Bowel Biofeedback Training to Improve Bowel Function in Individuals with SCI

神经源性肠作为脊髓损伤（SCI）的后遗症，其特征是排空困难， 慢性腹痛和大便失禁胃肠道（GI）功能障碍和相关症状可 对情绪、职业、社区和社会功能产生重大不利影响。那里 在过去的十年里，肠道护理技术几乎没有进步， 管理在SCI患者中普遍存在。肠道生物反馈是一种新颖的， 治疗方法，已被证明可以改善便秘，大便失禁，和协同失调， 一般人群的排便。生物反馈的概念是基于操作的原则， 条件反射，其中有关正常潜意识生理功能的信息被有意识地 传递给患者，让他们积极参与学习，有意识地控制这一功能。 虽然SCI患者的肠功能障碍症状是众所周知的，但迄今为止的研究有限 观察肛门直肠（AR）功能和运动。各种技术，如压力测量 意志活动期间的曲线，可以促进GI精细运动功能的评估。这些压力 评估被称为测压研究，它们可以提供有关AR的有价值的信息 physiology.在过去，水灌注测压系统受到宽间隔、单向 传感器，无法捕捉小的，活动负载区域的详细事件，如AR。高 分辨率测压（HRM）使用紧密的传感器间距和3-D地形表示， 详细的信息，括约肌的力量，排便动力学和反射机制的AR。到 迄今为止，AR-HRM研究尚未在SCI人群中进行。在这一试点建议中，人力资源管理局将首先 采用（第1部分）来确定SCI患者的测压曲线，并确定肠表型- 是基于HRM发现的存在于每个个体中的生理特征的集群。 其次（第2部分），将在一个个体子集中进行6周的生物反馈培训， 参与研究的第1部分，并比较培训前的测压曲线。最后，我们将评估 通过测压评估6周家庭生物反馈锻炼对肠功能的影响， 确定从家庭排便训练中获得的收益是否可以持续。 本研究第1部分的具体目的是（1）根据肠功能表型确定每个受试者的功能性肠表型。 AR-HRM结果（基线括约肌张力、对球囊扩张试验的反应、排便强度和 保留动作），并与健全的肠道表型进行比较，（2）以确定 基线AR-HRM特征与SCI完整性和病变水平，（3）并确定相关性 基线AR-HRM特征与10个问题肠道调查（10 Q-BS）评分和Wexner的 免疫评分（WIS）。本研究第2部分的具体目的是（1）进行为期6周的监督 肠生物反馈训练的一个子集的SCI受试者与不完全的伤害谁参加了部分 1，（2）评估6周家庭锻炼后肠道生物反馈的疗效，（3）评估 每个治疗期前后的AR-HRM特征，以及（4）将基线神经学和 AR-HRM特征与治疗后结局，以确定最佳预测治疗的因素 结果。如果发现肠道生物反馈是减少/预防失禁的有效手段， 在肠道护理过程中DWE的减少，这种新的方法可以在临床上提供作为治疗， 减少对泻药的依赖，减少适应不良的社交回避。此外，如果这些好处可以 通过简单的家庭肠道生物反馈练习来维持，这种肠道护理方法将代表一种 新的，有效的，和可获得的治疗形式，许多患有神经源性肠的个体可以 受益于，没有负担，不断参加临床培训课程。

Neurogenic bowel as a sequela of spinal cord injury (SCI) is characterized by difficulty with evacuation, chronic abdominal pain, and fecal incontinence. Gastrointestinal (GI) dysfunction and related symptoms can have significant adverse repercussions on emotional, occupational, community, and social functioning. There have been few advances in bowel care technology in the past decade, and dissatisfaction with bowel care management is prevalent amongst individuals with SCI. Bowel biofeedback is a novel and promising therapeutic approach which has been shown to improve constipation, fecal incontinence, and dyssynergic defecation in the general population. The concept of biofeedback is based on principles of operant conditioning, in which information concerning a normally subconscious physiological function is consciously relayed to patients, allowing them to become actively engaged in learning to consciously control this function. While the symptoms of bowel dysfunction in persons with SCI are well known, there are limited studies to date looking at anorectal (AR) function and motility. Various techniques, such as the measurement of pressure profiles during volitional activity, can facilitate assessment of GI fine motor function. These pressure assessments are known as manometric studies, and they can provide valuable information about AR physiology. In the past, water-perfused manometric systems were limited by widely spaced, unidirectional sensors, which were incapable of capturing detailed events in small, activity laden areas, such as the AR. High resolution manometry (HRM) uses tight sensor spacing and 3-D topographical representation to provide detailed information concerning sphincter strength, defecation dynamics and reflex mechanisms in the AR. To date, AR-HRM studies have not been conducted in a SCI population. In this pilot proposal, HRM will be initially employed (Part 1) to identify manometric profiles of persons with SCI, and to identify bowel phenotypes--that is, clusters of physiologic characteristics that are present in each individual which are based on HRM findings. Secondarily (Part 2), 6 weeks of biofeedback training will be performed in a subset of individuals who participated in Part 1 of the study, and to compare manometric profiles pre-post training. Finally, we will assess the effects of 6 weeks of home biofeedback exercises on bowel function by manometric evaluation to determine if the gains from this home bowel training can be sustained. The Specific Aims for Part 1 of this study are (1) to identify each subject’s functional bowel phenotype based on AR-HRM findings (baseline sphincter tone, response to balloon distension test, strength of defecation and retention maneuvers) and compare to able-bodied bowel phenotypes, (2) to determine the correlation of baseline AR-HRM characteristics with SCI completeness and lesion level, (3) and to determine the correlation of baseline AR-HRM characteristics with the 10 Question Bowel Survey (10Q-BS) score and Wexner’s Incontinence Score (WIS). The Specific Aims for Part 2 of this study are (1) to perform 6 weeks of supervised bowel biofeedback training in a subset of SCI subjects with incomplete levels of injury who participated in Part 1, (2) to assess the efficacy of bowel biofeedback after 6 weeks of home exercise, (3) to assess changes in AR-HRM characteristics pre and post each treatment period, and (4) to correlate baseline neurological and AR-HRM characteristics with post-treatment outcomes to determine factors that best predict treatment outcome. If bowel biofeedback is found to be an effective means for the reduction/prevention of incontinency or the reduction in DWE during bowel care, this novel method could be clinically offered as therapy, which would reduce reliance on purgatives and curtail maladaptive social avoidance. Additionally, if such benefits can be maintained through simple home bowel biofeedback exercises, this approach to bowel care would represent a novel, efficacious, and accessible form of therapy that many individuals suffering from neurogenic bowel could benefit from, without the burden of continuously attending clinical training sessions.