ABSTRACT
Background
International guidelines recommend anorectal biofeedback therapy or pelvic floor physical therapy for the treatment of constipation and fecal incontinence (FI). However, the similarities and differences between these therapies are unclear. Objective: This practitioner survey aimed to evaluate the practice patterns of biofeedback therapists (BTs) and pelvic floor physical therapists (PTs). Settings: This survey was targeted at BTs and PTs in community and hospital settings.
Methods
We conducted an international online survey about training, equipment, techniques, and practice patterns of BTs and PTs in treating patients with constipation and FI, distributed through specialist societies and known contacts. Language style was adjusted to the participants' preferences.
Results
We received 289 responses from 226 (78.2%) PTs and 63 (21.8%) BTs from Australia/New Zealand (119; 41.2%), the USA (90; 31.1%), and the rest of the world (80; 27.7%). The use of biofeedback in treating anorectal disorders often or always differed; BTs 80.4% versus PTs 51.8% (OR 4.50 (2.48–8.17)). Equipment for delivering biofeedback differed: electromyography (BTs 32.1% versus PTs 77.1%; OR 0.14 (0.07–0.27)), manometry (BTs 71.4% versus PTs 4.8%; OR 45.94 (18.35–115.02)), and ultrasound (BTs 0% versus PTs 50.3%). Ancillary device use differed (e.g., footstool (BTs 68.8% versus PTs 88.7%; OR 0.32 (0.18–0.55)), release device (BTs 6.5% versus PTs 27.9%; OR 0.06 (0.03–0.13)), trigger point (BTs 4.9% versus PTs 28.9%; OR 0.04 (0.02–0.11))). Techniques used differed: abdominal massage (BTs 31.1% versus PTs 59.6%; OR 0.27 (0.15–0.46)), balloon expulsion BTs 65.6% versus PTs 9.4% (OR 14.82 (7.95–27.65)).
Limitations: The uneven distribution of respondents between countries and groups and reliance on self‐reporting limits the generalizability of this exploratory study.
Conclusions
BTs and PTs reported vast differences in the delivery of care for anorectal disorders. PTs use biofeedback less often and, when delivering biofeedback, use less manometry and more electromyography and ultrasound. Recognition of these differences may better inform referring providers and facilitate a more collaborative, standardized approach in the future.
Keywords: anorectal disorders, biofeedback, dyssynergic defecation, fecal incontinence, outlet dysfunction, physical therapy
Summary
Unlike biofeedback therapists, approximately 50% of pelvic floor physical therapists use biofeedback techniques regularly and use many other techniques.
Pelvic floor physical therapists deliver biofeedback therapy using more EMG and ultrasound devices and less manometry and rectal balloon training.
Biofeedback therapy and pelvic floor physical therapy differ significantly and are not synonymous treatments. Consequently, healthcare providers and therapists should not use these terms interchangeably or equate their outcomes.
Improved dialogue and development of consensus programs between biofeedback therapists and pelvic floor physical therapists may lead to improved patient outcomes and access to therapy for anorectal disorders.
In our international survey of biofeedback therapists and pelvic floor physical therapists, there were vast differences in the delivery of care for anorectal disorders. Recognition of these differences may better inform referring providers and facilitate a more collaborative, standardized approach in the future.
Abbreviations
- BT
biofeedback therapist
- EMG
electromyography
- FI
fecal incontinence
- PT
pelvic floor physical therapists
1. Introduction
Anorectal biofeedback therapy is the evidence‐based gold standard therapy for constipation with dyssynergic defecation and fecal incontinence (FI) unresponsive to conservative management [1, 2]. It involves giving patients real‐time feedback of their own anorectal physiology in order to restore normal defecation dynamics, continence, and sensation. In randomized controlled trials, biofeedback was superior to sham therapy [3], osmotic laxatives [4], benzodiazepines [5], and standard constipation therapy [3] for patients with dyssynergic defecation.
However, there is a marked discrepancy between the large number of potential patients requiring anorectal biofeedback and the very limited availability of this highly specialized service. In the real world, most patients with anorectal disorders are being referred to and treated by the much larger community of pelvic floor physical therapists (PTs). Data are more limited on the potential efficacy of pelvic floor physical therapy in treating anorectal disorders. The assumption has been, however, that pelvic floor physical therapy is conducted in a similar fashion to biofeedback therapy and consequently, many consensus guidelines have used these terms interchangeably [1, 6]. However, there has been no prior systematic assessment of how these treatments are conducted in real‐world clinical practice. To discover if these therapies are similar or different may have very significant clinical relevance to models for delivery of care and cost‐effectiveness for conservative therapy of anorectal disorders.
Anorectal manometric‐based biofeedback therapy for constipation and FI has a standardized protocol as recommended by international consensus guidelines [7, 8, 9]. This includes education, advice about toilet positioning and behavior, prescription of exercises, biofeedback (often manometric‐based) to optimize defecatory dynamics and anal sphincter function, sensory retraining, and balloon expulsion training. Treatment outcomes using objective criteria report 70%–80% relief of symptoms [1]. Typically, six treatment sessions, 1–2 weeks apart, have been recommended [7, 9]. In contrast, international standardized protocols for pelvic floor physical therapy in anorectal disorders are emerging. It may include education, pelvic floor muscle exercises, abdominal massage, breathing and physical exercise correcting anal sphincter coordination with tactile feedback, biofeedback in lying, sitting and standing positions, rectal balloon training, educating home training and training diary [10, 11, 12, 13]. Session lengths of 45 min and a course duration of 6 weeks to 6 months have been reported [14]. Treatment outcomes are not well defined. It is unknown whether pelvic floor physical therapy is superior, equal, or inferior to biofeedback therapy; however, the first step is to discover if the treatments globally are conducted similarly or not, hence the motivation for development of the current study.
Given the high reported incidence of dyssynergic defecation in community‐dwelling adults at 19.3 per 100,000 person‐years [15] and the 8.0% who suffer from FI [16] and that conservative strategies are often ineffective [3, 17, 18], how biofeedback therapy is delivered is of enormous economic and practical consequence for providers and patients.
Hence, the aims of our study were to survey biofeedback therapists (BTs) and PTs globally to evaluate the practice patterns for assessment and management of patients with anorectal disorders and to evaluate what comprises a typical course of therapy for each group of practitioners.
2. Methods
2.1. Questionnaire Development
This was an exploratory survey targeting BTs and PTs currently practicing in community or hospital settings. The REDCap online survey platform was used for delivery [19, 20]. The questionnaire was divided into three sections: (i) demographics, training, practice settings, and funding; (ii) practice patterns, referral patterns, equipment used, assessment techniques, therapies, and treatment session structure; and (iii) specific inquiry regarding biofeedback techniques, e.g., what physiological information was used to provide biofeedback and what type of rectal balloons were used. For techniques, assessments, and practice style questions, respondents were asked specifically to provide their responses in treating constipation and fecal incontinence only. At the beginning of each question, respondents were given the initial prompt, “in your treatment of patients with constipation and fecal incontinence…”. We have opted to collect responses for both constipation and fecal incontinence together to avoid responder fatigue, acknowledging that there is a significant overlap in managing these conditions.
A pilot questionnaire was administered to a test population consisting of current biofeedback therapists and pelvic floor physical therapists. Based on the feedback, the style of questions, terminology, and response options were refined. The questionnaire was set to automatically adapt to different language styles and terminology for different countries (e.g., “physical therapy” was preferred by US participants and “physiotherapy” was preferred by Australian and UK participants) and was also adapted to each individual provider's preferred terminology. The questionnaire was designed to take approximately 20–30 min to complete, and there was an option to pause and resume the survey later.
2.2. Questionnaire Distribution
The survey was hosted on the Northern Sydney Local Health District server and could be accessed via a web address (URL) or QR code. Potential participants were invited by email via specialist societies of BTs and PTs, consistent with single‐stage convenience sampling. The survey was delivered online between May 2023 and March 2024. We aimed for a sample size of over 200 based on likely feasibility and the nature of previous studies.
The survey was anonymous, and a screening question (“Have you participated in this survey before”) was used to ensure that no duplicate responses were received. A return code option was available to allow participants to pause and resume the survey. Participants were asked to identify the name of the therapy and their qualification to ensure that only BTs and PTs participated in this survey. No reimbursement was provided to participants. Participants were recruited through specialist societies (such as the American Physical Therapy Association and the Australian Physiotherapy Association), pelvic floor physical therapy training societies, as well as hospital and private physical therapy and biofeedback practices.
2.3. Analysis
Survey participants self‐identified as either PTs or BTs, and these categories were further confirmed by the nature of their professional qualifications and training. The vast majority of measures reported in this manuscript are categorical and are reported as counts and percentages, while the quantitative measures are reported as means and standard deviations (SD). Since this study primarily aims to describe practice patterns, effect size measures that contrast biofeedback therapists' (BTs) responses with those from pelvic floor therapists (PTs) for either binary (yes/no) or ordinal (frequency‐scale) measures are reported with 95% confidence intervals, rather than p‐values from statistical hypothesis tests. Binary odds ratios are obtained from unconditional logistic regression, while for ordinal measures they are obtained from an ordinal regression model. Odds ratios > 1.0 indicate that BTs endorsed that response more often than PTs, while odds ratios < 1.0 indicate they endorsed it less often than PTs, and odds ratios close to 1.0 indicate approximate equality. In a few cases, the odds ratio could not be calculated due to zero variance in one group. For quantitative responses, linear regression has been used and the effect size measures are the difference in means (with 95% confidence interval). It is noted that BT respondents are outnumbered by PTs by a ratio > 3:1. While equal numbers of these respondent categories would have been ideal, the impact on effect size measures is not as great as it would have been on statistical power had that been the study's purpose.
2.4. Ethics
Ethics approval was granted by the Human Research Ethics Committee of the Northern Sydney Local Health District (NSLHD), Australia (2023/ETH00466), and the Institutional Review Board of Augusta University, USA (2042785–3). All participants provided online consent before completing the survey.
3. Results
3.1. Study Participants
A total of 289 survey responses (257F; 89%) were received from practitioners, of whom 226 (78.2%) identified themselves as PTs and 63 (21.8%) as BTs. Biofeedback therapists included doctors, nurses, and others (e.g., researchers, physician assistants, pelvic rehabilitation practitioners, and occupational therapists). The basic demographics of these practitioners, their qualifications and training, are outlined in Table 1. The country of practice for all respondents is shown in Figure 1 and grouped as Australia/New Zealand (ANZ) (119; 41.2%), the USA (90; 31.1%), and the rest of the world (80; 27.7%).
TABLE 1.
Basic demographics, training, and education of survey participants.
| Biofeedback therapists (n = 63) | Pelvic floor physical therapists (n = 226) | OR (95% CI) | |
|---|---|---|---|
| Sex (F/total number) | 63.5% | 96.0% | 0.07 (0.03–0.17) |
| Years of experience (mean (S.D.)) | 4.9 (8.4) | 6.0 (8.0) | −1.16 (−3.51–1.19) a |
| Female pelvic health | 90.5% | 94.6% | 0.54 (0.19–1.50) |
| Male pelvic health | 73.0% | 62.9% | 1.59 (0.86–2.96) |
| Pediatrics | 19.0% | 24.1% | 0.74 (0.37–1.49) |
| Practice settings | |||
| Institutional (Hospital or university) | 74.6% | 40.6% | 4.29 (2.29–8.04) |
| Outpatient (Private practice/clinic) | 41.3% | 59.8% | 0.47 (0.27–0.83) |
| Other | 0.0% | 10.7% | |
| Qualifications | |||
| Physical therapy degree | 100% | ||
| Nursing degree | 22.2% | ||
| Medical degree | 69.8% | ||
| Other | 7.9% | ||
| Training/Education | |||
| Received mentorship | 44.4% | 67.9% | 0.38 (0.21–0.67) |
| Training course | 33.3% | 82.6% | 0.11 (0.06–0.20) |
| Graduate certificate | 7.9% | 17.9% | 0.40 (0.15–1.05) |
| Bachelor's degree | 4.8% | 21.4% | 0.18 (0.06–0.61) |
| Master's degree | 11.1% | 27.7% | 0.33 (0.14–0.76) |
| PhD | 11.1% | 24.1% | 0.39 (0.17–0.92) |
| Other | 27.0% | 11.2% | 2.94 (1.47–5.89) |
Observed coefficient.
FIGURE 1.
Survey participants' country of practice. ANZ, Australia and New Zealand; USA, United States of America.
3.2. Referral Patterns
BTs received a higher frequency of referrals from gastroenterologists and colorectal surgeons, whereas PTs received a higher frequency of self‐referrals by patients or referrals from primary care physicians (OR 0.14 (0.07–0.24)) or obstetricians and gynecologists (OR 0.14 (0.08–0.24)) (Table 2). BTs treated a greater proportion of patients with anorectal disorders in their overall case mix compared with PTs, who had a relatively greater proportion of patients with urinary symptoms (OR 0.01 (0.00–0.02)) or perinatal issues (OR 0.08 (0.04–0.14)) (Table 2).
TABLE 2.
Referral patterns of biofeedback therapists and pelvic floor physical therapists.
| Biofeedback therapists (n = 63) | Pelvic floor physical therapists (n = 226) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Never | Sometimes | Often | Mostly | Never | Sometimes | Often | Mostly | OR (95% CI) | |
| Source of referral | |||||||||
| Self‐referral | 31.7% | 40.0% | 16.7% | 11.7% | 15.7% | 38.1% | 30.5% | 15.7% | 0.45 (0.27–0.78) |
| Primary care | 34.4% | 50.8% | 13.1% | 1.6% | 6.7% | 36.8% | 42.6% | 13.9% | 0.14 (0.07–0.24) |
| Gastroenterologist | 3.3% | 18.0% | 27.9% | 50.8% | 22.2% | 0.3% | 25.8% | 11.8% | 7.09 (4.01–12.53) |
| Colorectal surgeon | 6.7% | 36.7% | 35.0% | 21.7% | 24.9% | 40.7% | 24.0% | 10.4% | 2.70 (1.60–4.55) |
| Obstetrician and Gynecologist | 34.4% | 41.0% | 16.4% | 8.2% | 6.3% | 21.1% | 48.4% | 24.2% | 0.14 (0.08–0.24) |
| Physical therapist | 68.3% | 26.7% | 5.0% | 0.0% | 13.0% | 62.3% | 19.7% | 4.9% | 0.08 (0.04–0.15) |
| Nurse | 71.7% | 26.7% | 1.7% | 0.0% | 41.2% | 41.6% | 14.5% | 2.7% | 0.26 (0.14–0.48) |
| Other | 75.0% | 18.8% | 6.2% | 0.0% | 21.7% | 30.4% | 26.1% | 21.7% | 0.09 (0.03–0.31) |
| Reason for referral | |||||||||
| Constipation | 0.0% | 1.6% | 41.0% | 57.4% | 3.1% | 42.6% | 36.8% | 17.5% | 8.26 (4.62–14.75) |
| Fecal incontinence | 3.3% | 14.8% | 42.6% | 39.3% | 1.8% | 48.9% | 37.2% | 12.1% | 4.55 (2.60–7.96) |
| Urinary incontinence | 65.6% | 21.3% | 9.8% | 3.3% | 1.3% | 4.5% | 47.1% | 47.1% | 0.01 (0.00–0.02) |
| Pelvic organ prolapse | 41.0% | 47.5% | 8.2% | 3.3% | 3.1% | 13.0% | 49.8% | 34.1% | 0.03 (0.02–0.07) |
| Perinatal care | 57.4% | 29.5% | 11.5% | 1.6% | 10.3% | 19.3% | 41.3% | 29.1% | 0.08 (0.04–0.14) |
| Pelvic pain | 31.1% | 50.8% | 13.1% | 4.9% | 1.8% | 17.9% | 52.0% | 28.3% | 0.05 (0.03–0.11) |
| Anorectal pain | 11.5% | 55.7% | 24.6% | 8.2% | 13.5% | 52.9% | 24.2% | 9.4% | 1.01 (0.59–1.72) |
| Genitourinary pain | 73.8% | 21.3% | 3.3% | 1.6% | 7.6% | 26.5% | 43.0% | 22.9% | 0.03 (0.01–0.06) |
| Other | 70.6% | 5.9% | 17.6% | 5.9% | 32.4% | 24.3% | 24.3% | 18.9% | 0.24 (0.07–0.81) |
3.3. Practice Patterns
Numerous differences were found in the practice patterns of BTs versus PTs (see Table 3). BTs were more selective in who they treated (30.2% treating all patients versus 66.1%; OR 0.22 (0.12–0.41)), and they relied more on physiological assessment to guide patient selection (71.4% versus 18.8%; OR 10.83 (5.71–20.57)). Enema use prior to the procedure was more common among BTs (OR 20.57 (8.26–51.25)). In their assessment of patients with anorectal disorders prior to treatment, BTs were significantly less likely to perform vaginal examinations (1.6% versus 52.9%; OR 0.03 (0.02–0.06)), but more likely to perform digital rectal examinations and use rectal balloons for assessment (75.4% versus 40.4%; OR 4.45 (2.37–8.36), 55.74% versus 3.6%; OR 20.67 (10.73–39.84)) (Table S1). There were some, but not marked, differences in how education was delivered to patients. Group, rather than individual sessions were rare among PTs and not used at all by BTs (Table 3). The number of sessions in a course and the length of the sessions were similar between BTs and PTs (OR 0.57 (0.33–0.96)). BTs were more likely to have set follow‐up visits after completing therapy at three and six months (OR 3.56 (1.94–6.53); OR 3.50 (1.82–6.75)) whereas PTs were more likely to have “as required” follow‐up visits (OR 0.21 (0.11–0.40)) or no follow‐up (OR 0.16 (0.04–0.66)) after the completion of therapy.
TABLE 3.
Practice patterns of biofeedback therapists and pelvic floor physical therapists.
| Biofeedback therapists (n = 63) | Pelvic floor physical therapists (n = 226) | OR (95% CI) | ||
|---|---|---|---|---|
| Method used to select which patients to treat | ||||
| Treat all patients | 30.2% | 66.1% | 0.22 (0.12–0.41) | |
| Use Rome criteria | 33.3% | 20.5% | 1.94 (1.05–3.58) | |
| Nature of patient's symptoms (not specifically Rome IV criteria) | 57.1% | 62.5% | 0.80 (0.45–1.41) | |
| Physiological assessment | 71.4% | 18.8% | 10.83 (5.71–20.57) | |
| Other selection criteria | 14.3% | 9.8% | 1.53 (0.67–3.52) | |
| Method used to monitor patient progress | ||||
| Stool diary | 82.5% | 80.4% | 1.16 (0.56–2.40) | |
| Patient reported symptoms | 73.0% | 87.5% | 0.39 (0.20–0.77) | |
| Anorectal manometry | 68.3% | 11.2% | 17.11 (8.72–33.58) | |
| Electromyography | 20.6% | 31.7% | 0.56 (0.29–1.10) | |
| Rectal balloon testing | 65.1% | 23.2% | 6.16 (3.37–11.27) | |
| Digital rectal examination | 38.1% | 75.9% | 0.20 (0.11–0.35) | |
| Vaginal examination | 3.2% | 75.4% | 0.01 (0.00–0.05) | |
| Other | 4.8% | 8.5% | 0.54 (0.15–1.89) | |
| Education aids used | ||||
| Does not use aids | 11.1% | 0.4% | 27.88 (3.36–231.23) | |
| Handouts | 61.9% | 85.3% | 0.28 (0.15–0.53) | |
| Computer‐based aids | 50.8% | 44.2% | 1.30 (0.75–2.28) | |
| Model of pelvis | 19.0% | 91.1% | 0.02 (0.01–0.05) | |
| Other | 6.3% | 11.2% | 0.54 (0.18–1.61) | |
| Enema use | ||||
| Enema use before session | 40.0% | 3.1% | 20.57 (8.26–51.25) | |
| Type of sessions offered | ||||
| Individual sessions | 95.2% | 97.8% | 0.46 (0.11–1.97) | |
| Group sessions | 0.0% | 7.6% | ||
| Education | 100% | |||
| Pelvic floor exercise | 82.4% | |||
| Pilates | 41.2% | |||
| Other | 29.4% | |||
| Session structure | ||||
| Number of sessions (mean (S.D.)) | 7.0 (3.5) | 8.3 (5.5) | −1.29 (−2.49–0.09) a | |
| Duration of individual session | ||||
| 0–30 min | 18.0% | 10.9% | 0.57 (0.33–0.96) | |
| 30–45 min | 39.3% | 30.8% | ||
| 45–60 min | 32.8% | 46.6% | ||
| 60 min or more | 9.8% | 11.8% | ||
| Follow‐up time frame post treatment completion | ||||
| 1‐month post | 17.5% | 12.1% | 1.54 (0.72–3.32) | |
| 3‐month post | 42.9% | 17.4% | 3.56 (1.94–6.53) | |
| 6‐month post | 33.3% | 12.5% | 3.50 (1.82–6.75) | |
| 12‐month post | 17.5% | 4.9% | 4.10 (1.68–9.97) | |
| As required | 22.2% | 57.6% | 0.21 (0.11–0.40) | |
| No follow‐up | 3.2% | 17.4% | 0.16 (0.04–0.66) | |
Observed coefficient.
3.4. Management
The equipment used significantly differed between groups (e.g., footstool. BTs 68.8% versus PTs 88.7%, release device. BTs 6.5% versus PTs 27.9%, TENS. BTs 11.9% versus PTs 20.3%, trigger point. BTs 4.9% versus PTs 28.9%; Figure 2 and Table S2). Techniques used “often” and “most of the time” differed between groups (e.g., abdominal massage BTs 31.1% versus PTs 59.6%; OR 0.27 (0.15–0.46), balloon expulsion training BTs 65.6% versus PTs 9.4%; OR 14.82 (7.95–27.65)). All other massage types (perineal (OR 0.03 (0.01–0.14)), gluteal (OR 0.01 (0.00–0.08)), and pelvic release massage (OR 0.04 (0.01–0.09))) were more commonly used by PTs than BTs (Table S3). The frequency of using biofeedback devices differed between the two groups: BTs 80.4% versus PTs 51.8% (OR 4.50 (2.48–8.17)).
FIGURE 2.
Techniques and equipment used “often” or “most of the time” categorized by biofeedback therapist versus pelvic floor physiotherapist with regard to their treatment of patients with constipation and fecal incontinence: *p < 0.01. TENS, transcutaneous electrical nerve stimulation.
3.5. Use of Biofeedback Techniques
Among BTs, 91.8% (56/61) reported ever using a biofeedback technique in their therapy, compared with 70.1% (155/221) of PTs (OR, 4.77; 95% CI, 1.83–12.44). Equipment used to deliver biofeedback differed: electromyography (EMG) (BTs 32.1% versus PTs 77.1%; OR 0.14 (0.07–0.27)), ultrasound (BTs 0% versus PTs 51.0%), and other biofeedback methods such as tactile feedback or mirrors (BTs 0% versus PTs 9.0%) were more frequently used by PTs whereas, manometry was utilized more by BTs (BTs 71.4% versus PTs 4.8%; OR 45.94 (18.35–115.02)) (Figure 3). Whilst the type of sensory input used to deliver biofeedback was similar, PTs used more auditory biofeedback (Table S4) (OR 0.21 (0.10–0.46)) than BTs. A higher proportion of PTs used both short and long anal squeeze maneuvers (BTs 78.6% versus PTs 94.2% OR 0.23 (0.09–0.57) and BTs 78.6% versus PTs 93.5% OR 0.25 (0.10–0.63)), whereas, the bear‐down or push maneuver was used more often by BTs (BTs 92.9% versus PTs 81.3%, OR 2.99 (1.00–8.94)).
FIGURE 3.
Patterns of equipment usage for biofeedback by biofeedback therapists versus pelvic floor physical therapists in their treatment of patients with constipation and fecal incontinence: *p < 0.01. EMG, electromyography.
3.6. Simulated Defecation and Rectal Balloon Training for Dyssynergic Defecation
73.8% of BT and 38.9% of PTs utilized simulated defecation training with a balloon (OR 4.42 (2.35–8.30), Table S5). The type of balloon used differed, with greater use of Foley and manometric catheters by BTs and greater use of a commercial balloon by PTs. The inflation technique varied between BTs and PTs, with a higher proportion of BTs inflating to a set numerical threshold (OR 4.88 (2.25–10.60)) whereas PTs used more sensation‐based thresholds for inflation (OR 0.34 (0.16–0.73)) (Table S5).
4. Discussion
Although the terms biofeedback therapy and pelvic floor physical therapy have been used interchangeably in the literature in describing treatment of constipation and fecal incontinence, our exploratory study has highlighted multiple self‐reported differences between these two therapies including education and training, referral patterns, patient selection, practice patterns, equipment utilized, and management techniques undertaken. Perhaps the most striking finding of our study was that half of PTs utilized biofeedback devices regularly during their treatment of patients with anorectal disorders compared with 80% of BTs. Furthermore, PTs used more EMG, ultrasound, or tactile feedback compared with manometry‐based biofeedback. Balloon retraining (for sensation or expulsion training) was performed more by BTs.
There were a multitude of other differences in education and training, practice patterns, referral sources, patient selection, equipment used, and number and timing of follow‐up sessions. To highlight some of the more important differences, BTs were more likely to receive referrals from gastroenterologists or colorectal surgeons, whereas PTs were more likely to receive referrals from primary care physicians or obstetricians and gynecologists. BTs reported seeing a higher proportion of patients with anorectal disorders, whereas PTs had a much broader clinical scope frequently also addressing urinary symptoms, pelvic floor prolapse, perinatal issues, and pelvic pain. Patient selection and monitoring of therapeutic outcomes were more likely to use Rome criteria, physiology, and rectal balloons with BTs compared with greater reliance on physical examination alone with PTs. Patients are likely to receive different modalities of therapy between BTs and PTs. Abdominal massage, footstool, and release devices were used more often by PTs compared with manometry (including the bear‐down maneuver) and simulated defecation with a rectal balloon with BTs. Some of these differences may stem from differences in training and a limitation in scope of practice for pelvic floor physical therapists versus other biofeedback therapists. Still, recognition of these major discrepancies is a first step toward a more unified, collaborative approach for improving management of anorectal disorders by both BTs and PTs.
Historically, there has been a difference in the principles by which these BTs and PTs have been developed over the years. Anorectal biofeedback was developed as a therapeutic extension from anorectal physiology testing by early clinicians in the 1960s or 1970s. It involves providing patients with real‐time feedback of their own physiology (typically using manometry, EMG, and rectal balloons) with subsequent exercises and home practice aimed at normalizing disordered physiology. Pelvic floor physical therapy, on the other hand, developed as an extension of principles of musculoskeletal and neuromuscular physiology and conditioning/training from studies in other parts of the body and translated to the specifics of the pelvic floor. In addition, pelvic floor physical therapy for anorectal conditions has been developed as a subspecialty area distinct from the physical therapies utilized for urinary, perinatal, or gynecological conditions. Although the evidence, in terms of randomized controlled trials, lies with the biofeedback approach, pelvic floor physical therapists treat a vastly greater number of patients worldwide, tailor their approach to each patient, and selectively utilize biofeedback techniques within their holistic pelvic floor treatment. The efficacy of pelvic floor physical therapy compared with biofeedback therapy is unknown but could be superior, inferior, or equivalent.
Our study has uniquely revealed that PTs commonly utilize ultrasound for biofeedback, which is rarely performed by biofeedback therapists. This may reflect that pelvic floor physical therapists focus on the whole pelvis (including the bladder and uterus) and not just the anorectum. Furthermore, ultrasound is used by physiotherapists in many other parts of the body, and we additionally showed that techniques utilized by therapists were strongly driven by equipment availability.
PTs also typically employed a vast number of additional techniques (over and above biofeedback) in their treatment course. It is particularly intriguing to consider whether components of both physical therapy and biofeedback programs could be incorporated together to develop a superior therapeutic approach that is tailored to individual patients' needs in the treatment of anorectal disorders. It is also unknown if some patients may be better suited for biofeedback therapy versus pelvic floor physical therapy.
This study has limitations. Although we have been successful in recruiting a good number of both PTs and BTs globally, the reliance on self‐report by therapists and convenience sampling reduces the generalizability of these findings to all populations, and we note the larger number of PTs than BTs. In particular, by recruiting participants through specialist societies, we may have surveyed a more academic or more motivated population; however these issues are potentially present for both BTs and PTs. Furthermore, recall bias and social desirability bias may mean that true practice is somewhat different from this self‐reported practice. Importantly, as this was a survey of practicing therapists rather than a prospective trial of biofeedback or physical therapy, no clinical outcomes regarding efficacy of treatment were measured. Nonetheless, the findings are so strong regarding the many differences in training, equipment, and clinical practice between BTs and PTs that these results allow meaningful conclusions and hypotheses to be made regarding future directions for research and policy development in the field of behavioral therapies for anorectal disorders.
5. Conclusion
Our study found significant differences in the delivery of anorectal biofeedback therapy for fecal incontinence and dyssynergic defecation reported by BTs and PTs. Consequently, these two terms, namely biofeedback therapy and pelvic floor physical therapy, cannot be used interchangeably, and both referring physicians and therapists should be aware of the strengths and limitations of each modality. There is an urgent need for controlled studies examining the efficacy and outcomes of real‐world pelvic floor physical therapy for the treatment of anorectal disorders and to comparing this with biofeedback therapy. Given the high prevalence of constipation and fecal incontinence, the financial implications of such findings are significant. Furthermore, studies that evaluate which patients are better suited for physical therapy or biofeedback therapy may allow strategic use of these treatments. Finally, developing standardized protocols and purposefully designed biofeedback equipment may help to improve standards, and utilizing the most effective evidence‐based components of each therapy could create a superior treatment paradigm with higher response rates.
Author Contributions
Calvin Joomann Park, Satish Rao, Allison Malcolm, and Büşra İnal conceived the study. Calvin Joomann Park, Satish Rao, Allison Malcolm, Büşra İnal, Roshini Nadarajah, and Tracey Cragg contributed to creating and reviewing the survey questions. Calvin Joomann Park implemented the survey into the REDCap platform. Michael P. Jones provided statistical analysis. Calvin Joomann Park, Satish Rao, Allison Malcolm, Büşra İnal, and Michael P. Jones were involved in analyzing the study. Calvin Joomann Park, Satish Rao, and Allison Malcolm created the first draft, and all the authors reviewed subsequent revisions.
Funding
This study was partly supported by the “Ramsay research and training fund”.
Disclosure
Satish Rao: Consultant, Neuroguts.com.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Methods of patient assessment used by biofeedback therapists and pelvic floor physical therapists in the treatment of patients with anorectal disorders.
Table S2: Frequency of different management approaches used by biofeedback therapists and pelvic floor physical therapists in the treatment of anorectal disorders.
Table S3: Types of massage therapy used by biofeedback therapists and pelvic floor physical therapists in the management of patients with anorectal disorders.
Table S4: Details of biofeedback use and exercise schedules used by biofeedback therapists and pelvic floor physical therapists.
Table S5: Rectal balloon training used by biofeedback therapists and pelvic floor physical therapists.
Acknowledgments
Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australasian University Librarians.
Data Availability Statement
Research data are not shared.
References
- 1. Wald A., Bharucha A. E., Limketkai B., et al., “ACG Clinical Guidelines: Management of Benign Anorectal Disorders,” American Journal of Gastroenterology 116, no. 10 (2021): 1987–2008, 10.14309/ajg.0000000000001507. [DOI] [PubMed] [Google Scholar]
- 2. Rao S. S., Bharucha A. E., Chiarioni G., et al., “Functional Anorectal Disorders,” Gastroenterology 150, no. 6 (2016): 1430–1442, 10.1053/j.gastro.2016.02.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Rao S. S., Seaton K., Miller M., et al., “Randomized Controlled Trial of Biofeedback, Sham Feedback, and Standard Therapy for Dyssynergic Defecation,” Clinical Gastroenterology and Hepatology 5, no. 3 (2007): 331–338, 10.1016/j.cgh.2006.12.023. [DOI] [PubMed] [Google Scholar]
- 4. Chiarioni G., Whitehead W. E., Pezza V., Morelli A., and Bassotti G., “Biofeedback Is Superior to Laxatives for Normal Transit Constipation Due to Pelvic Floor Dyssynergia,” Gastroenterology 130, no. 3 (2006): 657–664, 10.1053/j.gastro.2005.11.014. [DOI] [PubMed] [Google Scholar]
- 5. Heymen S., Scarlett Y., Jones K., Ringel Y., Drossman D., and Whitehead W. E., “Randomized, Controlled Trial Shows Biofeedback To Be Superior to Alternative Treatments for Patients With Pelvic Floor Dyssynergia‐Type Constipation,” Diseases of the Colon and Rectum 50, no. 4 (2007): 428–441, 10.1007/s10350-006-0814-9. [DOI] [PubMed] [Google Scholar]
- 6. Shah E. D., Pelletier E. A., Greeley C., et al., “Utility of Anorectal Testing to Predict Outcomes With Pelvic Floor Physical Therapy in Chronic Constipation: Pragmatic Trial,” Clinical Gastroenterology and Hepatology 21, no. 4 (2023): 1070–1081, 10.1016/j.cgh.2022.05.014. [DOI] [PubMed] [Google Scholar]
- 7. Rao S. S. C., Benninga M. A., Bharucha A. E., Chiarioni G., Di Lorenzo C., and Whitehead W. E., “ANMS‐ESNM Position Paper and Consensus Guidelines on Biofeedback Therapy for Anorectal Disorders,” Neurogastroenterology and Motility 27, no. 5 (2015): 594–609, 10.1111/nmo.12520. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Markland A. D., Jelovsek J. E., Whitehead W. E., et al., “Improving Biofeedback for the Treatment of Fecal Incontinence in Women: Implementation of a Standardized Multi‐Site Manometric Biofeedback Protocol. Multicenter Study Randomized Controlled Trial,” Neurogastroenterology and Motility 29, no. 1 (2017): e12906, 10.1111/nmo.12906. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Mazor Y., Kellow J. E., Prott G. M., Jones M. P., and Malcolm A., “Anorectal Biofeedback: An Effective Therapy, but Can We Shorten the Course to Improve Access to Treatment?,” Therapeutic Advances in Gastroenterology 12 (2019): 1756284819836072, 10.1177/1756284819836072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Ussing A., Dahn I., Due U., Sorensen M., Petersen J., and Bandholm T., “Supervised Pelvic Floor Muscle Training Versus Attention‐Control Massage Treatment in Patients With Fecal Incontinence: Statistical Analysis Plan for a Randomized Controlled Trial,” Contemporary Clinical Trials Communications 8 (2017): 192–202, 10.1016/j.conctc.2017.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Heymen S., Scarlett Y., Jones K., Ringel Y., Drossman D., and Whitehead W. E., “Randomized Controlled Trial Shows Biofeedback to Be Superior to Pelvic Floor Exercises for Fecal Incontinence,” Diseases of the Colon and Rectum 52, no. 10 (2009): 1730–1737, 10.1007/DCR.0b013e3181b55455. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Visscher A. P., Leemeijer A., and Felt‐Bersma R. J. F., “Nurse‐ and Pelvic Floor Physical Therapist‐Led Bowel Training in Patients With Fecal Incontinence in a Tertiary Care Center,” Gastroenterology Nursing 44, no. 1 (2021): 39–46, 10.1097/SGA.0000000000000498. [DOI] [PubMed] [Google Scholar]
- 13. Traugott A. L., Barten J., Bordeianou L., et al., “Incorporating Pelvic Floor Physical Therapy in the Treatment of Obstructed Defecation Syndrome and Posterior Compartment Pelvic Organ and Rectal Prolapse: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the International Urogynecological Association, the American Urogynecologic Society, and the American Physical Therapy Association,” International Urogynecology Journal 37, no. 3 (2026): 537–551, 10.1007/s00192-026-06549-z. [DOI] [PubMed] [Google Scholar]
- 14. Hoder A., Stenbeck J., Fernando M., and Lange E., “Pelvic Floor Muscle Training With Biofeedback or Feedback From a Physiotherapist for Urinary and Anal Incontinence After Childbirth ‐ a Systematic Review,” BMC Women's Health 23, no. 1 (2023): 618, 10.1186/s12905-023-02765-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Noelting J., Eaton J. E., Choung R. S., Zinsmeister A. R., G. R. Locke, 3rd , and Bharucha A. E., “The Incidence Rate and Characteristics of Clinically Diagnosed Defecatory Disorders in the Community,” Neurogastroenterology and Motility 28, no. 11 (2016): 1690–1697, 10.1111/nmo.12868. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Mack I., Hahn H., Godel C., Enck P., and Bharucha A. E., “Global Prevalence of Fecal Incontinence in Community‐Dwelling Adults: A Systematic Review and Meta‐Analysis,” Clinical Gastroenterology and Hepatology 22, no. 4 (2024): 712–731.e8, 10.1016/j.cgh.2023.09.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Harris L. A., Horn J., Kissous‐Hunt M., Magnus L., and Quigley E. M. M., “The Better Understanding and Recognition of the Disconnects, Experiences, and Needs of Patients With Chronic Idiopathic Constipation (BURDEN‐CIC) Study: Results of an Online Questionnaire,” Advances in Therapy 34, no. 12 (2017): 2661–2673, 10.1007/s12325-017-0633-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Bharucha A., Rao A., Whitehead W., et al., “S728 Comparative Effectiveness of Biofeedback and Dextranomer/Hyaluronate Injection for Treatment of Fecal Incontinence: A Multicenter Randomized Controlled Trial,” American Journal of Gastroenterology 119, no. 10S (2024): S500. [Google Scholar]
- 19. Harris P. A., Taylor R., Minor B. L., et al., “The REDCap Consortium: Building an International Community of Software Platform Partners,” Journal of Biomedical Informatics 95 (2019): 103208, 10.1016/j.jbi.2019.103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Harris P. A., Taylor R., Thielke R., Payne J., Gonzalez N., and Conde J. G., “Research Electronic Data Capture (REDCap)‐a Metadata‐Driven Methodology and Workflow Process for Providing Translational Research Informatics Support,” Journal of Biomedical Informatics 42, no. 2 (2009): 377–381, 10.1016/j.jbi.2008.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Methods of patient assessment used by biofeedback therapists and pelvic floor physical therapists in the treatment of patients with anorectal disorders.
Table S2: Frequency of different management approaches used by biofeedback therapists and pelvic floor physical therapists in the treatment of anorectal disorders.
Table S3: Types of massage therapy used by biofeedback therapists and pelvic floor physical therapists in the management of patients with anorectal disorders.
Table S4: Details of biofeedback use and exercise schedules used by biofeedback therapists and pelvic floor physical therapists.
Table S5: Rectal balloon training used by biofeedback therapists and pelvic floor physical therapists.
Data Availability Statement
Research data are not shared.