Q J Med 1997; 90:545–550

Commentary

QJM

Biofeedback, relaxation training, and cognitive behaviour
modification as treatments for lower functional
gastrointestinal disorders

G. BA SS OTTI

1,2 and W.E. WHITEHEA D2

From the

1Laboratorio di Motilita` Intestinale, Clinica di Gastroenterologia ed Endoscopia

Digestiva, Dipartimento di Medicina Clinica, Patologia e Farmacologia, Universita’ di Perugia,
Italy; and

2University of North Carolina Center for Functional Gastrointestinal Diseases and

Division of Digestive Diseases and Nutrition, Department of Medicine, University of North
Carolina at Chapel Hill, Chapel Hill, USA

Summary

Biofeedback, relaxation training, and cognitive

those related to the lower part of the gut seem to
be more likely to benefit from this therapeutic

behaviour modification are being increasingly pro-
posed for the treatment of numerous functional

approach. We examine and discuss the literature
studies adopting such techniques.

disorders of the gastrointestinal tract. Among these,

Introduction

Biofeedback, relaxation training, and cognitive

Irritable bowel syndrome

behaviour modification are increasingly recognized

Irritable bowel syndrome (IBS) is a disorder character-

as helpful treatment strategies for functional gastroin-

ized by abdominal pain or discomfort, relieved by

testinal disorders in which stress plays an important

defaecation, associated with a change in the fre-

role in eliciting or exacerbating symptoms. This is

quency of consistency of stools and a varying pattern

particularly true of functional disorders of the colon,

of defaecation (altered stool frequency, altered stool

rectum and anus, which represent about 50% of the

form, altered stool passage, passage of mucus) at

overall functional disorders observed in the popula-

least 25% of the time.

3 IBS is a very common

tion.

1 Biofeedback is appropriate when specific

disorder, being present in 8–20% of the general

pathopysiological mechanisms are known and the

population,

4–6 and accounts for up to 50% of consul-

control of relevant responses can be achieved by

tations to the gastroenterologist.

7,8

systematic information about a function that is not

Several factors make IBS a candidate for psycholo-

usually monitored consciously.

2 Relaxation training

gical treatment: (i) more than 70% of IBS patients

involves teaching the patient a technique for counter-

have significant psychological symptoms, the most

acting the effects of stress; it does not require a

frequent being somatization disorder, depression,

knowledge of the pathophysiological mechanism for

and anxiety;

9 (ii) about 85% of IBS patients complain

the symptom. Cognitive-behaviour therapy is also a

of exacerbation of symptoms under stress;

10 and (iii)

stress-reduction technique which does not require a
knowledge of the pathophysiology.

available medical treatments are often ineffective.

11

Address correspondence to Dr G. Bassotti, Clinica di Gastroenterologia ed Endoscopia Digestiva, Policlinico Monteluce,
06100 Perugia, Italy

© Oxford University Press 1997

G. Bassotti and W.E. Whitehead

546

The above considerations prompted several research-

negative expectations about improvement, this study
design maximizes the probability that placebo effects

ers to try alternative therapeutic approaches.

Published studies suggest that relaxation training

contribute to differences between experimental and
control groups. An improvement of at least 50% of

is effective in reducing pain and diarrhoea associated
with IBS. One study compared behavioural stress-

symptom severity was reported in 52%

16 and 64%17

of IBS patients receiving active treatment. After a

management training alone with medical manage-
ment in newly-diagnosed IBS patients.

12 The behavi-

1-year follow-up, 57% of patients in the first study
group still showed improvement of symptoms.

18 A

oural intervention included education about normal
variability in bowel function, stress-management

similar multicomponent therapeutic approach was
used in another study, in which the authors employed

training based on progressive relaxation exercises,
and training in self-instruction techniques to cope

assertiveness training instead of thermal biofeedback
training in addition to patient education, progressive

with stress. Medical management consisted of a
bulking agent, an anticholinergic, and a drug with

muscle-relaxation training, and cognitive coping-
strategies training. Bowel symptoms improved signi-

both anxiolytic and antidepressant properties. Both
treatments reduced abdominal pain and diarrhoea;

ficantly more in the treated IBS patients than in a
control group awaiting treatment. This difference was

however, psychological symptoms decreased signi-
ficantly more in the relaxation group.

maintained during a 5-month follow-up period. In
another study by Blanchard and colleagues, IBS

Another study compared conventional medical

treatment with relaxation training, and showed that

patients were randomized to three groups:

19 (i) the

multicomponent

behavioural

treatment

group,

the latter was associated with a significantly greater
reduction of pain episodes and number of medical

described above; (ii) a waiting-list control group; and
(iii) an active placebo group whose member received

consultations.

13 These results were maintained

during 40 months follow-up period.

a fake treatment intended to elicit positive ex-
pectations without providing effective treatment.

In a third study, Rumsey

14 reported an advantage

for a 6-week group intervention with cognitive beha-

The placebo involved two components paralleling
progressive muscle relaxation and biofeedback in

vioural stress management as compared to 6 weeks
of conventional pharmacological treatment (phenoti-

the active treatment: pseudomeditation (patients were
instructed to attend to muscle tension, but not to

azine and tricyclic antidepressants). Behavioural
stress

management

emphasized

information

relax) and biofeedback to decrease alpha EEG activ-
ity. Analysis of results showed no difference between

about IBS, progressive muscle relaxation, diet, fitness,
problem-solving, and long-term management. An

the placebo and treatment groups.

Other

psychological

treatments

have

been

assessment was made at the end of the treatment
period and after 6-month follow-up. Medical therapy

reported to be of value in IBS syndrome, including
cognitive-behavioural therapy,

20 cognitive therapy

and cognitive behavioural stress-management train-
ing reduced pain, bloating, anxiety, depression, and

alone,

21 relaxation alone,22 and interpersonal psycho-

therapy.

15,23 One recent review concluded that the

subjective stress to a similar degree by the end of
treatment, although at follow-up the psychological

efficacy of psychological treatment for IBS has not
been established because of methodological inad-

management showed a substantial advantage. A
controlled study compared six sessions of brief

equacies,

24 but other reviews25 suggested that psy-

chological interventions are useful in IBS.

psychotherapy (with relaxation as a major compon-
ent) combined with medical therapy to medical

The first attempts to use biofeedback to treat IBS

aimed at modifying colonic motility patterns. In a

therapy alone in a large group of IBS patients.

15 The

group receiving psychotherapy displayed greater

study, an electronic stethoscope was used to teach
a

small

group

of

patients

with

diarrhoea-

short- and long-term improvements.

Other authors have combined biofeedback to

predominant IBS to alternately increase and decrease
bowel sounds.

26 All patients reported symptom relief.

teach relaxation with cognitive therapy techniques.
Blanchard and colleagues emphasized four compon-

However, further investigations suggested a rather
weak treatment effect.

27,28 Other authors used a

ents:

16,17 (i) education concerning the relationship

between exacerbation of bowel symptoms and psy-

balloon probe to provide visual feedback on rectal
contractile activity, and reported that 14/21 IBS

chological stress; (ii) progressive muscle-relaxation
training through audiotaped instructions; (iii) relaxa-

patients could learn to decrease rectal motility.

29 A

follow-up study from the same laboratory, however,

tion training by means of thermal biofeedback; (iv)
cognitive-coping skills training to replace self-

showed that a simpler stress-management technique,
progressive relaxation training and systematic desens-

defeating thoughts with more positive thinking.
Outcomes in patients treated with this protocol were

itization training to anxiety-arousing stimuli yielded
better clinical results as compared to pressure bio-

compared to changes observed in patients awaiting
treatment. Since patients awaiting treatment have

feedback.

30 Therefore, biofeedback aimed at modify-

Biofeedback for lower functional GI disorders

547

ing colonic motility cannot be recommended for the

ation, and that this learning is associated with a
better clinical outcomes than those related to the

treatment of IBS.

laxatives alone. The same authors also evaluated
anorectal and psychological factors associated with
treatment failure,

37 and concluded that correcting

Pelvic floor dyssynergia

abnormal contractions of the pelvic floor by biofeed-
back treatment cures patients with normal or mildly

A normal defaecatory act involves relaxation of two

impaired recto-anal sensitivity, but not those in

usually contracted muscles, the puborectalis and the

whom sensitivity is severely impaired. The success

external anal sphincter, to allow the rectum to funnel

of biofeedback was attributed to restoration of normal

into the anal canal and stool to pass. However, some

defaecation dynamics.

38 Another uncontrolled study

chronically constipated patients display a paradoxical

in encopretic children reported a success rate of

contraction of the puborectalis and the external anal

100% by the end of the study, with no relapses

sphincter during attempts to defaecate.

31 This

during a follow-up period of up to 22 months.

39 In

‘obstructed’ defaecation was named ‘anismus’, in

a controlled study, Cox and colleagues

40 reported a

analogy to ‘vaginismus’, although a more appropriate

significant greater improvement in children with

definition is pelvic floor dyssynergia.

32 Pelvic floor

additional biofeedback compared to laxative treat-

dyssynergia is associated with symptoms of straining

ment alone. However, the above studies all included

and feelings of incomplete evacuation, and it has

relatively small groups of patients.

been suggested that it may contribute to complaints

In a recent controlled study in a large group of

of constipation in about 50% of chronically constip-

patients,

41 additional biofeedback training compared

ated patients.

33 Straining and feelings of incomplete

to conventional therapy did not result in higher

evacuation are also frequently found in patients with

success rates in chronically constipated children.

anxiety and other types of psychological distress.

34

Moreover, achievement of normal defaecation

Pelvic floor dyssynergia, characterized by inappro-

dynamics was not associated with success. The

priate contraction of striated muscles, is particularly

authors

concluded

that

abnormal

defaecation

suitable for biofeedback.

dynamics seem not to play a crucial role in the
pathogenesis of chronic constipation.

Studies in children

The first controlled study was carried out in encopre-

Studies in adults

tic children.

35 Half of patients with dyssynergia and

half of those with normal pelvic floor responses to

An uncontrolled study investigated 16 constipated
adults, who were asked to defaecate a simulated

straining were randomly assigned to biofeedback
training, in which they were instructed to relax and

faecal bolus while seated on a commode chair.

42

Pressure recordings were displayed on a computer

to decrease the pressure in the external anal balloon
while straining to defaecate. The remaining patients

screen, and patients were instructed to bear down
several times on the bolus without excessive effort

were given daily doses of mineral oil. Although
outcomes were similar for the two groups at the end

while either not increasing anal pressure or decreas-
ing it. Looking at the computer screen while per-

of treatment, at 6- and 12-month follow-up, patients
with pelvic floor dyssynergia prior to training tended

forming constituted visual reinforcement, and verbal
reinforcement helped patients to understand patho-

to benefit more from biofeedback than from mineral
oil. Patients with other causes of encopresis had

physiology and paradoxical striated sphincter con-
traction. The patients were then instructed to relax

more benefits from mineral oil than from biofeed-
back. A second controlled study in encopretic chil-

the sphincter during expulsion and to avoid straining
at home. This treatment was effective in 11/16

dren showed more definitive results. Encopretic
children with pelvic floor dyssynergia were given

patients, and the gains were maintained at 12-month
follow-up in 9 patients. The remaining 7 reported

either conventional laxative treatment (milk of mag-
nesia) or biofeedback plus laxative therapy.

36 After

easier defaecation than before training. This and
other studies

43–46 suggest that biofeedback is often

an average of three biofeedback training sessions,
86% of the children receiving this treatment learned

effective for the treatment of pelvic floor dyssynergia
and other forms of constipation.

47

to relax the external anal sphincter during attempts
to defecate. At 7- and 12-month follow-up, the

More recently, a few controlled investigations

were available for adult patients also. In one study, 11

percentage of children judged to be recovered was
significantly greater for the biofeedback group than

patients received electromyographic (EMG) biofeed-
back and 9 balloon biofeedback.

48 The results suggest

for the laxative-only group. It was thus suggested
that most children with pelvic floor dyssynergia can

that EMG biofeedback is the more effective for
treating this condition. Another study on 60 patients

learn normal sphincteric response during defaec-

G. Bassotti and W.E. Whitehead

548

with intractable constipation compared the outcome

are some promising although uncontrolled studies,
such as that of Grimaud and colleagues.

69 By means

of muscular training without any biofeedback device
with the same training supplemented by an EMG

of a visual biofeedback technique, these authors
taught patients with levator ani syndrome to reduce

record visible to the patients.

49 The outcome was

similar in the two treatment groups. The authors

anal canal pressures. After a 2-month treatment
period, pain relief was obtained for all patients

concluded that muscular coordination training using
personal instruction and encouragement without

investigated, and it was maintained in 11/12 patients
after a 16-month follow-up. It is worth noting that

visual display may be a potentially successful treat-
ment suitable for outpatient use by paramedical

pain relief was accompanied by decreased resting
pressure in the anal canal.

personnel.

Levator ani syndrome and proctalgia

Conclusions

fugax

From this review of literature, it is suggested that
biofeedback may constitute a valid alternative thera-

The levator ani syndrome is defined by a vague, dull

peutic approach for the treatment of patients with

ache or sensation of pressure localized high in the

constipation related to an inability to relax the

rectum, associated with difficult defaecation, strain-

striated pelvic floor muscle during attempts to defaec-

ing, and feelings of incomplete defaecation.

50,51 The

ate. It remains to be demonstrated whether biofeed-

prevalence of levator ani syndrome in the general

back will prove to be generally useful in treating

population is about 7%

52 and symptoms are more

constipation related to dyssynergia, or whether its

frequent in women than in men in the age range

utility will be limited to those patients with normal

40–60 years.

53,54 Diagnosis relies on clinical grounds,

or mildly impaired rectal or anal sensitivity. Further

and the diagnostic yield increases if posterior traction

studies are also needed to show whether biofeedback

on the puborectalis reveals tight levator ani muscles

may represent a first-line therapeutic approach to

and tenderness or pain. Psychological tension, stress,

levator

ani

syndrome

and

proctalgia

fugax.

and anxiety are sometimes associated with this

Biofeedback does not seem to be useful for the

syndrome,

55 although no systematic psychiatric

treatment of IBS, but relaxation training and cognitive

evaluation has been reported.

behaviour therapy do appear to be helpful.

Proctalgia fugax is an idiopathic disorder charac-

terized (in the absence of any other anorectal disease)
by recurring attacks of intense anorectal pain, occur-
ring at irregular intervals—typically

<6 episodes/

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