria, severity and cause of symptoms, amount of treatment, as well as the type of biofeedback protocols and instrumentation used. Finally, no patient characteristics were identified that would assist in predicting successful outcome. CONCLUSION: Although most studies report positive results using biofeedback to treat fecal incontinence, quality research is lacking. Recommendations are made for future investigations to 1) improve experimental design, 2) include long term follow-up data, and 3) to use an adequate sample size that allows for meaningful analysis.
DISCUSSION
Only six of the 35 studies (Table 1) reviewed used a parallel group design, and only three of those studies randomly assigned subjects to treatment groups. In addition, treatment protocols and instrumentation vary across studies. The cause and severity of incontinent symptoms is rarely identified, nor is the rationale for the choice of a treatment protocol. Finally, the criteria used to determine treatment outcome is inconsistent among these studies. Subjects in the majority of the studies reviewed have reported failed medical management of their symptoms. Therefore, it is assumed that the improvement that occurred was a result of the biofeedback treatment. However, no attempt was made to control for nonspecific treatment effects. These nonspecific components of treatment include education, attention, and the use of laxatives or antidiarrheal agents, all of which clearly contribute to the successful outcomes which appear in the literature.
Unfortunately, the specific cause of the incontinence is rarely identified in the literature making it
difficult to identify optimal treatment protocols for the various causes. It is not reported whether subjects receiving Coordination training had insufficient PFM contraction strength, poor rectal sensation, or suffered from both causes. Similarly, the cause of symptoms for subjects receiving Strength or Sensory training is not reported. It seems logical, as suggested by Rao et al. that treatment techniques be incorporated into an individualized treatment plan, based on diagnostic parameters. Subjects with weak PFM and normal rectat sensation may only need Strength training, and subjects with normal PFM strength and poor rectal sensation may only need Sensory or Coordination training, However, it is also possible that it does not matter which treatment intervention is used. As questioned earlier, nonspecific effects, such as attention and education may account for the positive results reported in the biofeedback literature. Perhaps feedback of the anorectal mechanism sensitizes the patient to improve control regardless of the method of feedback. It remains to be investigated in a wellcontrolled study, whether one type of biofeedback is superior to another and whether the protocol should be tailored to the specific cause of incontinence. |
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