This is a nurse-led service, headed by Nurse Consultant Professor Christine Norton PhD MA RN. We have a team of specialist nurses and physiotherapists who manage patients with a range of functional gastrointestinal disorders, including faecal incontinence and constipation as the two largest groups. We have 700-800 new referrals each year and 70-80% of patients report improved symptoms, with lasting effect for the majority (Chiotakakou-Faliakou 1998; Norton & Kamm 1999). The nurses and physiotherapists work within a multidisciplinary team and patients can be discussed with, or referred to a gastroenterologist, colorectal surgeon, counsellor, psychologist, psychotherapist, dietician and other nurse specialists if indicated. Regular clinical supervision and audit of case decisions is undertaken by the Nurse Consultant and a Consultant Gastroenterologist. However, we do expect that referring doctors have considered possible bowel pathology and investigated patients appropriately prior to referral for biofeedback.
Patients are posted a symptom questionnaire and bowel diary to complete and bring to the first appointment. Initially, each patient will have a one hour assessment interview initially. Biofeedback offers patients an individualised package of care: they are assessed and seen for 4-5 appointments at 4-6 weekly intervals with ongoing care from the same therapist. The team work flexible hours in order to accommodate most patients.
Biofeedback is widely regarded as a first line non invasive treatment in constipation, evacuatory disorders and faecal incontinence (NICE 2007). NICE have also identified the “positive effect” of Biofeedback on IBS patients. Studies have shown that Biofeedback for bowel dysfunction is effective in 80% of patients with the majority of these maintaining long term benefits (Ryn et al 2000; Rao 2008). Biofeedback is a behavioural approach to which there are no side effects, it is non-invasive and offers a non-surgical approach as an alternative for patients with bowel dysfunction. A recent audit of 370 patients at St Marks biofeedback department showed 90% of patients improved their symptoms. The patients rating of change to their bowel symptoms was a median of 3/5 and rating of satisfaction with the treatment was a median of 8/10.
The team consists of:
Nurse Consultant Professor Christine Norton
Lead Nurse Brigitte Collins
Clinical Nurse Specialist Elissa Bradshaw
Clinical Nurse Specialist Lorraine O’Brien
Clinical Nurse Specialist Anna Swatton
Clinical Biofeedback/Physiotherapy Specialist Patricia Evans
Constipated patients will have a pre-arranged abdominal transit X-ray study and a proctogram X-ray if indicated, on the same day and be seen with the result. Any further tests indicated by the assessment can be arranged by the nurse specialist. Each patient will have a one hour assessment interview with a clinical nurse specialist initially. This determines the symptoms and any contributing factors. A detailed explanation of bowel function is given. The patient is taught correct evacuation techniques using a range of exercises developed at this hospital (Storrie 1997). Advice is also given of a range of related issues such as diet, fluid intake, lifestyle and stress management.
Patients with faecal incontinence will have an anal ultrasound and anorectal physiology tests pre-arranged on the same day and be seen with the results. Any further tests indicated by the assessment can be arranged by the nurse specialist. Each patient will have a one hour assessment interview with a clinical nurse specialist (Norton & Chelvanayagam 2000). This determines the symptoms and any contributing factors. A detailed explanation of bowel function is given. The patient is taught to exercise the anal sphincter and pelvic floor, usually using computer-assisted biofeedback equipment (Norton & Chelvanayagam 2001). Some patients are also loaned a home electrical stimulator. Advice is also given of a range of related issues such as diet, fluid intake, lifestyle and stress management (Norton & Kamm 1999a).
For further details contact Lead Nurse (Bowel Control) Brigitte Collins: firstname.lastname@example.org
For further information on advice given to patients see St Marks Hospital website.
In addition to their specialist Biofeedback knowledge the team also provides a nurse led SNS (Sacral Nerve Stimulation) clinic for patients who have undergone implantation at St Marks. Sacral Nerve Stimulation is advocated by NICE (1) for patients who have undergone Biofeedback for faecal incontinence but not gained satisfactory outcome. Patients are carefully selected following specialist consultant and registrar review where it is agreed the treatment is indicated.
All women who have a 3rd and 4th degree tear at NWLH are given a routine appointment at 4-6 months after delivery. Assessment is by nurses and midwives. A biofeedback therapist attends who can commence biofeedback at the initial consultation for symptomatic women. The therapist is then able to refer on to the biofeedback team as and when appropriate. This clinic has been important in contributing to audit in the Maternity Department. Approximately 12-14 patients are seen each month.
The team are also able to offer Porridge Enema Testing.
Increasingly the Porridge Enema Test (PET) is becoming widely accepted as an additional tool for continence assessment prior to stomal reversal – the premise being to ascertain the patients’ sphincter function to give an indication of post closure anal continence (5;6). It is a simple test which is used in conjunction with the surgical consultants’ specialist opinion, with anorectal Physiology tests and endoanal ultrasound results. Number of patients seen for porridge enema testing in 2010 was three.
The lead nurse commenced a diploma in hypnosis in October 2010 to be able to add this as another treatment within the biofeedback service. NICE guidelines (2008) recommend that referral for hypnosis should be considered for people with IBS. The guidelines suggest that hypnosis provides patients with benefits in a cost effective manner.