Biofeedback wins Trial for Chronic Rectal Pain

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Biofeedback wins Trial for Chronic Rectal Pain

Postby Savaici » 25 Jun 2014, 18:51

Biofeedback Wins Trial for Chronic Rectal Pain

Published: Mar 31, 2010

By  Crystal Phend , Senior Staff Writer, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

Explain to interested patients that while biofeedback therapy appeared to be most effective treatment for chronic and recurring rectal pain, it is unavailable in many areas.

Chronic rectal pain may respond best to biofeedback therapy, particularly for patients with tenderness on palpation, according to the first randomized, direct comparison trial of the three most common treatments.

Teaching patients with levator ani syndrome to relax the pelvic floor muscles using biofeedback resulted in "adequate" symptom relief for 59.6% of patients at one month in the intent-to-treat analysis, Giuseppe Chiarioni, MD, of the University of Verona, Italy, and colleagues reported online in Gastroenterology.

By comparison, the other two most commonly used treatments -- electrogalvanic stimulation and massage of the levator muscles -- resulted in symptom relief in 32.7% and 28.3% of patients (both P<0.01 versus biofeedback).

Massage was scored lowest in pain relief, leading the researchers to conclude that this treatment, though frequently recommended, "is ineffective and should be abandoned."

These chronic or recurring episodes of rectal pain or aching are often severe and are frustrating to treat, since no option works for the majority of patients, said co-author William E. Whitehead, PhD, of the University of North Carolina at Chapel Hill.

One of the most important findings of this study, he said, was that biofeedback and electrogalvanic stimulation worked only in patients with tenderness when posterior, left, and right aspects of the pelvic floor were pressed vigorously.

Restricting analysis to only those with a highly likely diagnosis of levator ani syndrome boosted the efficacy of biofeedback to 87.1% relief at one month.

In these patients, electrogalvanic stimulation helped roughly 45%, though that was not significantly higher than massage's 20% (both P<0.025 versus biofeedback).

"We would encourage physicians to incorporate this into their physical exam and to use it as a method for selecting patients for treatment," Whitehead said in an interview.

Patients without such tenderness -- the "possible" rather than "highly likely" cases of levator ani syndrome -- had no benefit from any of the treatments.

These patients might be suffering from a type of hypervigilance to pain, making them good candidates for a trial of antidepressants, Whitehead told MedPage Today.

The researchers prospectively studied 157 patients, referred to the University of Verona from 2000 through 2006, who met Rome II symptom criteria for levator ani syndrome. They all had pain at least weekly but didn't have functional constipation, irritable bowel syndrome, or other conditions or pelvic disorders that could cause similar symptoms.

Chiarioni's group randomized participants to receive a total of nine sessions of psychological counseling plus biofeedback (five sessions using protocols identical to that for dyssynergic defecation), electrogalvanic stimulation (nine 30- to 45-minute sessions of high-voltage stimulation using an intra-anal probe), or massage (three times each week for three weeks of digital pressure to the levator muscles followed by twice daily self-massage and hip baths).

At 12 months, 57.7% of biofeedback-treated patients maintained "adequate" relief compared with 26.5% of electrogalvanic stimulation-treated patients and 20.8% of massage-group patients (both P<0.01).

Among the secondary outcomes, the same pattern was seen: no benefit in any "possible" diagnosis group but significant differences between treatments in the "probable" groups favoring biofeedback and electrogalvanic stimulation for a number of days per month. Pain and intensity were measured as an average Visual Analog Scale score.

A surprising finding was that the physiological mechanism that appeared to explain the recurring pain looked similar to that of people who have difficulty evacuating the rectum, Whitehead said.

Patients with tenderness on palpation of the levator ani muscles were substantially less likely than others to be unable to evacuate a 50-mL water-filled balloon to simulate a bowel movement and failed to relax their pelvic floor muscles when straining.

Furthermore, those for whom the biofeedback and electrogalvanic treatments were effective showed significant restoration of these abilities.

The similarity to patients with dyssynergic defecation warrants further exploration, Whitehead said.

He cautioned that while biofeedback was most effective, it is also the most expensive and least available.

Electrogalvanic stimulation, for which probes are commercially available, may be the second best option, retaining a role for those who don't have access to biofeedback, the researchers noted.

The study was supported by a grant from the National Institute of Diabetes, Digestive, and Kidney Diseases.

The researchers reported no conflicts of interest.

Primary source: Gastroenterology
Source reference: Chiarioni G, et al "Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome" Gastroenterol 2010; DOI:10.1053/j.gastro.2009.12.040. ... ment/19314
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