What's New in EMG...

HAVE YOU THOUGHT ABOUT CONSTIPATION?

Chances are you'd rather forget about it. But we're not talking about bad personal experiences, we talking about good business opportunities. You may not realize it, but chronic constipation is the latest disease to get the attention of biofeedback. And the results are very encouraging.

You may think of this as a - pardon the expression - "messy" topic, but that isn't so at all, at least not any more. Some basic principles of behavior therapy have now been applied to the treatment of constipation, with the result that treatment is just as clean and easy as treating migraine headaches and stress-related disease.

In the beginning, behavioral treatment of constipation was crude and messy, because therapists didn't understand principles of "generalization" of learning. Gastroenterologists began (literally) by filling their patients with an oatmeal paste, and then trying to teach them "normal" defecation patterns. This required special facilities and equipment, including potty chairs, and, of course, extensive clean-up. And it was only partially successful. Then they took a lesson from standard biofeedback practice, and the treatment became both simpler and more effective.

When we treat patients for job-related stress, for example, we don't begin by accompanying them to the workplace and watching them go to pieces on the job. Instead, we construct a special safe environment using comfortable reclining chairs and suitable calming surroundings. Then we begin to teach techniques of physiological relaxation, using biofeedback to enhance the learning process. We use daily home practice, with portable instruments whenever possible, to strengthen and hasten skill acquisition. We now know that patients should be trained to a "criterion" level of skill for lasting results. When the patient has mastered the technique in the special environment, we then begin generalization training, using mental techniques such as visualization and covert rehearsal. Finally, we ask the patient to apply the new physiological skills in the workplace, while continuing the office therapy and daily home practice.

This standard biofeedback treatment plan is now being applied to the treatment of constipation. It wouldn't have happened, however, if it were not for recent new discoveries about the nature of constipation. The change began several years ago with "motility studies"; patients swallow radio-opaque capsules, and X-Rays are taken to document the progress, or motion, of the capsules through the digestive track until they are expelled days later at the distal end. It was soon discovered that when the capsules slowed or even stopped moving in certain sections of the colon, the cause was a lack of peristalsis (or rhythmic contractions) of the colon itself. When the inert, inactive colon section was surgically removed, bowel contents moved once again in a regular pattern. Many patients were completely cured by this form of surgery.

Unfortunately, the same operation had no effect on as many as 50% of constipation patients. At first researchers blamed surgical technique, but that didn't resolve the problem. Then it was discovered that for those patients who didn't get better, the reason was farther down the digestive track. For them, bowel motion stopped because the opening (the sphincter) was closed when it was supposed to be open. No matter how hard the patient tried to evacuate, nothing moved because the outlet was blocked by inappropriate muscle contractions. In fact, the harder they tried, the less results they obtained. It was called "paradoxical" contraction, or "dyssynergic" sphincter. Eventually a new term, "anismus", was coined, based on the parallel orifice problem, "vaginismus".

Around 1985 several leading surgeons in the US and Europe came to the same conclusion, and began using EMG muscle-monitoring equipment to train patients to relax their sphincters. For many patients, the constipation went away without surgery when they learned to relax their muscles. (Does it sound familiar now?) It wasn't long before law-suit-wary physicians realized that major surgery should not be performed on patients with minor muscular problems. In 1990, a leading Dutch surgeon, Han Kuijpers, said in a speech "Now, I wouldn't think of scheduling surgery until my patient was checked out by my biofeedback technician!" Today almost all colorectal surgeons have accepted the wisdom of that conservative conclusion; the problem now is a shortage of biofeedback technicians willing to do the evaluations-and subsequent sphincter muscle re-training.

The technique, as published by Kuijpers, and more recently refined by Jim Fleshman in St. Louis and Steve Wexner of Cleveland Clinic Florida, involves the use of a special anal sensor with three longitudinal EMG electrodes (PerryAnalª sensors). First the patient is asked to relax, and the resting level noted. Then the patient is asked to "squeeze", and the sphincter's contractile strength is noted. Finally, the patient is asked to "push out", as if to defecate. If the "push" is like the resting level, (and the resting level is low), everything is fine. But for "anismus" patients, the "push" is usually similar to the "squeeze"; a "paradoxical" or "dyssynergic" contraction that causes constipation.

The therapy is similar to the standard therapy for levator syndrome, commonly called "chronic pelvic pain". In fact, anismus is merely an acute or situational version of the chronic muscle tension habit that causes levator syndrome, and is equally easy to treat, almost always with complete success. First the patient is taught "Kegel" exercises, using EMG sphincter biofeedback. Since "control" and/or "resting tension" are more commonly the problem, training emphasis is on these factors, rather than on strengthening the sphincter (which is the focus in fecal incontinence). Home practice with a portable EMG instrument (there are many suitable brands) greatly increases the acquisition of skill. [At first, several consecutive days of intensive in-patient practice on an office system was used, but this hosptialization expense was rejected by insurance carriers as unnecessary.]

Just is in stress management training, after the patient masters the basic skill, the training moves towards generalization; the patient is asked to alternatively (1) relax, (2) squeeze, and (3) push out. With the help of biofeedback, the patient learns to remain relaxed (in the sphincter) while pushing out (with the diaphragm and abdominal muscles). When this skill is mastered, some therapists move on to the "practice porridge" phase, but most find this step as unnecessary as it is invasive and humiliating. The patient is finally encouraged to apply the skill while on the toilet, and eventually, it works. Office and home practice continue until it does.

Recently the treatment of constipation benefited from understanding the historical development of biofeedback in general, and the principle of "training to criterion" in particular. In the early days of biofeedback, patients were given a fixed number of "treatments" (usually based on the number of weeks left before the term paper had to be submitted.) In this model, biofeedback was no more effective than, say, six weeks of yoga or TM. Then it was discovered that when patients were trained until they reached a mastery level (96¡ F in hand-warming, for example), biofeedback training was significantly better than the other methods.

There has been a similar development in anismus treatment. At first researchers defined an arbitrary number of biofeedback training sessions and then calculated the percentage improvement. Now the emphasis is on finding an appropriate "criterion level" by which to judge patient progress. The new Orion/Perry Teacherª (by Self Regulation Systems, Redmond, WA) is the first EMG device to calculate "latency to contract" and "latency to relax" as a measure of muscular control. The new Orion/Perry System prints an evaluation report which includes latency, as well as resting and contracting levels, to facilitate this development, but as yet there is no published research on it.