The effectiveness of biofeedback therapy in managing Bladder Bowel Dysfunction in children: A systematic review

Abstract

PURPOSE:

The purpose of this study was to examine the effects of biofeedback therapy as a non-invasive intervention to treat Bladder Bowel Dysfunction in pediatrics.

METHODS:

Six databases were searched between February 2016 and September 2016. Biofeedback studies for children aged 4–16 with idiopathic urinary or fecal incontinence were included. Articles were excluded on subjects’ medical histories, study design, timeline of study, and lacking expert review. Quality was determined using Sackett’s Levels of Evidence and the PEDro scale.

RESULTS:

Twelve articles were included in the review. Quality of evidence was moderate, as the average PEDro score of the selected articles was 5.3. The participants’ ages ranged from 4–16 years old. Studies demonstrated that a multifactorial approach consisting of biofeedback therapy and behavioral modification can be successful in resolving Bladder Bowel Dysfunction.

CONCLUSION:

Biofeedback is a beneficial treatment for children with dysfunctional voiding and functional fecal incontinence. More conclusive research needs to be completed to explore the effects of biofeedback therapy treatment to make more concrete conclusions. Healthcare professionals should consider biofeedback as an alternative approach in conjunction with traditional treatments. A multidisciplinary approach is best when treating dysfunctional voiding and functional fecal incontinence in the pediatric population.

1. Introduction

The term Bladder Bowel Dysfunction (BBD) encompasses both lower urinary tract (LUT) dysfunction and bowel dysfunction. The International Children’s Continence Society (ICCS) suggests that because the LUT and bowel have a close functional relationship that these systems should be grouped together [1]. BBD is common among school-aged children. The cause of BBD may be neurogenic or nonneurogenic. One disorder under the umbrella of BBD is dysfunctional voiding. Dysfunctional voiding is defined as habitual abnormal contraction of the urethral sphincter or pelvic floor during voiding [1, 2]. It is often the result of overactive pelvic floor muscles and excessive tightening of the urethral sphincter [1]. When this occurs, the common result is incomplete bladder emptying. Secondary symptoms include overflow or urge incontinence and urinary tract infection.

As mentioned earlier, concomitant bowel dysfunction may be seen with dysfunctional voiding. Studies have found that both disorders are closely related in the pediatric population. Functional fecal incontinence, also commonly referred to as encopresis, is defined as voluntary and involuntary passage of feces in inappropriate places in a child 4 years or older [2]. Further, like dysfunctional voiding, functional fecal incontinence may be caused by abnormal contractions of the associated external sphincter. Children with functional fecal incontinence often have chronic constipation and painful bowel movements. Cox et al. [3] suggests that this may be due to avoiding the bathroom and/or failing to maintain adequate intra-abdominal pressure during defection.

In addition to physical discomfort, children with dysfunctional voiding and functional fecal incontinence can experience emotional anguish in social situations or public places due to soiling or wetting their undergarments. Children who experience urinary or fecal incontinence in public are at higher risk for peer rejection and teacher alienation. Further, untimely urination and bowel movements may lead to undue parental punishment. This may result in deeper emotional issues such as humiliation, decreased self-esteem, familial estrangement, and withdrawal from social activities and friends [3].

According to the ICCS [1, 2], standard therapy for BBD consists of urotherapy. Urotherapy is a non-invasive, conservative treatment of lower urinary tract dysfunction. Standard therapy includes five basic components that include a variety of professionals. The five components include: providing information about the dysfunction and demystifying it, providing instruction on resolving the dysfunction, advising the patient on lifestyle changes, teaching the patient how to use a voiding diary, and providing support and encouragement from the caregiver [1]. In addition to previously mentioned factors, standard urotherapy can also include pelvic floor retraining, behavioral therapy, and psychotherapy if the standard proves ineffective for the child.

Biofeedback therapy is a readily available, non-invasive technique in treating pediatric pelvic floor dysfunction. Biofeedback used as a physical therapy intervention attempts to train the appropriate pelvic muscle activity necessary for normal bowel and bladder function. Two main types of biofeedback utilized by therapists in treating these dysfunctions are electromyography (EMG) and uroflow. EMG biofeedback tends to be used with functional fecal incontinence, while both uroflow or EMG biofeedback is used for dysfunctional voiding [4]. The treatment methods consist of training the child through video-like games, which provides direct feedback to relax previously contracted sphincters during bowel movements and urination. Though it has been shown to be effective in the treatment of women with pelvic floor disorders, there is a discrepancy regarding the effectiveness of biofeedback therapy in the pediatric population.

2. Purpose

Previous systematic reviews of the effectiveness of biofeedback for dysfunctional voiding and functional fecal incontinence have been conducted. However, they were either comprised of mostly low-level evidence or limited amounts of evidence [5, 6]. The authors felt that an updated systematic review was warranted. The purpose of this study was to examine the effects of biofeedback therapy as a non-invasive intervention to treat dysfunctional voiding and functional fecal incontinence in pediatric patients.

3. Methods

3.1 Study identification

Two searches of the literature were performed to identify appropriate articles for the review. The first search was completed between February and March 2016, and the second during September 2016 using PEDro, PubMed, and EBSCO (Medline, CINAHL) databases. Search terms used were “biofeedback,” “child”, or “children”, in combination with “voiding”, “encopresis”, “incontinence”, and “dysfunctional voiding”. See Fig. 1.

Figure 1.

Methods.

3.2 Study selection

The inclusion criteria were 1) children with dysfunctional voiding, incontinence, and/or encopresis, 2) biofeedback as an intervention, 3) peer-reviewed articles, and 4) PEDro score four or greater [7]. Exclusion criteria for articles included 1) subjects with a neurological or congenital disorder and/or prior pertinent surgeries, 2) systematic reviews without meta-analyses, 3) were written prior to 1995, or 4) had hierarchy level of evidence four and below [8].

3.3 Validity assessment

The authors determined the validity of the individual studies utilizing the 10-point scale according to PEDro [7]. The PEDro scale is a measure of the methodological quality of clinical trials. After independently rating each article for their PEDro score, the authors conferred to discuss the ratings of each article and agreed upon a score. See Table 1. The authors determined that studies scoring below 4/10 on the PEDro scale were excluded from the study in order to incorporate the most credible information in the systematic review. Each article was also assessed independently for its level of evidence according to Sackett [8], and the authors again conferred on the scores. This information is presented in Table 2.

Table 1

PEDro Scale Results ${}^7$

	Eligibility	Random	Concealed	Baseline	Blind	Blind
	criteria ${}^{*}$	allocation	allocation	comparability	subjects	therapists
Van der Plas 1996	1	1	1	1	0	0
Cox 1998	1	1	0	1	0	0
Nolan 1998	1	1	1	1	0	0
Borowitz 2002	1	1	0	1	0	0
Croffie 2005	1	1	0	1	0	0
Klijn 2006	1	1	1	1	0	0
Khen-Dunlop 2006	1	0	0	1	0	0
Vasconcelos 2006	0	1	0	1	0	0
Kajbafzadeh 2011	0	1	0	1	0	0
Zeng 2012	1	1	0	0	0	0
Ladi-Seyedian 2015	1	1	0	1	0	0
Tugtepe 2015	1	0	0	1	0	0
	Blind	Adequate	Intention to	Between-group	Point estimates	Total ${}^{**}$
	assessors	follow-up	treat analysis	comparisons	and variability
Van der Plas 1996	0	1	0	1	1	6/10
Cox 1998	0	1	0	1	1	5/10
Nolan 1998	1	1	0	1	1	7/10
Borowitz 2002	0	1	0	1	1	5/10
Croffie 2005	0	1	0	1	1	5/10
Klijn 2006	0	1	1	1	1	7/10
Khen-Dunlop, 2006	0	1	1	0	1	4/10
Vasconcelos 2006	0	1	0	1	1	5/10
Kajbafzadeh 2011	0	1	0	1	1	5/10
Zeng 2012	1	1	1	1	1	6/10
Ladi-Seyedian 2015	0	1	0	1	1	5/10
Tugtepe 2015	0	1	0	1	1	4/10

Key: One point for every criteria met. Criteria: 1) Eligibility criteria were specified ( ${}^{*}$ does NOT contribute to total score), 2) Subjects were randomly allocated to groups, 3) Allocation was concealed, 4) Groups were similar at baseline regarding the most important prognostic indicators, 5) There was blinding of all subjects, 6) There was blinding of all therapists who administered the therapy, 7) There was blinding of all assessors who measured at least one key outcome, 8) Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups, 9) All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analyzed by “intention to treat”, 10) The results of between-group statistical comparisons are reported for at least one key outcome, 11) The study provides both point measures and measures of variability for at least one key outcome.

4. Results

Thirty seven articles, according to their titles and abstracts, were identified by the authors to be relevant to this systematic review. Twelve out of the 37 articles were chosen based on the inclusion and exclusion criteria and were critically analyzed. Ten of the selected articles were randomized control trials (RCT) studies [3, 9, 10, 11, 12, 13, 14, 15, 16, 17], one was a comparative study [18], and one was a cohort study [19]. See Table 2. The participants’ ages ranged from 4–16 years old. The average PEDro score of the selected articles was 5.3.

In the reviewed articles, the results varied on the effectiveness of biofeedback in children with two separate diagnoses: dysfunctional voiding and functional fecal incontinence. In the majority of articles, the results were positive for biofeedback contributing to improvements in dysfunctional voiding, whereas the results were inconclusive for functional fecal incontinence. There was no defined difference in effectiveness of biofeedback with relation to older participants as compared to younger participants. Each of the studies had its own definition of “standard therapy” which may or may not have aligned with the definition provided by the ICCS. The following results are organized according to diagnoses and the alternative therapies applied.

4.1 Dysfunctional voiding

Of the 12 articles analyzed, seven examined the effects of biofeedback on dysfunctional voiding. Outcomes analyzed included urine flow, voiding episodes, post-void volume, flow curve, maximum urine, voiding time, and urinary tract infection (UTI) occurrence. All of the articles cited improvements in voiding as a result of biofeedback, although significant differences were not attained when compared to standard therapy. In a study by Zeng et al. [18], biofeedback helped to resolve 16 cases compared to six in a pharmacologic comparison group, suggesting that biofeedback be the first intervention attempted for children specifically with post-urination dribbling. In a study by Ladi-Seyedian et al. [16], animated biofeedback significantly improved voiding episodes, voiding time, and maximum urine flow in patients who underwent biofeedback training compared to patients who underwent only standard urotherapy at six months and one year after treatment. Although none of these studies had detrimental side effects, the effectiveness varied anywhere from measurable results to simply improve-

Table 2

Question: What is the effectiveness of Biofeedback therapy in managing Bowel Bladder Dysfunction in children?

	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
Van der Plas 1996	Randomized Control Trial (1b)	6	71 children (5–16 y/o males and females) Conventional treatment group; 32 children Treatment group with biofeedback training; 39 children Control group; 21 children	Each group received dietary and toilet advice, enemas, laxatives, and anorectal manometry One group also received 5 biofeed- back training sessions Conducted for 6 weeks with intensive treatment	PC Polygraph HR preamplifiers Electromyography (EMG) biofeed- back records Parents and school teachers completed child behavior checklist (CBCL)	Normal defecation dynamics increased to 86% in biofeedback (BF) training and to 74% in the laxative alone group After 6 weeks, successful treatment was estimated in 39% of children in BF group and in 19% of those in laxa- tive alone group Scores on CBCL were comparable for children in BF group and laxative group BF training did not result in significantly higher success rates than conventional treatment group Overall success rate of about 50% in both treatment groups	Subjects were poorly defined, as were the groups Subjects did not show homogeneity; some received special school education while others did not Focused more on psych- ological aspects than BF and conventional training	BF training in children appears to be more successful initially than treatment with laxatives alone, but in long term, both tend to improve Children with encopresis gain from treatment consisting of attention, toilet training, and laxatives Successful treatment is also effective in improving behavioral problems
Cox 1998	Randomized Control Trial (1b)	5	87 children (6–15 y/o males and females) Intensive Medical Care (IMC) Enhanced Toilet Training (ETT) $+$ IMC Biofeedback (BF) $+$ ETT $+$ IMC	IMC: enemas, laxa- tives in beginning. Fluid, foods con- taining fiber later. ETT: enemas, laxatives, incentive programs, hand feedback, instruction. BF: same instruc- tions as above, and simultaneous electromyographic BF training All groups conducted for three months from baseline	Recording by computerized telephone voice mail system; included daily soiling, etc. Pain on 5 point Likert scale	All groups had significant pre-post reduction in soiling Reduction in soiling for ETT and BF were superior to IMC and equivalent Mean percent reduction in IMC, ETT, and BF were 21%, 76%, and 65% ETT required fewer treatments and was less expensive Reduction in soiling was significantly related to parental-prompted toileting, increase in bowel movements, and reduction in defecation pain	Number of treatment sessions was open-ended Sessions were scheduled- led every 1–2 weeks on an “as needed” basis Data did not allow an answer as to why BF (containing everyth- ing ETT had) was less effective	Early response to treatment predicted eventual response to treatment, except with ETT, which improved Laxative therapy should be paired with enhanced toilet training BF may be better introduced after toilet training is established

Table 2, continued
	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
Nolan 1998	Randomized Control Trial (1b)	7	29 children with anismus (4–14 y/o males and females) EMG biofeedback training and con- ventional medical treatment (BFT); 14 children Conventional medical treatment alone (control); 15 children	BFT: Up to four sess- ions at weekly inter- vals of EMG biofeed- back, consisting of 30– 35 defecation attempts. Verbal reinforcement of skills at monthly inter- vals by pediatrician. Both: medication use was decreased to con- sistent level and diary monitoring.	Before randomiza- tion and at follow up 6 months later Anorectal manom- etry EMG biofeedback records Parents completed CBCL	At follow up, 2 of 14 in BFT and 2 of 15 in control were laxative free; only 1 of these 4 (BFT) group did not exhibit anismus BFT: remission or improv- ement occurred in 4. Dem- onstrated anismus was still present in 6. Control: remission or improvement occurred in 6. Demonstrated anismus was still present in 11. Significant improvement in school CBCL scores in BFT group	Successful and sustained BF outcomes were not occurring; revised sample size had to be calculated Detailed report on clinical characteristics of subjects was published elsewhere and not included Further sessions could have potentially improved study outcome	No lasting benefit clin- ically for BF training in children with encopre- sis and abnormal defec- ation tendencies (anismus). BF training did improve child behavior in sch- ool, but unsure as to why.
Borowitz 2002	Randomized Control Trial (1b)	5	87 children (5–13 y/o male & female) 29 IMT (intensive medical therapy) 27 ETT (enhanced toilet training) 31 BF (biofeedback)	IMT group – received enemas with laxative therapy ETT group-received IMT treatment plus reduction in laxatives with proper behavior. Incentive programs and parent/child education used BF group – IMT and ETT interventions in addition to BF of the anal sphincter	Automated Patient Symptom Monitor system computerized telephone voicemail system	All 3 groups had statisti- cally significant and comparable decreases in frequency of soiling. Number of children cured did not significantly differ between groups. ETT group significantly benefited more children with less laxatives and trend toward fewer sessions.	BF therapy focused too much on anal function rather than the overall effects on toileting behavior	Although all groups were effective, the addition of BF did not prove effective. All 3 groups had similar 1 year total cure rates with ETT group showing significantly lower daily frequency of soiling for the greatest number of children.
Croffie 2005	Randomized Control Trial (1b)	5	36 children (6–14 y/o males and females) Group 1: BF therapy in motility lab alone group; 24 children Group 2: BF therapy in motility lab and at home group; 12 children	Had 5 sessions of BF at 2 week intervals for 30 minutes each At home, did 25 minute BF sessions of squeeze, relax, and push exercises each day	MyoTrac EMG biofeedback device Sandhill Anorectal menometry kit Daily log of bowel movements Long term follow- up by telephone/ mailed in question- naires	Mean number of bowel movements per week increased in all patients Soiling decreased in all patients Laxative use decreased in all patients At 2 month follow-up, 71% in group 1 and 83% in group 2 had recovered At 4 months, 92% in group 1 and 83% in group 2 had recovered	Large involvement of male subjects (30); not very generalizable to females Performing BF in the motility lab placed limits on the frequency of prac- tice More parental support was given to group with BF training at home, which was not researched	Biofeedback can be a useful addition to conventional therapy Supplemental home biofeedback therapy does not improve long term recovery

Table 2, continued
	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
						No significant difference was found between BF therapy in lab alone and BF therapy in lab and at home at all follow-up periods
Khen- Dunlop 2006	Cohort (2b)	4	60 children Ages 5–14 48 girls 12 boys Within groups design Biofeedback using surface perineal electrodes Exercises focusing on relaxation of perineum	All participants received 10 weekly sessions Instructions for pelvic floor training, toileting, and posture	At home chart of voiding frequency and liquid intake Assessment before and after 6 month period from last session	96% of participants with daytime incontinence and 83% of participants with night-time incontinence were asymptomatic or improved after treatment 84% of participants were free from infection vesicoureteral reflux (VUR) resolved in 50% of participants 8% with daytime incontin- ence & 33% with night- time incontinence relapsed	No randomization into groups Within groups design Short follow up of 6 months Small sample size	Biofeedback therapy is a viable treatment for dysfunctional voiding Improvement in only secondary enuresis; not primary Further studies need to be done
Klijn 2006	Randomized Control Trial (1b)	7	143 children Standard therapy group; 44 children Home video group; 46 children Uroflowmetry biofeedback group; 53 children	All groups had standard therapy (outpatient behavioral therapy) for 8 weeks For proceeding 16 weeks: One group continued with standard therapy Other group had home video instructions Other group had uroflowmetry BF	Presence of incon- tinence and any urinary infections at 12 months after randomization	Home uroflowmetry group had urinary relief and inf- ection relief results that were better compared to the other two groups, but no associations were statistically significant Results of resolution of urinary incontinence were better with video instruc- tions and home uroflowm- etry compared to standard treatment, but not statistically significant	Technical problems occu- rred during the study with new home uroflowmeter; had to give instruction by telephone to parents Same therapist instructed all interventions and supervised trainings Study was open, with possible biased observations	Appears to be a benefit of home uroflow bio- feedback training over standard treatment, particularly with good patient compliance Biofeedback training with home uroflowme- try is beneficial to children with nonneurogenic bladder-sphincter dyssynergia (reduces overall complaints)

Table 2, continued
	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
Vasconcelos 2006	Randomized Control Trial (1b)	5	56 children (5–15 y/o males and females) Group 1: 24 train- ing sessions over 3 months; 26 children Group 2: 16 train- ing sessions over 2 months; 30 children	Both groups: treat- ment at outpatient clinic, voiding and drink schedule, toilet posture, voiding diaries, propriocep- tive and pelvic floor muscle (PFM) train- ing Group 1: 7 PFM exercises Group 2: Biofeed- back therapy	Renal and dynamic ultrasonography PFM recordings by surface electrodes Diary of wetting episodes All assessed at 1, 6, and 12 months	Percentage of patients with urinary incontinen- ce decreased significan- tly in both groups after treatment Differences in effectiv- eness between the 2 training programs were not statistically sig. for any parameters Group 2 showed sig. decrease in those with inadequate bladder capacity, excessive post-voiding residual, and pelvic floor contractions after treatment Incontinence episodes in both groups decrea- sed significant Pelvic floor relaxation showed sig. difference between groups (volt- age decrease in 16/26 for group 1 and 26/30 for group 2)	Objective results did not match up with patients’ subjective improvements through diaries Short term study (trea- tment provided usually lasted less than 4 mon- ths) Small sample size gave only 58% power No control group	No difference between the two techniques for treating dysfunctional elimination syndrome Decrease in incidence of incontinence epis- odes after both training programs Training program that included biofeedback was effective in reduc- ing post-voiding residual and pelvic floor relaxa- tion
Kajbafzadeh 2011	Randomized Control Trial (1b)	5	80 children (5–16 y/o males and females) Group A: Animated feedback; 40 children Group B: Conser- vative therapy; 40 children	Group A: Animated feedback (2 weekly sessions), pelvic floor muscle exercises, behavioral modification (hydration, high fiber diet, scheduled voiding) Group B: Behavioral modification only	Dysfunctional voiding score (DVSS) Stool passage episodes per week Uroflowmetry EMG All assessed before, 6 months, and 12 months	Group A: 73% were dry at night at 6 months and 64% at 1 year. Urgency resolved in 88% at 6 months and 1 year Mean decrease in DVSS in group A was 5.51 versus 2.94 in group B (also significantly greater at 1 year) At 6 months, 68% in group A and 40% in group B were not constipated	Small sample size in the children who had conc- urrent vesicoureteral reflux and UTIs Number of treatment sessions with animated biofeedback was high compared to other studies Stool passage and con- stipation episodes were reported by parents, rather than valid ques- tionnaire	Animated biofeedback effectively treats chil- dren with bowel and voiding dysfunction Pelvic floor muscle exercises are beneficial in improving bowel dysfunction Considerable improve- ment in daytime wett- ing, nocturnal enuresis and urgency, abnormal voiding, and EMG activity during voiding with biofeedback

Table 2, continued
	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
						At 1 year, fecal soiling resolved in 100% in group A and 20% in group B Post-void residual and voiding time decreased, while urine flow increased significantly at 1 year for group A, in which this beneficial effect disappeared at follow up for group B
Zeng 2012	Comparative Study (3a)	6	45 children (8–14 y/o males and females) Group 1: Biofeedback Group 2: Pharmacological therapy	Group 1: pelvic floor biofeedback Group 2: 1 mg tolterodine, orally, twice daily Both treatments continued for 12 weeks	Biofeedback: simultaneous recording of urine flow, abdominal pressure, and anal EMG	Only 1 child with BF compared to 2 children with tolterodine had 5 or more events of post- urination dribbling after the 12 weeks Partial improvement, or 2–4 dribbling events, involved 2 BF: 4 tolterodine Significant improve- ment, or 1 dribbling event, included 2 BF: 6 tolterodine Complete cure was 16 BF: 6 tolterodine	Difficulties in compre- hending biofeedback protocol Urodynamic studies were not performed after treatment completion Small number of patients	Both treatments demonstrated decreased post-urination dribbling Biofeedback training was significantly better than tolterodine
Ladi-Seyedian 2015	Randomized Control Trial (1b)	5	50 children (5–16 y/o males and females) Group A: Animated biofeedback Group B: Standard Urotherapy	Group A: Animated biofeedback, PFM exercise, standard urotherapy (hydra- tion, scheduled voiding, toilet training, and diet); 25 children Group B: Standard Urotherapy; 25 children	Voiding and bowel habit diary Uroflowmetry EMG Renal and bladder ultrasound All assessed before, 6 months, and 12 months	Mean number of voiding episodes significant increased in group A compared to group B after 6 months and 1 year (about 6.6 compared to 4.5 per day) Postvoid residual volume decreased to around 14.5 mL in group A compared to about 49 mL in group B	Mild laxatives were given only to children who had constipation Short follow-up of 6 months Small sample size	Animated biofeedback and PFM exercises improves the sensation of a full bladder and contractility in children with voiding dysfunc- tions Helping children beco- me aware of their PFMs through BF allows rela- xation of these muscles and decrease uroflow obstruction during voiding

Table 2, continued
	Study		Methods				Reviewer comments
Citation	Study type (LOER)	PEDro score	Subject # and groups	Intervention	Assessment tool	Outcomes	Limitations	Conclusion
						All had abnormal flow curve at beginning, but 68% became normal in group A and 36% in group B at end Maximum urine flow increased and voiding time decreased signif- icant in group A compared to group B
Tugtepe 2015	Randomized Control Trial (1b)	4	45 Children (5–11 y/o males and females) BF in children with overactive bladder (OAB); 17 children BF in children with dysfunctional voiding (DV), 28 children	All patients received 6 months of biofeedback therapy. Once per week during month one Once every two weeks during month two Once per month during the last 4 months	MMS Solar Blue urodynamics/ biofeedback device Urinary System Symptoms (frequency, UTI, urge incontinence, fractionated void- ing, constipation) Uroflow parameters (voided volume, Qmax, Qave, flow time, voiding time, post-voiding residue)	Patients with DV had decreased USS (UTI, urgency, fractionated voiding, constipation); Increase in voided volume, Qmax, Qave; Decrease in flow time, voiding time, PVR. Patients with OAB had decreased USS (UTI, frequency, urge inconti- nence, constipation); Increase in Qmax, Qave; Decrease in flow time voiding time, PVR.	Boy to Girl ratio; 10 boys: 35 girls Follow up time of 3 months may not have been long enough to determine long term effects of BF.	Both USS and uroflow improved in both groups; however, DV patients had a better overall response to BF therapy. DV response was 85.7% vs OAB response of 64.7%)

ment in total relief or shorter treatment duration due to a learning curve [10, 14].

Computer games may augment the effectiveness of biofeedback as a physical therapy intervention, particularly by increasing the child’s level of active participation in the treatment. Khen-Dunlop et al. [19] found that there are two critical factors needed for biofeedback to be effective: a) there must be a relationship between the therapist, the patient, and the patient’s caregivers; and b) interactive computer games greatly contributed to the success of biofeedback in this population. Computer games increase the child’s attention span as well as teach proper pelvic floor muscle activity through visualization as a form of mental practice.

4.2 Functional fecal incontinence

Six of the 12 studies examined the effects of biofeedback therapy on children with functional fecal incontinence [3, 11, 12, 13, 15, 17]. Two of the six studies reported positive improvements in symptoms with biofeedback therapy [11, 15]. In these studies, biofeedback therapy was found to reduce the use of laxatives as well as the episodes of incontinence. Furthermore, there is evidence that regardless of treatment location, solely in lab or at home, children presented with increased bowel movements in just 2 months with biofeedback therapy [15]. However, improvements in fecal and urinary incontinence were not experienced in all 12 studies. Four of the six studies found that biofeedback therapy did not contribute to the alleviation of symptoms in children with functional fecal incontinence [3, 11, 12, 17]. In those studies, biofeedback did not appear to provide relaxation of the pelvic floor muscles for defecation unless combined with other therapies such as laxative treatments and toilet training [3, 17]. However, although biofeedback therapy did not significantly improve functional fecal incontinence in children, it did improve the children’s behaviors in school. The authors are unsure why the children behaved more appropriately after biofeedback. However, it did appear to make a lasting impact to them, particularly in relation to social behaviors at school [12, 17].

4.3 Standard therapy

In addition to biofeedback, all of the studies included multiple interventions that are considered to be standard therapy for children with both of these disorders. Seven of the 12 studies included a conventional treatment group, in which dietary and toilet advice, enemas, laxatives, and diaries were utilized, as well as other varying standards of therapy [10, 11, 12, 14, 16, 17, 19]. Although behavioral modification was found to be important in reducing functional fecal incontinence, animated biofeedback therapy and pelvic floor exercises helped to diminish constipation and were able to completely resolve functional fecal incontinence [11]. In the sole study regarding post-urination dribbling, pharmacological therapy was incorporated as an intervention, in which one group was administered 1 mg of tolterodine twice daily. Biofeedback had a cure rate of 16 as compared to six cures in the pharmacologic group, suggesting that biofeedback should be the first intervention attempted for children with a disturbance of muscular coordination of the detrusor and sphincter urethrae with post-urination dribbling [18]. The remaining four studies examined the effects of enhanced toilet training, anorectal manometry, and uroflow parameters into their interventions in relation to biofeedback therapy [3, 9, 11, 15]. According to Cox et al. [3], toilet training was found to be the most beneficial route for children with functional fecal incontinence. The researchers found that enhanced toilet training required fewer treatments with a 76% reduction in incontinence. They noted that biofeedback therapy might contribute to more successful treatments if introduced after toilet training [3]. Standard therapies have been shown to be effective in conjunction with biofeedback treatments in decreasing the symptoms of dysfunctional voiding and functional fecal incontinence.

5. Discussion

This systematic review analyzed selected literature to determine the efficacy of biofeedback therapy as a non-invasive intervention to treat functional fecal incontinence and dysfunctional voiding in pediatric populations. The selected studies allowed us to examine the results of the intervention of various forms of biofeedback over a period of nearly ten years. Although levels of evidence remained limited, our review determined that children ages (4–16) with dysfunctional voiding can benefit from biofeedback therapy. Most of the articles examining voiding dysfunction had positive benefits from biofeedback therapy, including completely resolving 16 cases compared to six in the pharmacological comparison group in the Zeng et al. study [18]. In addition to measurable benefits related to the dysfunction, biofeedback also increased the patient’s participation in the therapy by making it fun and engaging, along with encouraging the mental practice of correct pelvic floor contractions [15].

Our research was unable to provide a more definitive conclusion on the efficacy of biofeedback therapy on functional fecal incontinence due to the limitations stated above. Some studies found an increase in number of bowel movements, while others found that biofeedback had no effect unless it was combined with adjunctive therapies [3, 15, 17]. A positive, yet unrelated effect of biofeedback on children with fecal incontinence is an improvement in social relationships and behavior at school. The authors were unable to identify a plausible reason why this effect occurred with the use of biofeedback, but nevertheless it is a positive side effect of the therapy [12, 17]. When analyzing these results together, it appears that a multifactorial approach consisting of biofeedback therapy and behavioral modification can be successful in resolving functional fecal incontinence, although further studies are necessary on the topic.

This systematic review had similar results when compared with other systematic reviews on dysfunctional voiding within the pediatric population. Desantis et al. [5] concluded that biofeedback is an “effective and non-invasive treatment for dysfunctional voiding, whereby approximately 80% of children benefited from the treatment.” Three of the articles they analyzed were also analyzed in our systematic review [10, 14, 19]. However, in the Desantis et al. [5] study, most of their findings were from case series with a low level of evidence, with only one RCT analyzed.

Fazeli et al. [6] performed a systematic review with a meta-analysis on the effect of biofeedback as an adjunctive therapy for symptoms of nonneuropathic voiding disorder in children. The meta-analysis pooled the data on 382 participants from four of the five studies examining resolution of urinary incontinence, incidence UTI, post-void residual volume, flow rate and mean maximal flow rate. Of the five articles they included with their study, three were also included in the current review [10, 13, 14]. Similar to our findings, Fazeli et al. [6] recognized that high quality RCTs on this topic are sparse and some findings support the use of biofeedback while others have shown no benefit. In the meta-analysis, Fazeli et al. [6] concluded that there was no significant difference in outcomes when biofeedback is used as an adjunctive therapy.

5.1 Limitations of our review

This systematic review has several limitations related to the quality of the articles included in the results. A majority of the articles exhibited a small sample size, thus reducing the power of the study [11, 16, 18, 19]. The time span for follow-up with the participants was often either short or non-existent [9, 10, 16, 19]. A limitation not directly related to the articles themselves was that the research available was sparse on current, innovative studies pertinent to the topic. Most studies were published in 2006 or prior, with only four relevant studies published after 2011. Finally, the differences among the studies’ assessment tools and outcome measures prevented the authors from conducting a meta-analysis.

5.2 Implications for practice

Physicians and physical therapists should consider the results of this systematic review in their clinical practice. In treating dysfunctional voiding and urinary incontinence, the evidence suggests that significant relief can be attained when biofeedback therapy is used in conjunction with other interventions. The therapist may want to consider alternative approaches in combination with biofeedback with a team of healthcare professionals in order to best address the patient’s goals and limitations. In treating functional fecal incontinence in pediatrics, the therapist will best find success in utilizing behavioral modification in conjunction with biofeedback and referring to other providers such as physicians and nurse practitioners to provide standard medical therapies. As with any method of intervention, the therapist should place high priority on establishing rapport with the patient and patient’s network of support [19]. The administration of biofeedback by a physical therapist provides a viable, non-invasive treatment for the pediatric population that experiences dysfunctional voiding and functional fecal incontinence.

6. Conclusion

The current systematic review on BBD focused on the treatment of dysfunctional voiding and functional fecal incontinence with biofeedback. Through analysis of articles that were collected, the authors concluded that biofeedback is a beneficial treatment for children with dysfunctional voiding and functional fecal incontinence. More conclusive research needs to be completed to explore the effects of biofeedback therapy treatment in order to make more concrete conclusions.

Footnotes

Conflict of interest

The authors have no conflict of interest to report.