Continence Coalition Utilization Parameters
for
PELVIC
MUSCLE REHABILITATION
USING
BIOFEEDBACK
September 22, 1999
The
Society of Urologic Nurses & Associates (SUNA) and the Wound, Ostomy &
Continence Nurses (WOCN)
Working
together for the benefit of patients
Urinary Incontinence (UI)
is expensive to Medicare both directly and indirectly, owing to its preventable
consequences. Biofeedback is effective
in reducing UI and in decreasing UIs associated costs. The Continence Coalition shares HCFAs
concerns regarding potential misuse of CPT codes for diagnosis or treatment of
pelvic muscle dysfunction, but maintain that these procedures should be
reimbursed when appropriately applied.
The cost-effective, outcome-oriented treatment
of voiding and defecation dysfunction requires a focused, thorough assessment
and a step-wise approach. Failure to treat voiding and defecation dysfunction
not only impairs quality of life, but also leads to more costly complications
including falls, urinary tract infections, skin breakdown, prolonged acute care
stays, and increased skilled nursing facility admissions (Kane et al., 1994; Bergstrom, 1992; Kohn et
al., 1991),(Baker et al., 1995),(Tromp et al., 1998) (Johansson et al., 1996; Tinetti et al., 1995;
Haalboom et al., 1999). In
1995, according to Wagner and Hu, the total US expenditure for UI alone for
persons over 65 years of age was approximately $27.8 billion. This figure represents a 164% increase over
1984 estimates and exceeds the combined costs to Medicare of dialysis and
coronary bypass surgery (Health Care
Financing Review, Medicare and Medicaid Statistical Supplement, 1997) ( Resnick, 1998). While it is widely accepted that expenditures for UI are significant,
almost half represents Medicare costs for medical services. This contradicts the commonly held view that
UI is merely a social and hygienic problem with costs primarily borne by the
patient, family and community.
Specifically, UI evaluation and treatment account for 8% of these costs
and only a minuscule portion of that was spent on behavioral therapies a
recommended first-line treatment. The
remaining 92% of Medicare costs were spent on preventable sequelae(Wagner et al., 1998)
While Kegel exercises are
the time-honored approach for treating UI through PMR (PMR), studies by Bump,
et al. show that verbal or written instructions alone are not adequate (Bump
et al., 1991). When a
specially trained, licensed health-care professional provides instruction and
coaching using digital palpation, pelvic muscle exercise demonstrates good
short- and long-term effectiveness for managing stress, urge, and mixed urinary
incontinence(Bo
et al., 1990; Cammu et al., 1995; Wells et al., 1991; Ferguson et al., 1990). Scientific literature shows, however, that
even better results are obtained when mechanical or electronic
confirmation of proper muscle use is presented to the patient by means of
biofeedback(Burgio
et al., 1986; Baigis-Smith et al., 1989; Burgio et al., 1989; Burgio et al.,
1998; Glavind et al., 1996; Mathewson-Chapman, 1997; McDowell et al., 1999;
O'Donnell et al., 1991; Payne, 1998; Woolner et al., 1994)Without biofeedback,
many patients could not benefit from PMR at all(Tries,
1990).
The most widely accepted
textbook in the Biofeedback field defines biofeedback as: "(1) a group of therapeutic
procedures that (2) utilizes electronic or electromechanical instruments (3) to
accurately measure, process and "feed back" to persons (4)
information with reinforcing properties (5) about their neuromuscular and
autonomic activity, both normal and abnormal, (6) in the form of analogue or
binary, auditory and/or visual feedback signals. (7) Best achieved with a competent biofeedback professional, (8)
the objectives are to help persons develop greater awareness and voluntary
control over their physiological processes that are otherwise outside of
awareness and/or under less voluntary control, (e.g., strengthening pelvic muscles) (9) by first controlling the
external signal, (10) and then with internal psychophysiological cues(Schwartz, 1995).
Biofeedback-assisted PMR is
generally a component of a comprehensive behavioral program and has become a
standard of practice as detailed by Krissovich in Suggestions for
Cost-effective Continence Treatment.(Krissovich,
1997)
Specifically, biofeedback:
ˇ
Provides keys to muscle activity of which
patients are often unaware.
ˇ
Translates muscle responses into more
understandable events.
ˇ
Provides powerful and instant information on
muscle performance.
ˇ
Demonstrates the effectiveness of efforts to
control pelvic muscles(Burgio
et al., 1986; Tries et al., 1995; Krissovich, 1997).
Biofeedback therapy must be ordered/referred by the patients
attending physician
and
should be covered when all of the following criteria are met:
1.
The patient is motivated to actively participate
in the treatment plan, including being responsive to the care plan requirement
(i.e., practice and follow-through at home):
2.
The patient must be capable of participating in
the treatment plan (physically as well as intellectually).
3.
The patients condition can be appropriately
treated with biofeedback (i.e., pathology does not exist preventing success of
the treatment, e.g., cognitive deficit)(Fantl
et al., 1996).
Biofeedback coverage under
Medicare should be allowed for medically necessary biofeedback training when
performed by a physician or by a qualified, non-physician practitioner under
the incident to coverage and general supervision guidelines.
Biofeedback-directed PMR is indicated
for stress, urge and mixed urinary incontinence, as well as fecal incontinence,
and for urinary urgency and frequency, or overactive bladder(Baigis-Smith et al., 1989; Burgio et al., 1986; Burgio,
1990; Burgio et al., 1989; Burgio et al., 1998; Glavind et al., 1996; McDowell
et al., 1999; Mathewson-Chapman, 1997; O'Donnell et al., 1991; Woolner et al.,
1994; Flynn et al., 1994; Rousseau et al., 1992; Tries et al., 1995; Farrugia
et al., 1996; Patankar et al., 1997; Schuster, 1977; Schmidbaur et al., 1992;
Barnett et al., 1999)It is also indicated for dysfunctional voiding and
defecation, particularly when associated with striated sphincter dyssynergia(Kaplan et al., 1997; Merkel et al., 1992; Papachrysostomou
et al., 1994; Rao et al., 1997; Whitehead, 1996). ICD-9 codes appropriate to cover the aforementioned
conditions include, but are not limited to:
|
625.6 |
Stress incontinence female |
727.6 |
Incontinence of feces |
|
788.30 |
Urinary incontinence, unspecified |
564.0 |
Constipation(secondary to proven neuromuscular pelvic dysfunction) |
|
788.31 |
Urge incontinence |
728.85 |
Spasm of muscle |
|
788.32 |
Stress incontinence - male |
564.6 |
Anal spasm |
|
788.33 |
Mixed incontinence- male, female |
728.2 |
Muscular wasting and
disuse atrophy, not elsewhere classified (appropriate use in constipation
secondary to proven neuromuscular pelvic dysfunction, or striated sphincter
dyssynergia) |
|
596.55 |
Detrusor sphincter dyssynergia |
EVALUATION
PRIOR TO BIOFEEDBACK:
The following evaluation elements are
supported by review of the literature and
advocated by the International
Continence Society, WOCN, SUNA, AUA, AUGS, and the AHCPR.
A
past medical history includes the history of present illness (continence
history), as well as a review of systems, a review of medication, previous
surgeries or treatments, and a social and environmental assessment. Documentation of the patient's goals,
including target symptom(s) for treatment, should also be included in this
initial assessment.
1.
Progress made since
last session
2.
Goal of each session
(which may include strengthening or lengthening contractions, lowering resting
levels, isolation of pelvic muscles, or increased neurological control).
3.
Documentation of
compliance with treatment plan.
4.
Assessment of current
muscle function including
a.
Determination of
resting level, before and after exercise
b.
Measured contractile
strength (amplitude and duration of contraction)
c.
Latencies of
recruitment and release of contraction (control)
5.
Plan for continued
rehabilitation(Tries et al., 1995)
These utilization parameters, if
accepted and applied, will diminish the misuse of biofeedback and patients will
receive the benefits of this modality.
1. Kane, R.L., Ouslander, J.G., &
Abrass, I.B. (1994). Essentials of
clinical geriatrics. (2 ed.). New York, NY: McGraw-Hill, Inc.
2. Bergstrom, N. (1992). Pressure Ulcers in Adults: Prediction and
Prevention. Clinical Practice
Guideline, Number 3. Rockville: AHCPR Publication.
3. Kohn, D., Sinoff, G., Strulov, A.,
Ciechanover, M., & Wei, J.Y. (1991).
Long-term follow-up of patients aged 75 years and older admitted to an
acute care hospital in Israel. Aging
(Milano.), 3(3), 279-285.
Notes: Geriatric Department, Carmel
Hospital, Haifa, IsraelPMID- 0001764496
Abstract: Certain biomedical and
psychosocial factors may be important in predicting short-term and long-term
outcomes in elderly inpatients in an acute care hospital. We prospectively
studied all patients aged 75 years and older who were admitted to an acute
inpatient geriatrics unit between June, 1984 and May, 1985, and we followed
them for 5 years. Patients were followed by phone and/or the outpatient
ambulatory service; follow-up visits occurred at 4 to 6 weeks following
discharge and annually thereafter. After 5 years, 21% of the patients were
alive. Apparently, age and gender were the major parameters associated with
prognosis. Functional status and nutritional state (body weight, serum albumin)
were also important prognostic factors. Of the geriatric syndromes, urinary
incontinence seemed to be most strongly associated with a poor outcome,
followed by falls and confusion. Iatrogenic conditions apparently had no such
association. These findings suggest that certain demographic and clinical
factors may be useful prognosticators for elderly hospitalized patients
4. Baker, D.I., & Bice, T.W.
(1995). The influence of urinary
incontinence on publicly financed home care services to low-income elderly
people. Gerontologist., 35(3), 360-369.
Notes: Yale University School of
Nursing, Program on Aging, New Haven, CT 06510, USAPMID- 0007542620
Abstract: Urinary incontinence (UI)
has been shown to be prevalent and a risk factor for permanent institutionalization;
yet it is not routinely measured in research of home care utilization. A
retrospective cohort design is used to directly estimate the effect of UI on
the public costs of home care services to elderly individuals. Multivariate
analyses controlling for other individual, household, and supply
characteristics demonstrate that those with UI generate significantly greater
public costs for home care services. Patterns of service use suggest palliative
rather than rehabilitative service, raising questions regarding the effective
use of resources
5. Tromp, A.M., Smit, J.H., Deeg, D.J.,
Bouter, L.M., & Lips, P. (1998).
Predictors for falls and fractures in the Longitudinal Aging Study
Amsterdam. J.Bone Miner.Res., 13(12), 1932-1939.
Notes: Institute for Research in
Extramural Medicine (EMGO Institute), Vrije Universiteit, Amsterdam, The
NetherlandsPMID- 0009844112
Abstract: The objective of this
study was to identify easily measurable predictors for falls, recurrent falls,
and fractures using a population- based prospective cohort study of 1469
elderly, born before 1931, in three regions of the Netherlands. The baseline
at-home interview was in 1992. In 1995, falls experienced in the preceding year
and fractures over the preceding 38-month period were registered. In a period
of 1 year, 32% of the participants fell at least once, and 15% fell two or more
times. The rate of recurrent falls was similar in men and women up until the
age of 75 years. The total number of fractures was 85, including 23 wrist
fractures, 12 hip fractures, and 9 humerus fractures. The incidence density per
1000 person-years for any fracture was 25.1 (95% confidence interval [CI],
18.9-31.4) for women and 8.2 (95% CI, 4.5-12.0) for men, respectively. Multiple
logistic regression identified urinary incontinence, impaired mobility, use of
analgetics, and use of antiepileptic drugs as the predictors most strongly
associated with recurrent falls. Female gender, living alone, past fractures,
inactivity, body height, and use of analgetics proved to be the predictors most
strongly associated with fractures. The probabilities of recurrent falls were
4.7% (95% CI, 2.9-7.5%) to 59. 2% (95% CI, 24.1-86.9%) with zero to four
predictors, respectively. The probability of fractures ranged from 0.0% (95%
CI, 0.0-0.4%) without any of the identified predictors to 12.9% (95% CI,
4.4-32. 2%) with all six predictors present. Our study shows that the risk of
recurrent falls and of fractures can be predicted using up to, respectively,
four and six easily measurable predictors. This study emphasizes the importance
of impaired mobility and inactivity as predictors for falls and fractures
6. Johansson, C., Hellstrom, L., Ekelund,
P., & Milsom, I. (1996). Urinary
incontinence: a minor risk factor for hip fractures in elderly women. Maturitas, 25(1), 21-28.
Notes: Department of Geriatrics,
Vasa Hospital, Goteborg, SwedenPMID- 0008887305
Abstract: OBJECTIVE: The aim of the
study was to study the influence of urinary disorders as urinary incontinence
on the prevalence of hip fracture in 85-year-old women. METHODS: A
representative community-based population study was performed at the geriatric
outpatient department of a university hospital in a sample consisting of 658
85-year-old women, of which 69% were living at home and 31% were living were
living in institutions. The prevalence of hip fractures was registered and
measurement with dual photon absorptiometry of the right calcaneum was
performed. The subjects were questioned covering sociodemographic background,
the occurrence, type, frequency and amount of urinary incontinence, medical
examinations and investigations of the prevalence of hip fracture. RESULTS: Hip
fracture was significantly associated with urinary incontinence (P < 0.001)
for women and the odds ratio of hip fracture was twice that found in general
population (OR = 2.42). Body mass index and weight were both significant higher
(P < 0.01) among women with urinary incontinence and hip fracture. The
frequency of urinary incontinence was also significant correlated to hip
fracture (P < 0.001). Subjects with diabetes had a tendency to be associated
with urinary incontinence (P < 0.06). In a logistic multiple regression
analysis, body mass index, urinary incontinence and cancers were the only
explanatory factors for hip fractures at 85 years of age. CONCLUSION: The
association between postmenopausal urinary incontinence and hip fractures are
multifactorial and whether this is a result of decreasing estrogen levels or a
result of general aging process is still under debate. Women with urinary
incontinence and earlier atrumatic multiple postmenopausal fractures should be
considered a special target group for estrogen prophylaxis in order to prevent
further severe fractures
7. Tinetti, M.E., Inouye, S.K., Gill, T.M.,
& Doucette, J.T. (1995). Shared
risk factors for falls, incontinence, and functional dependence. Unifying the
approach to geriatric syndromes [see comments]. JAMA, 273(17),
1348-1353.
Notes: Department of Internal Medicine,
Yale University School of Medicine, New Haven, CT 06520-8025, USA
Abstract: OBJECTIVE--To determine
whether a set of factors representing impairments in multiple areas could be
identified that predisposes to falling, incontinence, and functional dependence.
DESIGN--Population- based cohort with a 1-year follow-up. SETTING--General
community. PARTICIPANTS--A total of 927 New Haven, Conn, residents, aged 72
years and older who completed the baseline and 1-year interviews. MAIN OUTCOME
MEASURES--At least one episode of urinary incontinence per week, at least two
falls during the follow-up year, and dependence on human help for one or more
basic activities of daily living. RESULTS-- At 1 year, urinary incontinence was
reported by 16%, at least two falls by 10%, and functional dependence by 20% of
participants. The four independent predisposing factors for the outcomes of
incontinence, falling, and functional dependence included slow timed chair
stands (lower extremity impairment), decreased arm strength (upper extremity
impairment), decreased vision and hearing (sensory impairment), and either a
high anxiety or depression score (affective impairment). There was a
significant increase in each of incontinence, falling, and functional
dependence as the number of these predisposing factors increased. For example,
the proportion of participants experiencing functional dependence doubled (7%
to 14% to 28% to 60%) (chi 2 = 119.8; P < .001) as the number of
predisposing factors increased from zero to one to two at least three.
CONCLUSIONS--Our findings suggest that predisposition to geriatric syndromes
and functional dependence may result when impairments in multiple domains
compromise compensatory ability. It may be possible to restore compensatory
ability and prevent or delay the onset of several geriatric syndromes and,
perhaps, functional dependence by modifying a shared set of predisposing
factors. Perhaps it is time to take a more unified approach to the geriatric
syndromes and functional dependence
8. Haalboom, J.R., den Boer, J., &
Buskens, E. (1999). Risk-assessment
tools in the prevention of pressure ulcers.
Ostomy.Wound.Manage., 45(2),
20-24.
Notes: Department of Internal
Medicine, Utrecht University Hospital, The NetherlandsPMID- 0010223012
Abstract: Some screening tools exist
for assessing increased risk of the development of pressure ulcers, but none of
these tools has undergone actual testing for validity and predictive value.
This is important in clinical practice because the combination of high
sensitivity and rather low specificity implies that the number of patients at
increased risk is overestimated and thus overtreated (i.e., unnecessary
preventive measures are taken). Risk scores are usually composed of items
considered to influence the development of pressure ulcers. Although for some
scoring systems attempts have been made to enhance specificity by changing the
cutoff points or the relative value of individual items, good results have not
been achieved. The influence that individual items have on the development of
pressure ulcers and the impact of this influence on score outcomes has not yet
been established. In this study, 65 patients with and 58 patients without
pressure ulcers were compared using all of the known risk factors analyzed by
multivariate logistic regression. We found that only the Norton, Douglas, and
Dutch Consensus Meeting scoring systems appeared to predict the development of
pressure ulcers. Also, it appeared that incontinence for urine and the presence
of both neurologic disorders and friction forces to the skin effectively
predict the development of pressure ulcers. Considering the important
implications of this study, a larger study--consisting of several thousand
patients--should be performed to assess in more detail the variables currently
perceived as risk factors and construct and evaluate a scoring system based on
these results
9. Health Care Financing Review, Medicare
and Medicaid Statistical Supplement. (1997).
10. Resnick, N.M. (1998). Improving treatment of urinary incontinence
[editorial; comment]. JAMA, 280(23), 2034-2035.
11. Wagner, T.H., & Hu, T.W. (1998). Economic costs of urinary incontinence in
1995. Urology., 51(3), 355-361.
Notes: Health Services and Policy
Analysis Program, School of Public Health, University of California at
Berkeley, 94720-7360, USAPMID- 0009510336
Abstract: Urinary incontinence
imposes a significant financial burden on individuals, their families, and
healthcare organizations. For individuals 65 years of age and older these costs
are substantial, increasing from $8.2 billion (1984 dollars) to $16.4 billion
(1993 dollars). Both of these cost-of-illness estimates, however, relied on
data and factors that have changed over time. This study updates these cost
estimates. The 1995 societal cost of incontinence for individuals aged 65 years
and older was $26.3 billion, or $3565 per individual with urinary incontinence.
Limitations, implications, and directions for future research are also
discussed
12. Bump, R.C., Hurt, W.G., Fantl, J.A.,
& Wyman, J.F. (1991). Assessment of
Kegel pelvic muscle exercise performance after brief verbal instruction. Am.J.Obstet.Gynecol., 165(2), 322-327.
Notes: Department of Obstetrics and
Gynecology, Medical College of Virginia, Virginia Commonwealth University,
Richmond 23298PMID- 0001872333
Abstract: Forty-seven women had
urethral pressure profile determinations performed at rest and during a Kegel
pelvic muscle contraction, after brief standardized verbal instruction. Twenty-three
(49%) had an ideal Kegel effort--a significant increase in the force of
urethral closure without an appreciable Valsalva effort. Twelve subjects (25%)
displayed a Kegel technique that could potentially promote incontinence. Age,
parity, weight, estrogen deprivation, prior continence surgery or hysterectomy,
and passive urethral function did not predict a successful effort. We concluded
that simple verbal or written instruction does not represent adequate
preparation for a patient who is about to start a Kegel exercise program
13. Bo, K., Kvarstein, B., Hagen, R., &
Larsen, S. (1990). Pelvic floor muscle
exercise for the treatment of female stress urinary incontinence: II. Validity
of vaginal pressure measurements of pelvic floor muscle strength and the
necessity of supplementary methods for control of correct contraction. Neurourology and Urodynamics, 9, 479-487.
14. Cammu, H., & Van Nylen, M.
(1995). Pelvic floor muscle exercises:
5 years later. Urology., 45(1), 113-117.
Notes: Urogynecological Unit,
Academisch Ziekenhuis-Vrije Universiteit Brussel, BelgiumPMID- 0007817462
Abstract: OBJECTIVES. To determine the outcome of pelvic floor
muscle exercises for genuine stress incontinence after 5 years. METHODS.
Questionnaires were sent to 48 women, mean age 57 years, with troublesome
stress incontinence treated as outpatients by a skilled female physiotherapist
to elucidate a self-assessment of therapy outcome and to determine patients'
compliance concerning fulfillment of home exercises and attitude toward
physiotherapy. Patients' self-assessment responses indicated cured, much
improved, some improvement, or unchanged/worse and incidence of
anti-incontinence surgery after physiotherapy. RESULTS. The overall cure/much
improvement rate for physiotherapy at the end of therapy was 54% and 5 years
later it was 58% (confidence interval, 43 to 72); (P = 1.000, binomial test).
Thirteen women (27%) underwent surgery. Seven unoperated women (15%) showed
only some improvement or relapse and may have been undertreated. Severity of
symptoms before therapy was an important factor in therapy outcome but not in
therapy maintenance. Frequency of home practicing was comparable in those who
had surgery afterward and those who had not. There was no clear linear
relationship in long-term effect and frequency of home practicing. Severity of
symptoms and behavioral changes bias this relationship. Physiotherapy was well
tolerated, as 73% would still prefer it as first choice. Pelvic floor muscle
exercises were recommended to friends or relatives by 77% of the patients.
CONCLUSIONS. Once a certain level of incontinence is established with pelvic
floor muscle exercises, that level is maintained over 5 years
15. Wells, T.J., Brink, C.A., Diokno, A.C.,
Wolfe, R., & Gillis, G.L. (1991).
Pelvic muscle exercise for stress urinary incontinence in elderly
women. J.Am.Geriatr.Soc., 39(8), 785-791.
Notes: University of Rochester,
School of Nursing, NY 14642PMID- 0002071809
Abstract: PURPOSE: To compare pelvic
muscle exercise to pharmacologic treatment of stress urinary incontinence, the
most common cause of urine leakage reported by community-living elderly women.
SUBJECTS: Convenience sample of 157 community-living women, aged 55 to 90
years, after completion of a comprehensive diagnostic evaluation. METHODS:
Eighty- two subjects were randomly assigned to the exercise protocol (with a
34% attrition rate). Pelvic muscle exercises were taught and monitored for 6
months. Phenylpropanolamine hydrochloride was given to the other group in a
dose of 50 mg a day, increasing to 50 mg twice a day. MAIN RESULTS: Treatment
outcomes (subjective improvement, self recorded frequency of wetting) were
equally satisfactory in both groups. The response to exercises was as good in 5
months as in 6. It was also as good when the minimum recommended number of
exercises per day was 80 as when it was 125. CONCLUSIONS: Among those
completing the protocol, pelvic exercises were beneficial in reducing stress
incontinence, and the benefit was comparable to that produced by
phenylpropanolamine
16. Ferguson, K.L., McKey, P.L., Bishop,
K.R., Kloen, P., Verheul, J.B., & Dougherty, M.C. (1990). Stress urinary incontinence: effect of
pelvic muscle exercise. Obstet.Gynecol., 75(4), 671-675.
Notes: Department of Obstetrics and
Gynecology, College of Medicine, University of Florida, GainesvillePMID-
0002314786
Abstract: Twenty women with stress
urinary incontinence diagnosed by urodynamic testing participated in a 6-week
pelvic muscle exercise program. The aim of the study was to evaluate the
effectiveness of the exercise program, with or without an intravaginal balloon,
on urinary leakage as determined by a 30-minute and a 24-hour pad test.
Relative strength of the pelvic muscles was evaluated using an intravaginal
device that measures the pressure generated during a muscle contraction. After
completion of the exercise program, 18 of the 20 subjects had an increase in
strength of the pelvic floor muscles, as demonstrated by increased intravaginal
pressure or a decrease in urinary loss on the 24- hour pad test. The use of an
intravaginal balloon did not improve performance of the pelvic muscles or
decrease urinary loss as compared with the subjects who exercised without an
intravaginal balloon. Twelve months after the completion of the exercise
program, 19 of the participants responded to a questionnaire about their
urinary loss and performance of pelvic muscle exercises. None of the subjects
stated that her urinary loss was worse, three had undergone surgical
intervention, and ten had not continued to exercise. Seven subjects still
exercised, with subjective improvement of urinary loss. It appears that pelvic
muscle exercises may be successful in improving the condition of stress urinary
incontinence; however, half of the subjects did not continue to exercise
independently
17. Burgio, K.L., Robinson, J.C., &
Engel, B.T. (1986). The role of
biofeedback in Kegel exercise training for stress urinary incontinence. Am.J.Obstet.Gynecol., 154(1), 58-64.
Abstract: This study examined the
effectiveness of teaching pelvic floor exercises with use of bladder-sphincter
biofeedback compared to training with verbal feedback based on vaginal
palpation in 24 women with stress urinary incontinence. Verbal feedback
training consisted of instructing the patient to squeeze the vaginal muscles
around the examiner's fingers and providing her with verbal performance
feedback. Biofeedback patients received visual feedback of bladder pressure,
abdominal (rectal) pressure, and external anal sphincter activity. The
biofeedback group improved the strength and selective control of pelvic floor
muscles; the verbal feedback group did not. Both groups significantly reduced
the frequency of incontinence. The biofeedback group averaged 75.9% reduction
in incontinence, significantly greater than the 51.0% reduction shown by the
verbal feedback group. Twelve of 13 patients in the biofeedback group improved
by 60% or better. Six patients in the verbal feedback group improved by 68% or
better, and five were less than 30% improved
18. Baigis-Smith, J., Smith, D.A., Rose, M.,
& Newman, D.K. (1989). Managing
urinary incontinence in community-residing elderly persons. Gerontologist., 29(2), 229-233.
Abstract: This two-year project
demonstrated a significant decrease over time in urinary accidents after
instruction in Kegel exercises augmented by the use of biofeedback, habit
training, and relaxation techniques in 54 cognitively intact volunteers aged 60
years and over who had stress, urge or complex types of incontinence. This
decrease in urinary accidents per week was maintained from the end of focused
treatment through 6-month and 1-year follow-up, despite the age of the
participants, previous urinary-related surgeries, or duration of incontinence
19. Burgio, K.L., Stutzman, R.E., &
Engel, B.T. (1989). Behavioral training
for post-prostatectomy urinary incontinence.
J.Urol., 141(2), 303-306.
Notes: Laboratory of Behavioral Sciences, National Institute on Aging,
Baltimore, MarylandPMID- 0002913349
Abstract: We treated 20 men with
persistent post-prostatectomy incontinence by biofeedback-assisted behavioral
training procedures. Initially, scheduled 2-hour voiding resulted in a mean
33.1 per cent increase in urge incontinence, a mean 28.5 per cent decrease in
stress incontinence and no change in continual leakage. Subsequently,
biofeedback was used to teach selective control of the sphincter muscles and/or
inhibition of detrusor contractions. Individualized home practice included a
voiding schedule, sphincter exercises, active use of the sphincter to prevent
urine loss and strategies to manage urgency. After 1 to 5 biofeedback sessions
patients with urge incontinence demonstrated an average 80.7 per cent decrease
in incontinence, while stress incontinence was decreased an average 78.3 per
cent and patients with continual leakage were less successful, with a mean 17.0
per cent improvement. The findings indicate that biofeedback training is an
effective intervention for episodic stress or urge incontinence after
prostatectomy. However, its usefulness appears to be limited in patients with
postoperative incontinence characterized by continual leakage
20. Burgio, K.L., Locher, J.L., Goode, P.S.,
Hardin, J.M., McDowell, B.J., Dombrowski, M., & Candib, D. (1998). Behavioral vs drug treatment for urge
urinary incontinence in older women: a randomized controlled trial [see
comments]. JAMA, 280(23), 1995-2000.
Notes: Department of Medicine,
School of Medicine, University of Alabama at Birmingham, USA
Kburgio@Agingdomuabedu
Abstract: CONTEXT: Urinary
incontinence is a common condition caused by many factors with several
treatment options. OBJECTIVE: To compare the effectiveness of
biofeedback-assisted behavioral treatment with drug treatment and a placebo
control condition for the treatment of urge and mixed urinary incontinence in
older community-dwelling women. DESIGN: Randomized placebo-controlled trial
conducted from 1989 to 1995. SETTING: University-based outpatient geriatric
medicine clinic. PATIENTS: A volunteer sample of 197 women aged 55 to 92 years
with urge urinary incontinence or mixed incontinence with urge as the
predominant pattern. Subjects had to have urodynamic evidence of bladder
dysfunction, be ambulatory, and not have dementia. INTERVENTION: Subjects were
randomized to 4 sessions (8 weeks) of biofeedback- assisted behavioral
treatment, drug treatment (with oxybutynin chloride, possible range of doses,
2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. MAIN
OUTCOME MEASURES: Reduction in the frequency of incontinent episodes as
determined by bladder diaries, and patients' perceptions of improvement and
their comfort and satisfaction with treatment. RESULTS: For all 3 treatment
groups, reduction of incontinence was most pronounced early in treatment and
progressed more gradually thereafter. Behavioral treatment, which yielded a
mean 80.7% reduction of incontinence episodes, was significantly more effective
than drug treatment (mean 68.5% reduction; P=.04) and both were more effective
than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009,
respectively). Patient-perceived improvement was greatest for behavioral
treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment
and placebo, respectively). Only 14.0% of patients receiving behavioral
treatment wanted to change to another treatment vs 75.5% in each of the other
groups. CONCLUSION: Behavioral treatment is a safe and effective conservative
intervention that should be made more readily available to patients as a
first-line treatment for urge and mixed incontinence
21. Glavind, K., Nohr, S.B., & Walter, S.
(1996). Biofeedback and physiotherapy
versus physiotherapy alone in the treatment of genuine stress urinary
incontinence. Int.Urogynecol.J.Pelvic.Floor.Dysfunct., 7(6), 339-343.
Notes: Department of Gynecology and
Obstetrics, Aalborg Sygehus, DenmarkPMID- 0009203484
Abstract: Biofeedback is a method of
pelvic floor rehabilitation using a surface electrode inserted into the vagina
and a catheter in the rectum. Forty women with genuine urinary stress
incontinence were randomized to compare the efficacy of physiotherapy and
physiotherapy in combination with biofeedback. The effect of the treatment was
determined by a standardized pad-weighing test. Long-term status was determined
using a questionnaire after 2-3 years. Thirty-four women completed the
treatment. The study showed a statistically significant better improvement in
the biofeedback group. The long-term effect in the biofeedback group seemed
better and the patients were more motivated for training afterwards
22. Mathewson-Chapman, M. (1997). Pelvic muscle exercise/biofeedback for
urinary incontinence after prostatectomy: an education program. J.Cancer Educ., 12(4), 218-223.
Notes: University of Florida College
of Nursing, Gainesville 32610-0187, USA
Abstract: BACKGROUND: This study
tested the effectiveness of pelvic muscle exercise (PME) with biofeedback in
reducing the length of time urinary incontinence (UI) was experienced following
a radical prostatectomy for localized prostate cancer. METHODS: Fifty-three men
were randomly assigned to an education intervention group or a control group.
The education group received instruction in PME/biofeedback and were given a
PME protocol to perform three times per week for 12 weeks. The control group
did not receive instruction in PME technique. Both groups recorded urine losses
in three-day bladder diaries, and 24-hour pad tests were done in weeks 2, 5, 9,
and 12 after surgery. Study variables included: 1) length of time urine loss
was experienced; 2) episodes and frequency of urine loss; and 3) ounces of
urine lost and number of pads used. RESULTS: The PME/biofeedback group regained
continence at a mean of 51 days; the non-PME group at 56 days. Although the PME
group demonstrated reductions in episodes, frequency, ounces of urine lost by
UI, and pad usage, they were not statistically significant. CONCLUSIONS: After
prostatectomy, men experience UI for periods of one to 80+ days. The use of
biofeedback enhances learning PME and skill performance. Bladder diaries and
behavioral management techniques (PME) need to be further studied as
appropriate treatment methods to assist men in managing UI after cancer surgery
23. McDowell, B.J., Engberg, S., Sereika, S.,
Donovan, N., Jubeck, M.E., Weber, E., & Engberg, R. (1999). Effectiveness of behavioral therapy to treat
incontinence in homebound older adults.
J.Am.Geriatr.Soc., 47(3),
309-318.
Notes: University of Pittsburgh
School of Nursing, Pennsylvania 15261, USAPMID- 0010078893
Abstract: OBJECTIVES: To examine the
(1) short-term effectiveness of behavioral therapies in homebound older adults
and (2) characteristics of responders and nonresponders to the therapies.
DESIGN: Prospective, controlled clinical trial with cross-over design. SETTING:
Adults aged 60 and older with urinary incontinence and who met Health Care
Financing Administration criteria for being homebound were referred to the
study by homecare nurses from two large Medicare-approved home health agencies
in a large metropolitan county in southwestern Pennsylvania. MEASURES:
Structured continence and medical history, OARS Physical and Instrumental
Activities of Daily Living scales, Folstein Mini-Mental State Examination
Score, Clock Drawing Test, Geriatric Depression Scale, Performance-Based
Toileting Assessment, bladder diaries, and physical examination. RESULTS: One
hundred five subjects were randomized to biofeedback-assisted pelvic floor muscle
training (53 to the treatment group and 52 to the control groups). Control
subjects with complete pre- and post-control data (n = 45) experienced a median
6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in
subjects with complete pre- and post-treatment data (n = 48, P < .001).
Following the control phase, subjects crossed over to the treatment protocol.
Eighty-five subjects completed treatment, achieving a median 73.9% reduction in
UI. Exercise adherence was the most consistent predictor of responsiveness to
the behavioral therapy. CONCLUSIONS: Clinically significant reductions in
urinary incontinence are achievable with behavioral therapies in many
cognitively intact homebound older adults despite high levels of co-morbidity and
functional impairment
24. O'Donnell, P.D., & Doyle, R.
(1991). Biofeedback therapy technique
for treatment of urinary incontinence. Urology., 37(5), 432-436.
Notes: Little Rock Veterans Affairs
Medical Center, ArkansasPMID- 0002024391
Abstract: Biofeedback treatment of
urinary incontinence is a management method that has low risk and therapeutic
efficacy for selected patients. Biofeedback therapy techniques vary widely and
have not been well described or standardized. A technique for biofeedback
therapy is described that allows accurate signal monitoring and assures
appropriate biofeedback to the patient. External anal sphincter
electromyographic performance is presented to the patient as a color line graph
with pitch variable audio feedback. The method has complete flexibility in
providing biofeedback training according to patient performance level and is
one that can be easily interpreted by patients who have voiding dysfunctions
25. Payne, C.K. (1998). Biofeedback for community-dwelling
individuals with urinary incontinence. Urology., 51(2A Suppl), 35-39.
Notes: Center for Female Urology and
NeuroUrology, Stanford University Medical Center, California 94305-5118,
USAPMID- 0009495734
Abstract: OBJECTIVES: To review the
role of biofeedback in the management of community-dwelling individuals with
urge urinary incontinence (UUI), and to present a practical approach to patient
evaluation and treatment selection. METHODS: In view of a lack of objective
published information, perspectives on the use of biofeedback in UUI are
derived from extrapolation of studies in patients with stress incontinence as
well as from the author's personal experience. RESULTS: Through the use of
careful baseline evaluations, appropriate exercise and biofeedback treatment
for UUI can be selected for specific patients. Office-based biofeedback is
preferred for patients who have no or minimal ability to isolate and contract
the levator muscles at baseline. Such individuals cannot be expected to
exercise effectively without instruction but can be converted to home-based
treatment once responses have been achieved. Patients with weak contractions
but appropriate muscle isolation are appropriate candidates for Kegel
exercises; biofeedback has not been conclusively demonstrated to be superior to
exercise therapy alone in this group. Vaginal cones or simple home biofeedback
units may be useful adjuncts in these cases. Patients who have good muscle
isolation and strong pelvic contractions at baseline generally have more severe
bladder dysfunction and require aggressive treatment aimed at the detrusor.
Instruction in "quick flicks" may assist in inhibiting urgency, and
motivated patients may be offered vaginal cones. CONCLUSIONS: Pelvic floor
muscle dysfunction is an important but often- overlooked component of UUI. The
algorithm presented here can assist in tailoring exercise and biofeedback
therapy to the individual patient. However, more research is needed to help
stratify patients according to the degree of detrusor dysfunction and status of
pelvic floor muscles before intervention
26. Woolner, B., & Ouslander, J.
(1994). Biofeedback for urinary
symptoms among frail elderly women. Presented:Managing
Incontinence in Elderly Dependent Institutionalized and Community Dwelling
Persons: An Agenda for Research and Care,
March 17-20, 1-11.
Abstract: AIM: To evaluate the applicability of biofeedback
for urinary symptoms in frail elderly women.
SUBJECTS: One hundred thirteen
frail elderly female residents ofthe board and care sectino ofa multi-level
long-term care institution, average age 86.4.
METHOD: Over a 2 1/2
year period, 113 female residents with urinary symptoms were consecutively
treated in a biofeedback clinic. They
were either self-referred, referred by a physician or nurse, or identified
through new admissions screening for urinary symptoms. All underwent a focused
history, urinalysis, and education about normal voiding and pelvic muscle
exercise. The most common symptoms were
incontinence (72%), nocturia (39%), u;rgency (35%) and frequency (33%). Pelvic muscle exercises were taught using
EMG biofeedback with peri-anl and abdominal surface electrodes. Those with urge symptoms were also taught
bladder training techniques after learning to isolate their pelvic
muscles. All participant were asked to
maintain daily voiding diaries.
Participants were seen for an average of 5.5 weekly visit. RESULTS:
Sixty nine (61%) of the subjects had a favorable response based on
subjective reports and voiding diaries along with objective pelvic muscle
function. The reasons for poor response
were: non-compliance (N = 12), poor
memory (N = 10), failure to return (N = 9), refusal of further treatment (N =
8) and comorbid condition (N = 7).
CONCLUSIONS: Biofeedback appears
to be a useful noninvasive technique for a s;ubstantial number of frail elderly
women with incontinence and related symptoms.
27. Tries, J. (1990). Kegel exercises enhanced by
biofeedback. J.Enterostomal.Ther., 17(2), 67-76.
Abstract: New motor learning is
dependent on sensory feedback, both visual and kinesthetic. Many factors may
function to offset the effectiveness of Kegel exercises. These factors include
(1) faulty feedback generated by substituting muscles, (2) insufficient
kinesthetic feedback produced by the low intensity contraction of the weakened
pelvic floor, and (3) absent or impaired sensation that limits the sensory cues
that normally trigger a motor response or reflex that prevents incontinence.
Because biofeedback can compensate for the loss of sensation, its comprehensive
application can be an invaluable tool in the retraining of bowel and bladder
control, especially where function is lost through trauma, neurologic injury or
long term disuse/misuse. As such, biofeedback can enhance the many behavioral
interventions developed to decrease incontinence, including Kegel exercises
28. Schwartz, M. (1995). Biofeedback: A Practitioner's Guide, Second Edition. (Second ed.). Guilford Press.
29. Krissovich, M. (1997). Suggestions for Cost-Effective Continence
Treatment. In Anonymous, Patient
Access to Continence Services: Protecting It Under Managed Care. (pp.
19-23). Society for Urologic Nurses.
30. Tries, J., & Eisman, E. (1995). Urinary Incontinence: Evaluation and
Biofeedback Treatment. In M. Schwartz (Ed.), Biofeedback: A Practitioner's Guide, Second Edition. (pp.
597-632). New York, London: Guilford Press.
31. Fantl, J.A., Newman, D.K., & Colling,
J. (1996). Urinary Incontinence in
Adults: Acute and Chronic
Management. Clinical Practice Guideline. Rockville:
U.S. Department of Health and Human Services. Public Health Service,
Agency for Health Care Policy and Research. AHCPR Publication No. 96-0682.
32. Burgio, K.L., Robinson, J.C., & Engel,
B.T. (1986). The role of biofeedback in
Kegel exercise training for stress urinary incontinence. American Journal of Obstetrics and
Gynecology, 154(1), 58-64.
33. Burgio, K.L. Biofeeedback-assisted behavioral training for elderly men and
women
Notes: p. 89 - Overall, the data
show that behavioral training with bfb can be a practical, cost-effective
method of reducing inc in most community-dwelling elderly persons. Considering
the absence of documented side effects and the low risk level associated with
behavioral training, it might be considered the 1st treatment offered to
mentally alert patients with stress or urge incontinence
34. Flynn, L., Cell, P., & Luisi, E.
(1994). Effectiveness of pelvic muscle
exercises in reducing urge incontinence among community residing elders. J.Gerontol.Nurs., 20(5), 23-27.
Abstract: 1. Urinary incontinence is
a costly and prevalent problem, affecting 15% to 39% of all community residing
elders. 2. Some elders suffering from urge incontinence prefer pelvic muscle
exercises to bladder training as the behavioral intervention of choice. 3.
Although pelvic muscle exercises are frequently associated as an intervention
for stress incontinence, they have been found to be effective in significantly
reducing urge incontinence. 4. Nurses are in a key position to identify and
treat urinary incontinence among the elderly, and should incorporate continence
restoration interventions into their practice
35. Rousseau, P., & Fuentevilla-Clifton,
A. (1992). Urinary incontinence in the
aged, Part 2: Management strategies [published erratum appears in Geriatrics
1992 Sep;47(9):87]. Geriatrics., 47(6), 37-40, 45, 48.
Notes: VA Medical Center, Phoenix
Abstract: Treatments for urge
incontinence associated with uninhibited bladder contractions include
medications with anticholinergic and smooth muscle relaxant properties as well
as habit training, bladder retraining, contingency therapy, and biofeedback.
Pelvic floor (Kegel) exercises improve stress incontinence in 60 to 90% of
female patients. For patients who fail to improve with pelvic floor exercises,
a combination of an alpha-adrenergic agent and conjugated estrogen is
recommended. Surgery is particularly effective in elderly women with
significant pelvic prolapse. Management of overflow incontinence requires
surgery or intermittent/chronic catheterization. Functional incontinence may be
improved with correction of the underlying disorder and availability of a
motivated caregiver
36. Tries, J., Eisman, E., & Lowery, S.P.
(1995). Fecal Incontinence. In M.
Schwartz (Ed.), Biofeedback: A
Practitioner's Guide, Second Edition. (pp. 633-661). New York, London: Guilford Press.
37. Farrugia, G., Camilleri, M., &
Whitehead, W.E. (1996). Therapeutic
strategies for motility disorders. Medications, nutrition, biofeedback, and
hypnotherapy. Gastroenterol.Clin.North
Am., 25(1), 225-246.
Notes: Mayo Medical School,
Rochester, Minnesota, USA
Abstract: Gastrointestinal motility
is regulated by a complex balance of inhibitory and excitatory neuronal,
humoral, and mechanical factors. The goal in the management of motility
disorders is to maintain adequate nutrition while decreasing symptoms. This can
be accomplished by medications and support of nutrition and biofeedback; the
application of these therapeutic strategies to patients with gut motility
disorders is reviewed
38. Patankar, S.K., Ferrara, A., Levy, J.R.,
Larach, S.W., Williamson, P.R., & Perozo, S.E. (1997). Biofeedback in colorectal practice: a multicenter,
statewide, three- year experience. Dis.Colon
Rectum, 40(7), 827-831.
Notes: The Colon and Rectal Clinic
of Orlando, Florida 32806, USAPMID- 0009221861
Abstract: PURPOSE: Biofeedback
treatment is often offered to patients in colorectal centers; however,
standards of treatment are still lacking. A dedicated team approach is
desirable but difficult to coordinate. We present our three-year experience of
electromyographic-based biofeedback treatment offered within a multicenter,
statewide organization. METHODS: Between October 1992 and October 1995, 188
patients completed a biofeedback treatment program in one of five coordinated
centers within a 200-mile radius. A unified common database was established and
continuously updated. A colorectal surgeon served as statewide director, and
dedicated teams were established at each location. Each local team included the
medical director and a certified biofeedback therapist and had access to a
dietitian and a nurse data coordinator. Electromyographic-based biofeedback
sessions were given weekly, and a home trainer program was established.
RESULTS: A total of 116 patients with chronic constipation had a mean of eight
(range, 2- 14) weekly sessions. A total of 72 patients with fecal incontinence
had a mean of seven (range, 2-11) weekly sessions. A total of 84 percent of the
constipated and 85 percent of the incontinent patients had significant
improvement with biofeedback treatment. Patient compliance and satisfaction
were high. Constipated patients increased the mean number of weekly unassisted
bowel movements from 0.8 to 6.5. Incontinent patients decreased the mean number
of weekly gross incontinence episodes from 11.8 to 2. CONCLUSIONS: Biofeedback
treatment can be extremely successful in both incontinent and constipated
patients. A large geographic area can be covered with coordinated centers in
which each dedicated team uses a unified treatment protocol, and a common
database is established
39. Schuster, M.M. (1977). Gastrointestinal tract dysfunctions respond
to biofeedback. Geriatrics., 32(6), 32, 37, 41.
40. Schmidbaur, W., Barnert, J., &
Wienbeck, M. (1992). Anal incontinence:
evaluation and biofeedback therapy. Mater.Med.Pol., 24(3), 181-184.
Notes: Department of Internal
Medicine 3, Zentralklinikum Augsburg, Germany
Abstract: Incontinence is a very
stigmatizing symptom in our society. About 1% of the adult population is
affected by fecal incontinence. In the evaluation anorectal manometry and
defecography play a major role. Therapy often is still disappointing. In recent
years simple retaining or biofeedback therapy have been reported to improve
about 70% of incontinent patients. Within one year we treated 19 patients.
Success was achieved in 69%. Biofeedback training, therefore, should be
attempted prior to considering surgery
41. Barnett, J.L., Hasler, W.L., &
Camilleri, M. (1999). American
Gastroenterological Association medical position statement on anorectal testing
techniques. American Gastroenterological Association. Gastroenterology, 116(3),
732-760.
Notes: Direct exerpt
"Biofeedback training. Neurogenic
fecal incontinence associated with weakness ofthe EAS and/or decreased ability
to perceive rectal distention because of nerve injury can be treated with
biofeedback training desighned to teach the patient (1) how to recognize small
volumes of rectal distention and (2) how to contract the EAS while
simultaneously keeping intra-abdominal pressure low." ... " It was hypothesized that
anorectal dysfunction in patients with associated pelvic floor dyssynergia
might be amenable to biofeedback techniques.
The use of EMG biofeedback techniques has now been reported in seven
studies of constipated abult patients in which a total of 92 adults have been
evaluated with an overall impovment rate of 84%. ... Conclusion: (2) EMG
biofeedback training is of value in the management of pelvic floor
dyssynergia."
Abstract: This document presents the
official recommendations of the American Gastroenterological Association (AGA)
on Anorectal Testing Techniques. It was approved by the Clinical Practice and
Practice Economics Committee on May 17, 1998, and by the AGA Governing Board on
July 24, 1998
42. Kaplan, S.A., Santarosa, R.P., D'Alisera,
P.M., Fay, B.J., Ikeguchi, E.F., Hendricks, J., Klein, L., & Te, A.E.
(1997). Pseudodyssynergia (contraction
of the external sphincter during voiding) misdiagnosed as chronic nonbacterial
prostatitis and the role of biofeedback as a therapeutic option. J.Urol.,
157(6), 2234-2237.
Notes: Department of Urology, Squier
Urological Clinic, Columbia University, New York, New York, USAPMID- 0009146624
Abstract: PURPOSE: Chronic lower
urinary tract symptoms in young men are often attributed to misdiagnosed
chronic nonbacterial prostatitis. We analyzed contraction of the external
urinary sphincter during voiding (pseudodyssynergia) as an etiology of voiding
dysfunction in men with misdiagnosed chronic prostatitis. MATERIALS AND
METHODS: The video urodynamic studies of 43 men 23 to 50 years old with chronic
voiding dysfunction secondary to pseudodyssynergia performed between January
1990 and June 1996 were retrospectively analyzed. Pseudodyssynergia was
diagnosed based on several criteria, including electrical activity of the
external sphincter during voiding in the absence of abdominal straining, and
brief and intermittent closing of the membranous urethra during voiding
detected by electromyography and fluoroscopy. Patients with bacterial infection
or excessive leukocytes in expressed prostatic secretions were excluded from
the study. RESULTS: Of the patients 39 (91%) were firstborn men. Duration of
symptoms ranged from 17 to 146 months (mean 43.6). Average number of previous
antibiotic days ranged from 53 to 186 (mean 67.6). In addition, empirical
trials of alpha- blockers were unsuccessful. Mean American Urological
Association symptom score plus or minus standard deviation was 17.5 +/- 3.7,
mean maximum flow rate was 13.3 +/- 4.2 ml. per second, mean detrusor pressure
at maximum flow was 46.3 +/- 13.7 cm. water and mean detrusor contraction
duration was 132.8 +/- 27.7 seconds. Behavior modification and biofeedback were
successful in decreasing symptoms in 35 patients (83%) at 6 months.
CONCLUSIONS: These results indicate that some men who are categorized as having
and empirically treated for chronic nonbacterial prostatitis are misdiagnosed
and, in fact, have functional bladder outlet obstruction. Urodynamics are
helpful in diagnosing and predicting success with behavior modification and
biofeedback in these patients
43. Merkel, I.S., & Wald, A. (1992). Training for straining: biofeedback for
pelvic floor dyssynergia. Am.J.Gastroenterol., 87(9), 1223-1224.
Notes: University of Pittsburgh
Medical Center, PennsylvaniaPMID- 0001519591
44. Papachrysostomou, M., & Smith, A.N.
(1994). Effects of biofeedback on
obstructive defecation--reconditioning of the defecation reflex? Gut,
35(2), 252-256.
Notes: Department of Surgery,
University of Edinburgh, Western General HospitalPMID- 0008307478
Abstract: Twenty two patients with
obstructive defecation were recruited for relaxation training by domiciliary
self regulatory biofeedback. Each patient served as his or her own control for
anorectal and proctographic assessments. Biofeedback training improved the obstructive
symptoms of the patients and showed significant change in various parameters
related to the obstructive defecation syndrome. As examined by isotope dynamic
proctography: the defecation rate (% of evacuation/defecation time) was
significantly increased (p < 0.05), the anorectal angles at rest and during
attempted defecation were made more obtuse (p < 0.05), and the pelvic floor
movements were made more dynamic on voluntary contraction of the anal sphincter
(p < 0.03). The external anal sphincter electromyographic voltage recorded
during defecation was significantly reduced (p < 0.0005) as was the surface
anal plug electromyographic electrode voltage (p < 0.0001), which was
associated with a greatly reduced anismus index (p < 0.0001). The rectal
sensation was improved (p < 0.05), concomitantly. Biofeedback thus improves
the defecation act in patients suffering from inappropriate contraction of the
pelvic floor and sphincter musculature. Furthermore, this study has shown that
biofeedback objectively influences the defecation reflex leading to an improved
quality of higher control of bowel function
45. Rao, S.S., Enck, P., &
Loening-Baucke, V. (1997). Biofeedback
therapy for defecation disorders. Dig.Dis., 15 Suppl 1:78-92, 78-92.
Notes: Department of Medicine,
University of Iowa College of Medicine, Iowa City, USA
Abstract: Biofeedback therapy is a
useful adjunct to conventional treatment for many patients with refractory
defecation disorders. This article provides an overview regarding the historical
evolution of this treatment together with current perspectives regarding the
principles and techniques of performing biofeedback therapy and an assessment
of its outcome in adults and pediatric patients with defecation disorders
46. Whitehead, W.E. (1996). Functional anorectal disorders. Semin.Gastrointest.Dis., 7(4), 230-236.
Notes: University of North Carolina
at Chapel Hill, Division of Digestive Diseases 27599-7080, USA
Abstract: The functional anorectal
disorders-functional fecal incontinence, pelvic floor dyssynergia-type
constipation, levator ani syndrome, and proctalgia fugax-are common but poorly
understood gastrointestinal complaints. Fecal incontinence may occur in
constipated patients when a fecal impaction of the rectum reflexly inhibits the
internal anal sphincter and allows leakage of soft stool, or it may occur in
diarrhea. Constipation-related incontinence can be treated with habit training
(use of a routine time to defecate backed up by laxatives) or biofeedback to
teach relaxation of the pelvic floor, but diarrhea- related fecal incontinence
usually requires antidiarrheal medications. Pelvic floor dyssynergia occurs
when the pelvic floor muscles paradoxically contract instead of relaxing when
the patient strains to defecate. Biofeedback to teach relaxation of these
muscles is effective in two thirds of patients. Levator ani syndrome involves
chronic, and proctalgia fugax involves fleeting rectal pain. The cause of these
painful conditions is unknown, and no treatment of proven efficacy is available
47. Bo, K., Kvarstein, B., Hagen, R.,
Jorgensen, J., & Larsen, S. (1990).
Pelvic floor muscle exercise for the treatment of female stress urinary
incontinence: III. Effects of two different degrees of pelvic floor muscle exercises. Neurourology and Urodynamics, 9, 489-502.
48. Wells, T., Brink, C.A., Diokno, A.C.,
Wolfe, R., & Gillis, G.L. (1991).
Pelvic muscle exercise for stress urinary incontinence in elderly women. Journal of the American Geriatrics
Society, 39(8), 785-791.
49. Ferguson, K.L., McKey, P.L., Bishop,
K.R., Kloen, P., Verheul, J.B., & Dougherty, M.C. (1990). Stress urinary incontinence: Effect of
pelvic muscle exercise. Obstetrics
and Gynecology, 75(4), 671-675.
Notes: Aim: to evaluate effectiveness
of the exercise program, with or without an intravaginal balloon, on urinary
leakage as determined by a 30-minute and a 24-hr pad test
50. Middaugh, S.J., Whitehead, W.E., Burgio,
K.L., & Engel, B.T. (1989).
Biofeedback in treatment of urinary incontinence in stroke
patients. Biofeedback.Self.Regul., 14(1), 3-19.
Notes: Department of Physical
Medicine and Rehabilitation, Medical University of South Carolina, Charleston
29425PMID- 0002752058
Abstract: Urinary incontinence can
occur poststroke owing to weakness or incoordination of sphincter muscles,
impaired bladder sensation, or hyperreflexic, neurogenic bladder. Four male
subjects who had urinary incontinence associated with a stroke that had
occurred 8 months to 10 years earlier, and who averaged 1.6 to 7.5 accidental
voidings per week, participated in an outpatient study with a 4-week scheduled-
voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining,
and 6- to 12-month follow-up. Training sessions included stepwise filling of
the bladder and manometric feedback display of bladder pressure, abdominal
pressure, and external anal sphincter pressure. Training procedures were
designed to teach subjects to attend to bladder sensations, inhibit bladder
contractions, and improve voluntary sphincter muscle control. All four subjects
achieved and maintained continence regardless of substantial differences in
subject characteristics, including laterality of stroke, degree of sensory
impairment, and independence in daily activities
51. Tries, J., & Eisman, E. (1995). Urinary Incontinence: Evaluation and
Biofeedback Treatment. In M. Schwartz (Ed.), Biofeedback: A Practitioner's Guide, Second Edition. (pp.
597-632). New York, London: Guilford Press.
52. Perry, J.D., & Hullett, L.T.
(1988). The role of EMG home trainers
in the treatment of urinary and fecal incontinence [Abstract]. Presentation/Northeast Gerontological
Society, May 20, 1-5.
53. Susset, J.G., Galea, G., & Read, L.
(1990). Biofeedback therapy for female
incontinence due to low urethral resistance [see comments]. J.Urol.,
143(6), 1205-1208.
Notes: Urology Section, Veterans
Administration Medical Center, Brown University Medical School, Providence,
Rhode Island
Abstract: Urinary incontinence,
mostly secondary to low urethral resistance, in 15 women was treated for 6
weeks by biofeedback. A new device equipped with visual and audio signals
connected to an intravaginal probe was used by the patient for 15 minutes twice
a day. Of the patients 12 were continent subjectively and objectively, 2 had 65
and 75% improvement and could lead a normal life, and only 1 failed to respond
and was treated surgically. Besides the quality of the device, success depends
largely on the quality of moral support given to the patient during the
treatment
54. Taylor, K., & Henderson, J.
(1986). Effects of biofeedback and
urinary stress incontinence in older women.
J Gerontol Nurs, 12(9),
25-30.
55. Hirsch, A., Weirauch, G., Steimer, B.,
Bihler, K., Peschers, U., Bergauer, F., Leib, B., & Dimpfl, T. (1999). Treatment of female urinary incontinence
with EMG-controlled biofeedback home training.
Int.Urogynecol.J.Pelvic.Floor.Dysfunct., 10(1), 7-10.
Notes: Ludwig-Maximilians-Universitaet,
Muenchen, GermanyPMID- 0010207760
Abstract: The aim of the study was
to evaluate the efficacy of pelvic floor training with EMG-controlled home
biofeedback in the treatment of stress and mixed incontinence in women.
Subjects were recruited from the urodynamic outpatient clinic and performed
pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes
daily for 6 months. The number of pads used per day, the number of incontinence
and urgency episodes, voiding frequency, maximum urethral closure pressure,
functional urethral length and pressure/transmission ratio during stress were
assessed before and after treatment. Thirty-three patients (13 with stress and
20 with mixed incontinence) completed the study. There was a significant
decrease in the number of pads used per day, the number of incontinence and
urgency episodes, and the voiding frequency. Twenty-eight patients (85%)
reported that they were cured or improved. Urodynamic parameters did not change
significantly. It was concluded that home pelvic floor training with
EMG-controlled biofeedback is efficient in 85% of patients in alleviating the
symptoms of genuine stress and mixed incontinence without causing side effects
ATTACHMENT 1
Incontinence
Impact Questionairre short form (IIQ-7) |
||||
|
Has
urine leakage and / or prolapse (relaxation of pelvic contents) affected: |
||||
|
|
Not
at all |
Slightly |
Moderately |
Greatly |
|
1.
Household chores |
|
|
|
|
|
2.
Physical recreation |
|
|
|
|
|
3.
Entertainment activities |
|
|
|
|
|
4.
Traveling more than 30 minutes from home |
|
|
|
|
|
5.
Social activities |
|
|
|
|
|
6.
Emotional health (nervousness, depression, etc.) |
|
|
|
|
|
7.
Feeling frustrated |
|
|
|
|
|
|
||||
|
Urological
Distress Inventory short form
(UDI-6) |
|
|
|
|
|
1.
Do you experience, and if so, how much are you bothered
by: |
|
|
|
|
|
2.
Frequent urination |
|
|
|
|
|
3.
Urine leakage related to a feeling of urgency |
|
|
|
|
|
4.
Urine leakage related to physical activity, coughing, or
sneezing |
|
|
|
|
|
5.
Small amounts of urine leakage (drops) |
|
|
|
|
|
6.
Difficulty emptying your bladder |
|
|
|
|
|
7.
Pain or discomfort in the lower abdominal or genital area |
|
|
|
|
Shumaker, S. A., J. F. Wyman, et al.
(1994). Health-related quality of life measures for women with urinary
incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress
Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res
3(5): 291-306
Uebersax, J. S., J. F. Wyman, et al.
(1995). Short forms to assess life quality and symptom distress for urinary
incontinence in women: the Incontinence Impact Questionnaire and the Urogenital
Distress Inventory. Continence Program for Women Research Group. Neurourol
Urodyn 14(2): 131-9
I-PSS attached