Q J Med 1997; 90:545 550
Commentary
QJM
Biofeedback, relaxation training, and cognitive behaviour
modification as treatments for lower functional
gastrointestinal disorders
G. BASSOTTI1,2 and W.E. WHITEHEAD2
From the 1Laboratorio di MotilitÄ… 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
behaviour modification are being increasingly pro- be more likely to benefit from this therapeutic
posed for the treatment of numerous functional approach. We examine and discuss the literature
disorders of the gastrointestinal tract. Among these, studies adopting such techniques.
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
control of relevant responses can be achieved by population,4 6 and accounts for up to 50% of consul-
tations to the gastroenterologist.7,8
systematic information about a function that is not
usually monitored consciously.2 Relaxation training Several factors make IBS a candidate for psycholo-
involves teaching the patient a technique for counter- gical treatment: (i) more than 70% of IBS patients
acting the effects of stress; it does not require a have significant psychological symptoms, the most
knowledge of the pathophysiological mechanism for frequent being somatization disorder, depression,
the symptom. Cognitive-behaviour therapy is also a and anxiety;9 (ii) about 85% of IBS patients complain
stress-reduction technique which does not require a of exacerbation of symptoms under stress;10 and (iii)
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
546 G. Bassotti and W.E. Whitehead
The above considerations prompted several research- negative expectations about improvement, this study
ers to try alternative therapeutic approaches. design maximizes the probability that placebo effects
Published studies suggest that relaxation training contribute to differences between experimental and
is effective in reducing pain and diarrhoea associated control groups. An improvement of at least 50% of
with IBS. One study compared behavioural stress- symptom severity was reported in 52%16 and 64%17
management training alone with medical manage- of IBS patients receiving active treatment. After a
ment in newly-diagnosed IBS patients.12 The behavi- 1-year follow-up, 57% of patients in the first study
oural intervention included education about normal group still showed improvement of symptoms.18 A
variability in bowel function, stress-management similar multicomponent therapeutic approach was
training based on progressive relaxation exercises, used in another study, in which the authors employed
and training in self-instruction techniques to cope assertiveness training instead of thermal biofeedback
with stress. Medical management consisted of a training in addition to patient education, progressive
bulking agent, an anticholinergic, and a drug with muscle-relaxation training, and cognitive coping-
both anxiolytic and antidepressant properties. Both strategies training. Bowel symptoms improved signi-
treatments reduced abdominal pain and diarrhoea; ficantly more in the treated IBS patients than in a
however, psychological symptoms decreased signi- control group awaiting treatment. This difference was
ficantly more in the relaxation group. maintained during a 5-month follow-up period. In
Another study compared conventional medical another study by Blanchard and colleagues, IBS
treatment with relaxation training, and showed that patients were randomized to three groups:19 (i) the
the latter was associated with a significantly greater multicomponent behavioural treatment group,
reduction of pain episodes and number of medical described above; (ii) a waiting-list control group; and
consultations.13 These results were maintained (iii) an active placebo group whose member received
during 40 months follow-up period. a fake treatment intended to elicit positive ex-
In a third study, Rumsey14 reported an advantage pectations without providing effective treatment.
for a 6-week group intervention with cognitive beha- The placebo involved two components paralleling
vioural stress management as compared to 6 weeks progressive muscle relaxation and biofeedback in
of conventional pharmacological treatment (phenoti- the active treatment: pseudomeditation (patients were
azine and tricyclic antidepressants). Behavioural instructed to attend to muscle tension, but not to
stress management emphasized information relax) and biofeedback to decrease alpha EEG activ-
about IBS, progressive muscle relaxation, diet, fitness, ity. Analysis of results showed no difference between
problem-solving, and long-term management. An the placebo and treatment groups.
assessment was made at the end of the treatment Other psychological treatments have been
period and after 6-month follow-up. Medical therapy reported to be of value in IBS syndrome, including
and cognitive behavioural stress-management train- cognitive-behavioural therapy,20 cognitive therapy
ing reduced pain, bloating, anxiety, depression, and alone,21 relaxation alone,22 and interpersonal psycho-
subjective stress to a similar degree by the end of therapy.15,23 One recent review concluded that the
treatment, although at follow-up the psychological efficacy of psychological treatment for IBS has not
management showed a substantial advantage. A been established because of methodological inad-
controlled study compared six sessions of brief equacies,24 but other reviews25 suggested that psy-
psychotherapy (with relaxation as a major compon- chological interventions are useful in IBS.
ent) combined with medical therapy to medical The first attempts to use biofeedback to treat IBS
therapy alone in a large group of IBS patients.15 The aimed at modifying colonic motility patterns. In a
group receiving psychotherapy displayed greater study, an electronic stethoscope was used to teach
short- and long-term improvements. a small group of patients with diarrhoea-
Other authors have combined biofeedback to predominant IBS to alternately increase and decrease
teach relaxation with cognitive therapy techniques. bowel sounds.26 All patients reported symptom relief.
Blanchard and colleagues emphasized four compon- However, further investigations suggested a rather
ents:16,17 (i) education concerning the relationship weak treatment effect.27,28 Other authors used a
between exacerbation of bowel symptoms and psy- balloon probe to provide visual feedback on rectal
chological stress; (ii) progressive muscle-relaxation contractile activity, and reported that 14/21 IBS
training through audiotaped instructions; (iii) relaxa- patients could learn to decrease rectal motility.29 A
tion training by means of thermal biofeedback; (iv) follow-up study from the same laboratory, however,
cognitive-coping skills training to replace self- showed that a simpler stress-management technique,
defeating thoughts with more positive thinking. progressive relaxation training and systematic desens-
Outcomes in patients treated with this protocol were itization training to anxiety-arousing stimuli yielded
compared to changes observed in patients awaiting better clinical results as compared to pressure bio-
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
treatment of IBS. better clinical outcomes than those related to the
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-
A normal defaecatory act involves relaxation of two back treatment cures patients with normal or mildly
usually contracted muscles, the puborectalis and the impaired recto-anal sensitivity, but not those in
external anal sphincter, to allow the rectum to funnel whom sensitivity is severely impaired. The success
into the anal canal and stool to pass. However, some of biofeedback was attributed to restoration of normal
chronically constipated patients display a paradoxical defaecation dynamics.38 Another uncontrolled study
contraction of the puborectalis and the external anal in encopretic children reported a success rate of
sphincter during attempts to defaecate.31 This 100% by the end of the study, with no relapses
during a follow-up period of up to 22 months.39 In
 obstructed defaecation was named  anismus , in
analogy to  vaginismus , although a more appropriate a controlled study, Cox and colleagues40 reported a
definition is pelvic floor dyssynergia.32 Pelvic floor significant greater improvement in children with
dyssynergia is associated with symptoms of straining additional biofeedback compared to laxative treat-
and feelings of incomplete evacuation, and it has ment alone. However, the above studies all included
been suggested that it may contribute to complaints relatively small groups of patients.
of constipation in about 50% of chronically constip- In a recent controlled study in a large group of
ated patients.33 Straining and feelings of incomplete patients,41 additional biofeedback training compared
evacuation are also frequently found in patients with to conventional therapy did not result in higher
anxiety and other types of psychological distress.34 success rates in chronically constipated children.
Pelvic floor dyssynergia, characterized by inappro- Moreover, achievement of normal defaecation
priate contraction of striated muscles, is particularly dynamics was not associated with success. The
suitable for biofeedback. authors concluded that abnormal defaecation
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
straining were randomly assigned to biofeedback adults, who were asked to defaecate a simulated
training, in which they were instructed to relax and faecal bolus while seated on a commode chair.42
to decrease the pressure in the external anal balloon Pressure recordings were displayed on a computer
while straining to defaecate. The remaining patients screen, and patients were instructed to bear down
were given daily doses of mineral oil. Although several times on the bolus without excessive effort
outcomes were similar for the two groups at the end while either not increasing anal pressure or decreas-
of treatment, at 6- and 12-month follow-up, patients ing it. Looking at the computer screen while per-
with pelvic floor dyssynergia prior to training tended forming constituted visual reinforcement, and verbal
to benefit more from biofeedback than from mineral reinforcement helped patients to understand patho-
oil. Patients with other causes of encopresis had physiology and paradoxical striated sphincter con-
more benefits from mineral oil than from biofeed- traction. The patients were then instructed to relax
back. A second controlled study in encopretic chil- the sphincter during expulsion and to avoid straining
dren showed more definitive results. Encopretic at home. This treatment was effective in 11/16
children with pelvic floor dyssynergia were given patients, and the gains were maintained at 12-month
either conventional laxative treatment (milk of mag- follow-up in 9 patients. The remaining 7 reported
nesia) or biofeedback plus laxative therapy.36 After easier defaecation than before training. This and
an average of three biofeedback training sessions, other studies43 46 suggest that biofeedback is often
86% of the children receiving this treatment learned effective for the treatment of pelvic floor dyssynergia
to relax the external anal sphincter during attempts and other forms of constipation.47
to defecate. At 7- and 12-month follow-up, the More recently, a few controlled investigations
percentage of children judged to be recovered was were available for adult patients also. In one study, 11
significantly greater for the biofeedback group than patients received electromyographic (EMG) biofeed-
for the laxative-only group. It was thus suggested back and 9 balloon biofeedback.48 The results suggest
that most children with pelvic floor dyssynergia can that EMG biofeedback is the more effective for
learn normal sphincteric response during defaec- treating this condition. Another study on 60 patients
548 G. Bassotti and W.E. Whitehead
with intractable constipation compared the outcome are some promising although uncontrolled studies,
of muscular training without any biofeedback device such as that of Grimaud and colleagues.69 By means
with the same training supplemented by an EMG of a visual biofeedback technique, these authors
record visible to the patients.49 The outcome was taught patients with levator ani syndrome to reduce
similar in the two treatment groups. The authors anal canal pressures. After a 2-month treatment
concluded that muscular coordination training using period, pain relief was obtained for all patients
personal instruction and encouragement without investigated, and it was maintained in 11/12 patients
visual display may be a potentially successful treat- after a 16-month follow-up. It is worth noting that
ment suitable for outpatient use by paramedical pain relief was accompanied by decreased resting
personnel. pressure in the anal canal.
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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