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Beyond Biofeedback – Drs Elmer and Alyce Green

Engel, Nikoomanesh, and Schuster (1974) report on the use of biofeedback and verbal reinforcement in treating six adult patients with severe fecal incontinence of from three to eight years' duration and a six-year-old child who had been incontinent from birth.

The treatment consisted of three phases.

Phase 1 consisted of diagnostic procedures to determine the severity of impairment of recto-sphincteric reflexes. The external-sphincter response was either diminished or absent in all patients. The nature of the normal rectosphincter reflex and the way his or her response differed from normal was explained to each adult patient. Electrical outputs from devices positioned at the internal and external sphincters were amplified and recorded by a direct-wiring poly graph.

In Phase 2 instantaneous biofeedback was initiated by allowing the patient to watch the tracings on the polygraph record of the sphincter responses as they occurred. He or she was reminded of how they differed from normal, encouraged to modify them toward normal, told when the responses were poor, and praised when they were good. Verbal reinforcement was diminished as the patient learned what was expected and was able to affect the sphincter response.

Phase 3 consisted of refinement of motor control of sphincteric response and weaning the patient away from dependence on the equipment by intermittently asking the patient to perform without feedback for a number of trials and then allowing him to again observe his performance on the polygraph.

Each training session consisted of about fifty training trials in a two-hour period, interrupted by a ten-minute break. During the three weeks between training sessions patients were asked to assess the effectiveness of the training in helping them to remain continent. This assessment continued after training was completed. Patients were interviewed every three months until they had maintained bowel control over a six-month period, after which they were interviewed yearly. Follow-up periods range from three months to five years.

All patients (except one) completed training within four sessions or less. Four have remained completely continent, one nearly so. One patient withdrew after the first session. The child was trained to relax her internal sphincter as well as to control her external sphincter. She not only learned continence but also to have normal voluntary bowel movements, which she had never had before training.