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Gut. Aug 2001; 49(2): 214–219.
PMCID: PMC1728383
Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation
A Emmanuel and M Kamm
St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
BACKGROUND—Although behavioural treatment (biofeedback) successfully treats the pelvic floor abnormalities in patients with idiopathic constipation, many patients also normalise their impaired bowel frequency. We postulated that a response may be associated with altered cerebral outflow via extrinsic autonomic nerves to the gut. We investigated whether treatment changes extrinsic innervation, using mucosal laser Doppler flowmetry, whether autonomic changes are gut specific, and whether it changes gut transit.
MATERIALS AND METHODS—Forty nine patients (44 female, mean age 39 years) with idiopathic constipation were studied before and after biofeedback treatment (mean five sessions). Rectal mucosal blood flow was measured by laser Doppler flowmetry to assess direct extrinsic gut nerve autonomic activity. To assess general autonomic activity, RR (interval between successive R waves on the electrocardiogram) variability, Valsalva ratio, orthostatic adjustment ratio, and phase II:IV blood pressure ratio (II:IV) of the Valsalva manoeuvre were measured. All autonomic tests were compared with those of 26 healthy volunteers (19 female, mean age 37 years).
RESULTS—Twenty nine of 49 patients were symptomatically improved. Treatment reduced those with [less-than-or-eq, slant]3 bowel actions per week (27 v 9, pre v post), need to strain (26 v 9), and laxative or suppository use (34 v 9). Biofeedback reduced retained markers by 32% in those with slow transit and by 20% in those with normal transit. Twenty two had slow transit before treatment—14 felt symptomatic improvement of whom 13 developed normal transit. There was a significantly greater increase in rectal mucosal blood flow in patients who subjectively improved compared with those who did not (29% v 7%; p<0.03) and in those with improved bowel frequency (33% v 9%, increased v unchanged bowel frequency; p<0.05). Thirty five patients had abnormal RR variability and 33 an abnormal Valsalva ratio; one had an abnormal orthostatic adjustment ratio and one an abnormal II:IV ratio. None of the general cardiorespiratory autonomic reflexes was changed by treatment.
CONCLUSIONS—Biofeedback treatment affects more than the pelvic floor. Successful outcome after biofeedback treatment is associated with improved activity of the direct cerebral innervation to the gut and improved gut transit. This effect is gut specific; cardiovascular autonomic reflexes were not altered.


Keywords: biofeedback; constipation; gut transit; autonomic innervation
Figure 1
Figure 1  
An increase in rectal mucosal blood flow was observed in those subjects who reduced or stopped laxative use ("responders" or "successful treatment") after biofeedback compared with those who did not ("non-responders" or "failed treatment") (p=0.029). (more ...)
Figure 2
Figure 2  
Correlation between change in transit (reduction of retained markers) and change in extrinsic gut innervation (increased rectal mucosal blood flow) in patients after behavioural treatment (biofeedback) (r=−0.55, p=0.043).
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