CAM 20164

Biofeedback as a Treatment of Fecal Incontinence or Constipation

Category:Medicine   Last Reviewed:October 2018
Department(s):Medical Affairs   Next Review:October 2019
Original Date:December 2003    

Description:
Biofeedback is a technique to teach patients self-regulation of physiological processes not generally considered to be under voluntary control; a variety of approaches and devices are available. Among possible indications, biofeedback is proposed as a treatment of fecal incontinence and constipation.

For individuals who have fecal incontinence who receive biofeedback, the evidence includes randomized controlled trials (RCTs) and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. Whereas an RCT found that there was a significantly greater decrease in fecal incontinence symptoms with biofeedback plus exercise training than with exercise training alone, most trials did not show a significant benefit. Systematic reviews have not found that biofeedback provides additional benefit when offered in conjunction with conventional therapy compared with conventional therapy alone. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have constipation other than dyssynergia-type constipation who receive biofeedback, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. A systematic review of RCTs found a benefit of biofeedback as a treatment for constipation in adults. Conclusions of the systematic review were limited by variability in patient populations, comparator groups, and outcome measures, and biofeedback was not clearly beneficial for any other type of constipation. The evidence is insufficient to determine the effects of the technology on health outcomes.

Background 
FECAL INCONTINENCE AND CONSTIPATION 
Adults
Fecal incontinence in adults is the recurrent uncontrolled passage of fecal material. Pathophysiology of the disorder ranges from abnormalities in intestinal motility (diarrhea or constipation) to poor rectal compliance, impaired rectal sensation, or weak or damaged pelvic floor muscles. There is no increase in mortality attributable to fecal incontinence. Morbidity includes skin breakdown and urinary tract infections. Fecal incontinence may affect the quality of life by restricting work, recreation, and activities related to “getting out of the house,” impaired social role function, diminished sexual activity, and increase of social isolation due to embarrassment. Fecal incontinence can bring about the loss of independence and mobility. It is the second most common reason for elderly institutionalization. The most common causes of fecal incontinence in adults are obstetric trauma coupled with age-related degeneration, previous anorectal surgery, rectal prolapse, and perineal trauma. In many individuals, the condition is multifactorial, involving a combination of structural, physiological, and psychosocial factors. Conventional interventions to treat fecal incontinence include dietary recommendations (e.g., fiber), bowel and toilet scheduling, and medications (e.g., bulking or antidiarrheal agents).

Constipation refers to infrequent bowel movements and difficulty expelling stool during defecation. Primary constipation is categorized into 3 groups. The most common type is normal-transit constipation in which there is a normal rate of stool movement, but patients feel constipated and may complain of abdominal pain and/or bloating. In the second type, slow-transit constipation, stool moves more slowly through the colon and individuals often experience a limited urge to defecate. The third type, dyssynergic defecation, refers to a loss of ability to coordinate contractions of the pelvic floor muscles and to relax the anal sphincter during defecation. Patients often report an inability to defecate despite the urge to do so.There are also secondary causes of constipation such as the use of certain medications, including opioids and psychoactive drugs; neurologic, endocrine, or metabolic disorders; structural abnormalities; and lifestyle factors. Conventional treatment includes dietary changes (i.e., adequate fiber and fluid intake), use of supplemental bulking substances, exercises, and medications. 

Children
In children, most cases of fecal incontinence and constipation are functional, in which structural, endocrine, or metabolic diseases have been ruled out. Factors contributing to functional incontinence and constipation are fear and/or pain associated with large, hard stools. This leads to retentive posturing in approximately half the children with chronic constipation (ie, the avoidance of defecation by purposefully contracting the external anal sphincter, also termed anismus or paradoxical sphincter contraction).Customary or conventional medical intervention includes dietary changes, bowel and toilet scheduling, softening agents, and education. Behavioral interventions aim to restore normal bowel habits through toilet training, reward and incentive contingency management programs, desensitization of phobia and fear, or skill-building and goal-setting techniques with home practice. Counseling and psychotherapy provide support to the child and address social and psychological problems.

BIOFEEDBACK
Biofeedback, a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control, is used for various conditions and is proposed as a treatment of fecal incontinence and constipation.

Biofeedback training for fecal incontinence focuses on improving the ability to voluntarily contract the external anal sphincter and puborectalis muscles in response to rectal filling and to decrease delay in response to a sensation of distension. For constipation, biofeedback aims to teach patients how to tighten and relax their external anal sphincter to pass bowel movements.

Biofeedback attempts to improve rectal sensory perception, strength, coordination, or some combination of these 3 components. Sensory training involves inducing intrarectal pressure using a balloon feedback device. A manometric balloon probe is inserted into the rectum, and the balloon is filled with air to produce a sensation of rectal filling. Strength training uses either anal canal pressure (manometric) or intra-anal electromyography feedback of pelvic floor muscles. The purpose is to strengthen the force of the pelvic floor muscles contraction without including rectal distention. Some training increases endurance (duration of external anal sphincter contraction) as well as peak strength. Coordination training uses pressure feedback of intrarectal balloon distention with a water-perfused catheter or Schuster-type balloon probe and pelvic floor muscles contractions in a simultaneous feedback display. The purpose of coordination training is to synchronize the contraction of the external anal sphincter with the relaxation of the internal anal sphincter.

Biofeedback techniques convert the physiologic measures from an intra-anal electromyography sensor, anal manometric probe (measuring intra-anal pressure), or perianal surface electromyography electrodes to either a visual or audio display for feedback. Ultrasound has also been used to show patients’ contraction of the anal sphincter on a screen. Biofeedback training is done alone or in combination with other behavioral therapies designed to teach relaxation. Training sessions are performed in a quiet, nonarousing environment.

Regulatory Status
A variety of biofeedback devices are cleared for marketing though the U.S. Food and Drug Administration’s (FDA) 510(k) marketing clearance process. These devices are designated by the FDA as class II with special controls and are exempt from the premarket notification requirements. The FDA defines a biofeedback device as "an instrument that provides a visual or auditory signal corresponding to the status of one or more of a patient's physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters."

Related Policies
20127 Biofeedback as a Treatment of Urinary Incontinence in Adults
20158 Transanal Radiofrequency Treatment of Fecal Incontinence
70169 Sacral Nerve Neuromodulation/Stimulation

Policy

  • Biofeedback is considered INVESTIGATIONAL as a treatment of constipation in adults and children
  • Biofeedback is considered INVESTIGATIONAL as a treatment of fecal incontinence in adults and children.

Benefit Application
BlueCard®/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all U.S. Food and Drug Administration (FDA)-approved devices, drugs or biologics may not be considered investigational, and, thus, these devices may be assessed only on the basis of their medical necessity.

Biofeedback and biofeedback devices are specifically excluded under many benefit plans. In addition, biofeedback and biofeedback devices are considered behavioral training and education/training in nature, and such services are specifically excluded under many benefit plans.

Rationale
This evidence review was created in December 2003 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through September 14, 2017.

Assessment of efficacy for therapeutic interventions involves a determination of whether an intervention improves health outcomes. The optimal study design for a therapeutic intervention is a randomized controlled trial (RCT) that includes clinically relevant measures of health outcomes. Intermediate outcome measures may also be adequate if there is an established link between the intermediate outcome and true health outcomes. Nonrandomized comparative studies and uncontrolled studies can sometimes provide useful information on health outcomes but are prone to biases such as selection bias (e.g., noncomparability of treatment groups) and observation bias (e.g., the placebo effect).

Several specific methodologic difficulties exist in assessing biofeedback. For example, most interventions that include biofeedback are multimodal and include relaxation and behavioral instruction, which may have effects separate from those that may occur due to biofeedback. While some studies have reported a beneficial effect of multimodality treatment, without appropriate control conditions, it is impossible to isolate the specific contribution of biofeedback to the overall treatment effect. For example, relaxation, attention, or suggestion might account for successful results attributed to biofeedback. These are nonspecific therapeutic factors, some of which can be considered placebo effects. Moreover, it is important that studies demonstrate biofeedback improves disease-related health outcomes, as opposed to potentially affecting only physiologic, intermediate outcomes, and that they address the durability of effects beyond the initial, short-term biofeedback training period.

The relevant clinical outcome for biofeedback as a treatment for incontinence should be an overall change in patient symptoms. Reduction in episodes of fecal incontinence and increase in voluntary bowel movements are the primary clinical outcomes, and these are typically reported as the percentage of individuals cured or improved. Achieving normal defecation dynamics (e.g., anal pressure, squeeze pressure, sensory threshold, rectal inhibitory reflex, defecation dynamics) does not correspond with symptom relief (i.e., clinical outcomes). Anorectal physiology measurements are a poor proxy for changes in clinical symptoms. Patient symptoms are usually assessed through a diary, questionnaire, or interview (completed by the patient and, in the case of children, parents). The following is a summary of the key literature to date. 

FECAL INCONTINENCE 
Adults 
Systematic Reviews
Numerous RCTs and several systematic reviews of RCTs on biofeedback treatment for fecal incontinence in adults have been published. In 2009, Enck et al identified 11 RCTs evaluating the efficacy of biofeedback therapy for fecal incontinence in adult populations.2 Two RCTs were excluded, one because of the small sample size and the other because it did not include an appropriate control group. The remaining 9 studies comprised 5 comparisons of different biofeedback modalities and 6 comparisons of electromyographic (EMG) biofeedback vs other types of therapy, mainly pelvic floor exercises. (Two studies had multiple treatment groups and were included in both categories.) The total number of patients included in the 9 studies was 540; sample sizes of individual studies ranged from 18 to 171 patients. A meta-analysis of 5 studies did not find a significant difference in the efficacy of different types of biofeedback (pooled odds ratio [OR], 1.23; 95% confidence interval [CI], 0.74 to 2.20; p=0.38). Similarly, a meta-analysis of studies comparing biofeedback with other therapies did not find a significant difference in efficacy (pooled OR=1.19; 95% CI, 0.69 to 2.05). The outcome measure used in the analysis was not specified and appeared to vary from study to study.

Other systematic reviews have addressed biofeedback alone and in combination with other interventions. A 2013 systematic review by Vonthein et al identified 13 RCTs on biofeedback, electrical stimulation, or their combination for treatment of fecal incontinence.3 Ten trials compared biofeedback with an alternative treatment; some of the biofeedback interventions involved other components such as sensory training and pelvic floor exercises. A meta-analysis of studies comparing biofeedback with a control intervention significantly favored biofeedback (relative risk, 2.12; 95% CI, 1.42 to 3.16). Reviewers did not isolate the effect of biofeedback in multicomponent interventions that included pelvic floor exercise or other treatments. A 2012 Cochrane review identified 21 RCTs evaluating biofeedback and/or sphincter exercises for treating fecal incontinence in adults.4 Most studies used multifaceted interventions (e.g., biofeedback, education, sphincter exercise). Additionally, a wide variety of control interventions were used. Three trials compared biofeedback plus sphincter exercises with sphincter exercises alone, and a single trial compared biofeedback plus 1 type of exercise with biofeedback plus another type of exercise. Reviewers did not pool study findings due to heterogeneity among trials. 

Randomized Controlled Trials
In 2009, Heymen et al randomized 168 individuals with fecal incontinence to 3 months of biweekly pelvic floor exercise training alone (n=85) or exercise training with manometric biofeedback (n=83).5 Twenty-two patients in the exercise-only group and 38 in the biofeedback group improved during a 4-week run-in period and did not participate further, leaving 63 in the exercise group and 45 in the biofeedback group. The primary efficacy outcome was a decrease in scores on the Fecal Incontinence Severity Instrument, a validated 4-item scale, from the end of the run-in to 3 months. The analysis included all patients who completed at least 1 treatment (15 patients dropped out). Reviewers reported a greater reduction in Fecal Incontinence Severity Instrument scores in the biofeedback group than in the exercise-only group (p=0.01; exact scores were not reported). Complete continence (no staining) was reported by 13 (21%) of 63 patients in the exercise-only group and 20 (44%) of 45 in the biofeedback group; this difference was statistically significant (p=0.008). A study limitation was that only 108 (64%) of 168 randomized patients received the intervention and, therefore, baseline imbalances in the treatment groups might have affected study outcomes. A stronger design would have been to randomize patients after, not before, a run-in period.

In 2011, Bartlett et al in Australia published an RCT with 72 participants comparing 2 exercise regimens used with biofeedback for fecal incontinence.6 The trial did not find significant differences in outcomes between the 2 types of exercises. It is not possible to draw conclusions about the efficacy of biofeedback from this study’s findings because all participants received biofeedback.

Norton et al (2003) randomized 171 patients with fecal incontinence to one of 4 treatment groups: standard care (advice), advice plus instruction on sphincter exercises, hospital-based computer-assisted sphincter pressure biofeedback, and hospital biofeedback plus the use of a home EMG biofeedback device.Outcomes included diary reports of incontinence, quality of life, and anal manometry measurements. The authors reported that biofeedback yielded no greater benefit than standard care.

Solomon et al (2003) randomized 120 patients with mild-to-moderate fecal incontinence to one of 3 treatment groups: biofeedback with anal manometry, biofeedback with transanal ultrasound, or pelvic floor exercises with feedback from digital examination alone.8 There were no significant differences in outcomes among the treatment groups; all reported modest improvements.

Children
A Cochrane review of behavioral and cognitive interventions for children with fecal incontinence was published in 2006 and updated in 2011.9,10 Of 21 included studies, 9 compared conventional treatment alone (i.e., laxatives, toilet training, dietary advice) with conventional treatment plus biofeedback. Eight trials included children with functional fecal incontinence and the ninth included children with fecal incontinence due to myelomeningocele (n=12). Four trials included children who had fecal incontinence due to constipation, and three others included children who had fecal incontinence due to constipation and pelvic floor dyssynergia. When data from the 9 studies were combined, 133 (51%) of 260 children in the conventional treatment plus biofeedback group were not cured or improved at follow-up compared with 121 (48%) of 250 children in the conventional treatment-only group. In a meta-analysis (random effects), this difference was not statistically significant (pooled OR=1.08; 95% CI, 0.63 to 1.84). The analysis combined 6- and 12-month follow-up data; 12-month data were used when available. Reviewers concluded that findings from RCTs did not support the claim that biofeedback training provides additional benefit to conventional treatment in the management of fecal incontinence associated with constipation. They also stated that, due to a lack of sufficient trials, they could not evaluate the effects of biofeedback in children with organic fecal incontinence. 

Section Summary: Fecal Incontinence
The available evidence on biofeedback for fecal incontinence in adults and children includes RCTs and systematic reviews of those RCTs. Studies are characterized by heterogeneity of the interventions, comparators, and follow-up durations used. The studies generally failed to report significant differences between biofeedback and comparison groups in outcome improvements.

CONSTIPATION 
Idiopathic Constipation, Not Specifically Dyssynergic Type 
Adults
Several systematic reviews of RCTs have been published on idiopathic constipation. Most recently, in 2014, a Cochrane review identified 17 trials (total N=931 patients) addressing the efficacy of biofeedback for treating adults with idiopathic constipation.11 Seven trials compared biofeedback with conventional nonsurgical treatment, six compared alternative approaches with biofeedback, two compared biofeedback with surgical intervention, one compared biofeedback with electrical stimulation, and one used a sham control. Sample sizes ranged from 21 to 109 patients (mean, 48 patients per trial). Sixteen RCTs were judged to be at high risk of bias lack of blinding of patients and outcome assessment. Blinding in the remaining study was unclear. Trials all used different biofeedback protocols and eleven used EMG biofeedback. Length of follow-up varied; 4 trials followed patients to the end of the intervention and 7 trials followed patients for 1 year. In most trials, a symptom scoring system was used as an outcome, with scores varying by symptoms included. Due to heterogeneity among trials, meta-analyses were not conducted. Reviewers concluded that there was insufficient evidence to conclude the efficacy of any particular biofeedback protocol used to treat chronic constipation in adults.

Previously, in 2009, the Enck systematic review (described in the Fecal Incontinence section) also reviewed the literature on biofeedback for constipation and conducted several meta-analyses.2  Eight RCTs conducted in adults were identified. Four compared 2 types of biofeedback; meta-analysis of these 4 studies did not find a significant benefit for 1 technique over another (pooled OR=1.44; 95% CI, 0.69 to 3.09; p=0.32). The other 4 studies compared biofeedback with another treatment. Comparison treatments (1 study each) were botulinum toxin, laxatives, diazepam, and best supportive care (diet, exercise, laxatives). Two studies also included a third arm, in which treatment was a sham or placebo intervention. Three of the 4 studies included patients with dyssynergia-type constipation, and the fourth included patients with anismus. Meta-analysis of the 4 studies comparing 1 treatment with another (using the active intervention arm as the comparator in the 3-arm trials) found a significantly greater benefit of biofeedback in improving constipation symptoms (pooled OR=3.23; 95% CI, 1.88 to 5.58; p<0.001). Results of this systematic review were limited by heterogeneity in patient populations, comparator treatments, and outcome measures. 

Children
No systematic reviews or meta-analyses on biofeedback for constipation in children, not associated with fecal incontinence, were identified. The literature search identified a single RCT published since 2000. In 2001, van Ginkel et al selected 212 Dutch children at least 5 years old with constipation who met at least 2 of the following 4 criteria: (1) stool frequency fewer than 3 times per week; (2) 2 or more soiling and/or encopresis episodes per week; (3) periodic passage of very large amounts of stool every 7 to 30 days; or (4) a palpable abdominal or rectal fecal mass.12 Participants were randomized to 6 weeks of standard treatment (i.e., education, laxatives [n=111]) or standard treatment plus 2 sessions of anorectal manometry (n=91). During the manometry sessions, children were asked to squeeze the sphincter as tightly as possible 5 times. Squeeze pressure data were digitally converted; data could be viewed on a computer by the child and parent. Data were discussed after the sessions, and instructions were given on how to perform defecation exercises at home. Ten (5%) of 212 randomized patients did not receive treatment; the remainder completed the intervention. Treatment success was defined as achieving 3 or more bowel movements per week and fewer than 1 soiling and/or encopresis episodes per 2 weeks while not receiving laxatives. At 6 weeks, 4 (4%) of 111 in the standard treatment group and 6 (7%) of 91 in the biofeedback group were considered to have successful treatment; this difference was not statistically significant. There was also no statistically significant difference between groups at any other follow-up point. At the final follow-up, 36 (43%) of 83 patients in the standard treatment group and 23 (35%) of 65 in the biofeedback group were considered treatment successes. Data on 30% of randomized patients were missing at final follow-up. This trial did not control for nonspecific effects of biofeedback. 

Section Summary: Idiopathic Constipation, Not Specifically Dyssynergic Type
For adults with idiopathic constipation, the evidence for biofeedback consists of multiple randomized trials, which have been summarized in several systematic reviews. Overall, the evidence is limited by the heterogeneity of patient populations, comparator groups, and outcome measures, and does not show a significant benefit with biofeedback. For children, the evidence is more limited, with a single RCT published since 2000; it did not find any statistically significant differences for biofeedback regarding most treatment outcomes.

SUMMARY OF EVIDENCE
For individuals who have fecal incontinence who receive biofeedback, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. Whereas an RCT found that there was a significantly greater decrease in fecal incontinence symptoms with biofeedback plus exercise training than with exercise training alone, most trials did not show a significant benefit. Systematic reviews have not found that biofeedback provides additional benefit when offered in conjunction with conventional therapy compared with conventional therapy alone. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have constipation other than dyssynergia-type constipation who receive biofeedback, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. A systematic review of RCTs found a benefit of biofeedback as a treatment for constipation in adults. Conclusions of the systematic review were limited by variability in patient populations, comparator groups, and outcome measures, and biofeedback was not clearly beneficial for any other type of constipation. The evidence is insufficient to determine the effects of the technology on health outcomes.

PRACTICE GUIDELINES AND POSITION STATEMENTS 
American Neurogastroenterology and Motility Society et al
In 2015, the American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Mobility jointly published consensus guidelines on biofeedback therapy for anorectal disorders.16 The guidelines included the following recommendations:

  • “Biofeedback is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation.”
  • “Biofeedback therapy is recommended for the short-term and long-term treatment of fecal incontinence.”
  • “Biofeedback therapy is not recommended for the routine treatment of children with functional constipation, with or without overflow fecal incontinence.”

American Society of Colon and Rectal Surgeons
In 2015, the American Society of Colon and Rectal Surgeons updated its guidelines on the treatment of fecal incontinence.17 The guidelines recommended that biofeedback be considered as an initial treatment for patients with fecal incontinence who have some preserved voluntary sphincter contraction ability.

In 2016, the Society published guidelines on the evaluation and management of constipation.18 The guidelines state that biofeedback therapy is a first-line treatment for symptomatic pelvic floor dyssynergia (strong recommendation, moderate quality of evidence).

American Gastroenterological Association
In 2013, the American Gastroenterological Association updated its position statement on constipation. The statement included the following on biofeedback: “Pelvic floor retraining by biofeedback therapy rather than laxatives is recommended for defecatory disorders (Strong Recommendation, High-Quality Evidence).”19

National Institute for Health and Care Excellence
In 2010 (reaffirmed in 2017), the National Institute for Health and Care Excellence issued guidance on constipation in children and young people. The guidance indicated that biofeedback should not be used for ongoing treatment.20

In 2007, the Institute issued guidance on fecal incontinence in adults; the guidance stated the following on biofeedback: “The evidence we found did not show biofeedback to be more effective than standard care, exercises alone, or other conservative therapies. The limited number of studies and the small number of participants in each group of the studies make it difficult to come to any definitive conclusion about its effectiveness.”21

American College of Gastroenterology
In 2014, the American College of Gastroenterology published guidelines on the management of fecal incontinence.22 The guidelines indicated that pelvic floor rehabilitation techniques (e.g., biofeedback, therapeutic exercises) are effective in patients with fecal incontinence who do not respond to conservative measures (strong recommendation, moderate quality of evidence).

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS
The U.S. Preventive Services Task Force has not addressed biofeedback for fecal incontinence or constipation. 

ONGOING AND UNPUBLISHED CLINICAL TRIALS
A search of ClinicalTrials.gov in November 2016 did not identify any ongoing or unpublished trials that would likely influence this review.

References:

  1. 21 CFR § 882.5050.
  2. Enck P, Van der Voort IR, Klosterhalfen S. Biofeedback therapy in fecal incontinence and constipation. Neurogastroenterol Motil. Nov 2009;21(11):1133-1141. PMID 19566591
  3. Vonthein R, Heimerl T, Schwandner T, et al. Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review. Int J Colorectal Dis. Nov 2013;28(11):1567-1577. PMID 23900652
  4. Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev. Jul 11 2012;7(7):CD002111. PMID 22786479
  5. Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum. Oct 2009;52(10):1730-1737. PMID 19966605
  6. Bartlett L, Sloots K, Nowak M, et al. Biofeedback for fecal incontinence: a randomized study comparing exercise regimens. Dis Colon Rectum. Jul 2011;54(7):846-856. PMID 21654252
  7. Norton C, Chelvanayagam S, Wilson-Barnett J, et al. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology. Nov 2003;125(5):1320-1329. PMID 14598248
  8. Solomon MJ, Pager CK, Rex J, et al. Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the treatment of mild to moderate fecal incontinence. Dis Colon Rectum. Jun 2003;46(6):703-710. PMID 12794569
  9. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. Apr 19 2006(2):CD002240. PMID 16625557
  10. Brazzelli M, Griffiths PV, Cody JD, et al. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. Dec 07 2011(12):CD002240. PMID 22161370
  11. Woodward S, Norton C, Chiarelli P. Biofeedback for treatment of chronic idiopathic constipation in adults.Cochrane Database Syst Rev. Mar 26 2014;3(3):CD008486. PMID 24668156
  12. van Ginkel R, Buller HA, Boeckxstaens GE, et al. The effect of anorectal manometry on the outcome of treatment in severe childhood constipation: a randomized, controlled trial. Pediatrics. Jul 2001;108(1):E9. PMID 11433088
  13. Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum. Apr 2007;50(4):428-441. PMID 17294322
  14. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. Mar 2007;5(3):331-338. PMID 17368232
  15. Rao SS, Valestin J, Brown CK, et al. Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol. Apr 2010;105(4):890-896. PMID 20179692
  16. Rao SS, Benninga MA, Bharucha AE, et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. May 2015;27(5):594-609. PMID 25828100
  17. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. Jul 2015;58(7):623-636. PMID 26200676
  18. Paquette IM, Varma M, Ternent C, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the evaluation and management of constipation. Dis Colon Rectum. Jun 2016;59(6):479-492. PMID 27145304
  19. American Gastroenterological Association, Bharucha AE, Dorn SD, et al. American Gastroenterological Association medical position statement on constipation. Gastroenterology. Jan 2013;144(1):211-217. PMID 23261064
  20. National Institute for Health and Care Excellence (NICE). Constipation in children and young people: diagnosis and management [CG99]. 2017; http://www.nice.org.uk/guidance/CG99. Accessed September 18, 2017.
  21. National Institute for Health and Care Excellence (NICE). Faecal incontinence in adults: management [CG49]. 2007; https://www.nice.org.uk/guidance/cg49. Accessed October 25, 2017.
  22. Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. Aug 2014;109(8):1141-1157; (Quiz) 1058. PMID 25022811
  23. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Biofeedback Therapy (30.1). n.d.; https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?TAId=10&MEDCACId=15&CALId=185&MCDId=27&NCDId=41&ncdver=1&CoverageSelection =National&ncd_id=20.20&ncd_version=2&basket=ncd%2525253A20%2525252E20%2525253A2%2525253AExternal+Counterpulsation+%25252528ECP%25252529+for+Severe+Angin&bc=gAAAABAAAAAAAA%3D%3D&. Accessed October 25, 2017.

Coding Section

Codes Number Description
CPT  90875-90876 

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying, or supportive psychotherapy); code range 

  90901 Biofeedback training by any modality
  90911

Biofeedback training, perineal muscles, anorectal, or urethral sphincter,

ICD-9 Procedure 93.08 EMG
  94.39 Other individual psychotherapy (biofeedback)
ICD-9 Diagnosis 564.00-564.09 Constipation coding range
HCPCS E0746 Electromyography (EMG), biofeedback device
ICD-10-CM (effective 10/01/15)  K59.00-59.09 Constipation code range
ICD-10-PCS (effective 10/01/15)   ICD-10-PCS codes are only used for inpatient services.
  GZC9ZZZ Biofeedback
Type of Service Medicine  
Place of Service Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

10/11/2018 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

10/03/2017 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

10/04/2016 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

10/13/2015 

Annual review,no change to policy intent.Updated background, description, rationale, references and coding. 

10/06/2014

Annual review. No change in policy intent. Updating rationale and references. Added coding section.


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