Bernard T. Engel

Operant Conditioning of Rectosphincteric Responses in the Treatment of Fecal Incontinence

Six patients with severe fecal incontinence and manomctric evidence of external-sphincter impairment were taught to produce external-sphincter contraction in synchrony with internal-sphincter relaxation. These responses were induced by rectal distention. During follow-up periods ranging from 6 months to 5 years, four of the patients remained completely continent, and the other two were definitely improved. One patient who was trained to relax her internal sphincter as well as to contract her external sphincter not only was continent but also regularly had normal bowel movements, which she had not had before. The training technic was relatively simple to apply, and learning occurred within four sessions or less. The findings highlight the importance of synchronized rectosphincteric responses in the maintenance of fecal continence, and they show that these responses can be brought under voluntary control in patients with chronic fecal incontinence, even when the incontinence is secondary to organic lesions.

Urinary Incontinence in the Elderly: Bladder-Sphincter Biofeedback and Toileting Skills Training

Behavioral treatment of urinary incontinence was given to 39 elderly outpatients; 19 had stress incontinence, 12 detrusor motor instability, and 8 urge incontinence without instability. Biofeedback involving the bladder and sphincter was used to teach selective control of sphincter muscles or voluntary inhibition of detrusor contractions. Traditional behavioral methods used included habit training to gradually increase the voiding interval and relaxation training to cope with the urge to void. After an average 3.5 training sessions, patients with stress incontinence reduced the frequency of incontinent episodes an average of 82% (range, 55% to 100%). Patients with detrusor motor instability showed an average 85% improvement (range, 39% to 100%), and patients with urge incontinence reduced incontinence an average of 94% (range, 83% to 100%). Furthermore, 13 of the patients achieved total continence, and 19 had fewer than one accident per week after treatment.

Operant conditioning of heart rate in patients with premature ventricular contractions.

&NA; Operant conditioning of heart rate (HR) was carried out in 8 patients with premature ventricular contractions (PVCs). All of the patients showed some degree of HR control. Five of these patients showed a decrease in PVCs in association with the learning of HR control. Four patients have shown persistence of a low PVC frequency after study, the longest followup being 21 months. Pharmacologic studies suggested that decreased PVC frequency was mediated by diminished sympathetic tone in 1 patient and increased vagal tone in another. These findings suggest that some aspects of cardiac ventricular function can be brought under voluntary control. Once such control has been acquired, it can mediate clinically significant changes in cardiac function.

Biofeedback Treatment of Fecal Incontinence in Geriatric Patients

Eighteen fecally incontinent geriatric patients were first treated for constipation as a possible cause of incontinence, and the 13 who remained incontinent were provided sphincter biofeedback training. Half the patients were instructed to perform 50 sphincter exercises per day for a four‐week period prior to the start of biofeedback training to determine whether such exercises would improve bowel control in the absence of biofeedback training. Sphincter exercises alone did not produce clinical improvements and did not significantly increase the strength of sphincter contractions. Biofeedback training did significantly augment sphincter strength and was associated with greater than 75 per cent decreases in incontinence for 10 (77 per cent) of the patients. Improvements were maintained in 60 per cent at six months and in 42 per cent at one year. Thus biofeedback training appears to be of specific value in the treatment of fecal incontinence in geriatric patients.

Behavioral training for post-prostatectomy urinary incontinence

We treated 20 men with persistent post-prostatectomy incontinence by biofeedback-assisted behavioral training procedures. Initially, scheduled 2-hour voiding resulted in a mean 33.1 per cent increase in urge incontinence, a mean 28.5 per cent decrease in stress incontinence and no change in continual leakage. Subsequently, biofeedback was used to teach selective control of the sphincter muscles and/or inhibition of detrusor contractions. Individualized home practice included a voiding schedule, sphincter exercises, active use of the sphincter to prevent urine loss and strategies to manage urgency. After 1 to 5 biofeedback sessions patients with urge incontinence demonstrated an average 80.7 per cent decrease in incontinence, while stress incontinence was decreased an average 78.3 per cent and patients with continual leakage were less successful, with a mean 17.0 per cent improvement. The findings indicate that biofeedback training is an effective intervention for episodic stress or urge incontinence after prostatectomy. However, its usefulness appears to be limited in patients with postoperative incontinence characterized by continual leakage.

Behavioral Training for Urinary Incontinence in Elderly Ambulatory Patients

Research questions addressed by this study were: 1) Is the treatment of chronic urinary incontinence (UI) in elderly, nondemented ambulatory patients using bladder‐sphincter biofeedback as effective when performed by an internist/geriatrician and a nurse practitioner as that reported by behavioral scientists?; and 2) how does bladder‐sphincter biofeedback compare to a program of behavioral training that does not utilize biofeedback? Twenty‐seven patients with ill were assigned based on the number of baseline accidents documented in a self‐maintained log, their sex, and the predominant pattern of symptoms (urge or stress) to one of two treatment groups: biofeedback (13 patients) or behavioral training not utilizing biofeedback (14 patients). Patients were given up to six treatments. Patients in both groups achieved a highly significant (P < .001) reduction in urinary accidents 1 month following treatments compared with their baseline number of accidents. The average reduction of accidents over this time period was 79% for the biofeedback group and 82% for the group receiving behavioral training without biofeedback. All patients showed improvement and no patient experienced any side effect. A internist /geriatrician and a geriatric nurse practitioner may achieve success utilizing behavioral therapy with or without biofeedback for the treatment of chronic urinary incontinence for ambulatory elderly patients.

Behavioral treatment of high blood pressure II. Acute and sustained effects of relaxation and systolic blood pressure biofeedback.

&NA; The effects on blood pressure of regular patient and professional monitoring of blood pressure, extensive patient‐involved assessment of results, relaxation, and systolic blood pressure biofeedback are analyzed by comparisons of data from two 3‐month treatment periods with results from a 1‐month baseline period and by comparisons among control and treatment groups. Ninety borderline hypertensive patients completed the treatments. Major findings are: A Acute effects; 1) Both relaxation and systolic blood pressure biofeedback lowered blood pressure acutely. 2) Improvement in performance of relaxation and biofeedback with practice showed that they are learned skills. 3) Acutely, relaxation and biofeedback were equally effective for lowering systolic blood pressure, but relaxation lowered diastolic blood pressure more. B. Long‐term effects; 1) Blood pressure declined for at least 6 months with regular monitoring and patient‐involved assessment. 2) The greatest lowering of blood pressure by behavioral intervention occurred during periods when pressures tended to be highest. 3) A combination of relaxation and biofeedback, with biofeedback preceding relaxation, was better than either used alone and slightly, but not significantly, better than relaxation preceding biofeedback. 4) The long‐term effects of biofeedback were slightly greater than those of relaxation. A staged, incremental behavioral treatment of borderline hypertension is proposed.

Behavioral Treatment of Incontinence in the Long-Term Care Setting

he Laboratory of Behavioral Sciences (LBS) of the National Institute on Aging (NIA) has been studying behavioral treatments of fecal and uriT nary incontinence for about 20 years.’ Our findings have clearly shown that most elderly ambulatory, cognitively intact persons can learn, or can relearn, to regulate their bowel2 or b l addeF performance sufficiently to achieve and to maintain clinically significant, improved function. Based on our extensive experience with outpatients, we established a research project designed to evaluate behavioral treatments of incontinence in the long-term care setting. Since most longterm care patients present with significant motor and/or cognitive disabilities,6 we designed the treatment program to focus on prompted voiding methods,’r8 and we placed a major emphasis in the research design on the implementation and assessment of staff management procedures for the maintenance of treatment gains. In August 1985 we established a 15-bed Geriatric Continence Research Unit at the Mason F. Lord Building of the Francis Scott Key Medical Center (FSK), a Johns Hopkins affiliated hospital. The project was funded through a contract between NIA and FSK. Funds for this contract were provided in part by the NIA and in part by the Health Care Financing Administration. The research team included psychologists and nurses. The research program was divided into three phases: (1) a baseline assessment period of three weeks during which the patients were evaluated for mental status, depression, mobility, clinical conditions, and frequency of bowel and bladder incontinence; (2) a treatment phase during which the patients were admitted to a research unit

Behavioral treatment of high blood pressure: III. Follow-up results and treatment recommendations.

&NA; This article is the third in a series of studies designed to evaluate systolic blood pressure biofeedback and relaxation in the treatment of elevated blood pressure. It reports on the posttreatment follow‐up results. The main findings were that patients who received the behavioral treatments could achieve and sustain reductions in blood pressure for at least 18 months. Furthermore, a number of patients who were receiving diuretic therapy to control their pressures were able to maintain reduced pressure for at least 9 months after discontinuing medication. A model for a behavioral‐stepped care program is proposed.

The role of behavioral conditioning in the cardiovascular adjustment to exercise

The purpose of this study was to determine if normal subjects could be trained to attenuate their cardiovascular responses while exercising on a bicycle ergometer. Ten young, untrained subjects exercised on a bicycle ergometer for five sessions. Half of the group was asked to slow their heart rate while exercising with heart rate feedback during exercise. Their average heart rate increase was 20% less than that of the control subjects, who exercised without feedback. The control subjects subsequently also received feedback during exercise and they were able to attenuate their heart rate responses comparably. Systolic blood pressure was not affected by feedback training. Changes in rate-pressure product paralleled changes in heart rate. These data show that autonomically mediated adjustments to exercise can be brought under experimental control through the use of appropriate behavioral techniques.