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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_837_Библиотеки_им_академика_М_И_Перельмана.pdf
Defecation
Puborectalis
Anorectal angle is
31 Pelvic Outlet Obstruction
Fig. 31.2 Cross-section
of the normal pelvic
oor musculature at rest
(a) and during
defecation (b). During
defecation, the
puborectalis muscle
relaxes, and the
anorectal angle (shown
in red) broadens
a
Uterus
Bladder
Puborectalis
muscle
(contracted)
b
239
Anorectal angle
Anal sphincter
(closed)
Rest
muscle
(relaxed)
asked if they have a history of sexual abuse,
and also whether any psychiatric conditions
are present, including eating disorders, phobias, and obsessive-compulsive disorder.
J.In-ofce examination by the surgeon is essen-
tial, as a skilled examiner is likely to identify
obstructive defecation. After an abdominal
exam the patient should be placed in the prone
jackknife or left lateral decubitus position, an
in-depth anorectal exam is performed, begin-
ning with inspection of the anoderm. The
perineum should be examined for the presence
of scars and bulk to the perineal body.
Assessment should note the presence of hemorrhoids, skin tags, ssures, or other lesions
and pin- prick sensitivity of the anoderm
should be assessed. Digital rectal exam should
evaluate resting and squeeze tone, or any
masses, as well as the presence and consistency of stool in the vault. Presence or absence
broadened
Anal sphincter
(open)
240
J. S. Davids
Table 31.1 Important elements of the initial history in a
patient with suspected pelvic outlet obstruction
Duration of symptoms, age of onset (childhood,
teenage years, or adulthood)
Bowel movement frequency, consistency, timing
(erratic or consistent)
Toileting habits: daily routine, sitting, straining,
perineal or vaginal splinting
Is there tissue protrusion or a “bulge” with defecation?
Is there pain or blood?
Fecal incontinence
Urinary or sexual symptoms
Abdominal pain, cramping, bloating
Emotional or psychological stress, identiable
symptom triggers
Diet: ber and water intake
of rectocele should be evaluated. Additionally,
on digital rectal exam, the patient should be
asked to squeeze tightly “as if holding back a
bowel movement” and then asked to relax.
Next, the patient should be asked to “bear
down as if having a bowel movement.”
Patients with normal pelvic oor mechanics
should relax the puborectalis sling and sphincter complex, and there should be appreciable
descent of the pelvic oor; the examiner’s nger will shift anteriorly. Patients with pelvic
outlet obstruction will tighten rather than relax
the sphincter complex, and consequently the
pelvic oor will contract and not descend.
With a clean glove, the vagina may be palpated to assess for evidence of uterovaginal
prolapse.
K. Anoscopy should be performed, specically
looking for evidence of bulky internal hemorrhoids, proctitis, or mucosal redundancy. If
there is concern for signicant hemorrhoidal,
mucosal, or full thickness rectal prolapse, the
patient should be examined after straining on
the commode.
L.Diagnostic evaluation. Prior records should be
carefully reviewed to avoid unnecessarily
repeating often uncomfortable or invasive
studies. With that being said, some diagnostic
studies are user-dependent or may change over
time, and may therefore need to be repeated.
Careful consideration should be given to any
diagnostic evaluation to determine what spe-
cic question will be answered, and how it
could impact management. Accordingly, many
so-called “abnormal” ndings seen on these
diagnostic studies are also seen in asymptomatic individuals, leading to false- positives, further obscuring interpretation.
M.Endoscopic evaluation. Patients should have
either exible sigmoidoscopy or colonoscopy
depending on their age, symptoms, and the
index of suspicion of co-existing abnormalities of the lower gastrointestinal tract.
N.Evaluation of colonic motility. One method to
assess colonic motility is to perform serial
abdominal X-rays after the patient swallows a
capsule that dissolves in the stomach, releasing radiopaque markers. The X-rays will show
the progression of the markers over time.
Patients are generally instructed to discontinue all of their laxatives, motility agents, and
enemas for the duration of the test; however,
the clinician and patient may decide to continue these agents, as the study may otherwise
prove to be intolerable with respect to symptoms. X-rays are typically obtained on days 1,
3, and 5. The “classic” nding for patients
with pelvic outlet obstruction is that the markers will cluster in the rectosigmoid colon, as
they are not being passed through the pelvic
oor musculature into the lower rectum (and
then evacuated). Patients who also have slow
transit constipation may need additional lms
on day 7, 9, or potentially later to determine if
they do eventually cluster in the rectosigmoid
colon; transit studies in these patients may be
challenging to interpret.
Most commonly used is the Sitzmark capsule (Konsyl Pharmaceuticals, Easton, MD),
which contains 24 radio-opaque rings and dissolves when ingested. A simple image
obtained 5 days after capsule ingestion will
easily diagnose normal transit (Fig.31.3).
O. Anorectal physiology evaluation. A compre-
hensive evaluation by a highly skilled and
experienced surgeon or technician is essential.
Patients should be reassured that the examination should not be painful and will last
30–45min. Patients need to perform an enema
prep 90min prior to the procedure.
31 Pelvic Outlet Obstruction
Fig. 31.3 Colonic transit capsule (Konsyl Pharmaceuticals,
Easton, MD), which contains 24 radiopaque rings and dissolves when ingested. A simple image obtained 5days after
capsule ingestion will easily diagnose normal transit
(a) Manometry: A probe attached to a pres-
sure transducer is inserted into the rectum,
and will enable the examiner to determine
rectal pressures at rest, as well as in
response to stimuli or to voluntary movement. Using a balloon inated in the rectum, manometry can be used to assess
rectal sensation and compliance, by determining (1) the volume at which the balloon is sensed, (2) the volume that triggers
need to have a bowel movement, and (3)
the maximum tolerated volume.
Additionally it can be used to test RAIR
and RAER by monitoring the reex tracing of the internal and external sphincter
when the balloon is rapidly inated with
10-30mL of air to simulate rectal distension by stool.
(b) Balloon expulsion: A balloon lled with
50cc of warm water is inserted into the
rectum, to simulate the presence of stool.
241
Patients are instructed to expel the balloon. Most healthy subjects can pass the
balloon in under 60s. Failure to pass the
balloon is highly specic for obstructive
defecation, and around 50% sensitive.
(c) Electromyography (EMG): A probe is
used to quantify the electrical impulse of
the pelvic oor muscles and sphincter
complex at rest, with voluntary squeeze,
and with Valsalva or simulated evacuation. EMG can be used to detect paradoxical excitation of the pelvic oor during
Valsalva.
(d) Transanal Ultrasound: 2D or 3D images
can be obtained with frequencies ranging
from 6 to 16MHz. Images may demonstrate circumferential thickening of the
internal anal sphincter, consistent with a
history of chronic straining.
P. If the diagnosis is clear with the aforemen-
tioned initial evaluation, it is reasonable to
move forward and treat the patient, starting
with a conservative approach.
Q.If, by contrast, the diagnosis is still unclear, or
if there is evidence of multiple associated
abnormalities, it is recommended to pursue
further diagnostic evaluation.
R. Defecography is a useful adjunct study to
evaluate defecation mechanics in real time. It
can be difcult to interpret, as normal, asymptomatic subjects may also manifest abnormalities on defecography. It is an excellent
adjunct study if there is concern of concomitant rectocele, enterocele, cystocele, abnormal perineal descent, rectal intussusception,
or if the balloon expulsion test was inconclusive. Patients undergoing defecography have
barium paste placed into the rectum (approximately 150mL). Contrast can also be placed
in the vagina or instilled in the bladder, and
patients may also ingest oral contrast to
opacify the small intestine. While sitting on a
commode, the patients are asked to evacuate
the barium paste from the rectum, as serial
images are captured using uoroscopy. Cinedefecography refers to a series captured using
continuous uoroscopy. Studies of patients
with pelvic outlet obstruction will demonstrate
242
J. S. Davids
a narrowing of the anorectal angle (or no
change) with attempted defecation, with
retention of the contrast, corresponding to
paradoxical contraction (or nonrelaxation) of
the puborectalis sling. Dynamic pelvic magnetic resonance imaging (MRI), also referred
to as dynamic MR proctography, can also be
performed at some centers where this technology is available. This is performed either
in supine or sitting position (with open magnet system) and images are taken while the
patient strains, squeezes, and defecates. It
does not require intravenous contrast, or contrast to be instilled in the bladder, vagina, or
small intestine. The rectum is distended with
ultrasound gel. This modality may be particularly helpful to identify soft tissue planes in
patients with complex anatomy from prior
repairs, and also avoids ionizing radiation.
S.Ultrasound of the pelvic oor is also an effec-
tive adjunct to diagnose pelvic outlet obstruction. Both transperineal and endoanal
techniques are used to assess the anorectal
angle and pelvic oor motion. The study is
generally well-tolerated, is inexpensive, and is
not associated with ionizing radiation exposure. Dynamic 4D ultrasound technology
allows for 3D visualization of the pelvic
organs and musculature as a real-time simulation of defecation. With most modern equipment, the operator can record and store
multiple cine simulations. Despite its many
advantages, dynamic 4D ultrasound is not
widely available because it is highly operatordependent, and therefore it is imperative that
the examiner is skilled in this modality.
T. It is important that the clinician clearly
expresses honest, realistic goals of treatment
and expectations for recovery with the patient.
The goals of treatment are to improve defecation mechanics and stool texture, which ultimately, for most patients, will result in a
profound improvement in quality of life.
Treatment of pelvic outlet obstruction can be
extremely challenging and time-consuming.
Rarely is pelvic outlet obstruction “cured”
with one intervention or in just one setting.
Surgical approaches to pelvic outlet obstruc-
tion are quite limited; therefore, treatment
plans begin with conservative, simple measures aimed at improving stool texture. The
best treatment plans employ a multimodal
approach (e.g., dietary changes and biofeedback), reserving surgery for failure of the lessinvasive approaches.
U. Dietary changes are employed as the rst-line
therapy to improve stool texture. Patients
should increase their dietary ber intake to
25–30g per day, and may gradually increase
to up to 50g per day. This goal can be accomplished by adding high-ber cereal and powdered ber supplements such as psyllium,
methylcellulose, polycarbophil, and wheat
dextrin. Fiber wafer formulations or soluble
ber gummies can help bulk up stool. Along
with ber supplementation, patients should
stay well-hydrated, particularly in the warmer
weather, and consume 1–2L of uid over a
24h period. Patients with severe constipation
may also need to add laxatives and other
adjunct medications to soften hard stool.
V. Pelvic oor physical therapy can be helpful in
improving defecation mechanics in patients
with pelvic outlet obstruction. Pelvic oor
physical therapy is generally performed by a
licensed physical therapist with specialized
knowledge of pelvic oor anatomy and biomechanics. Additionally, biofeedback may be
performed, which will allow the provider to
evaluate the pelvic oor muscle pressure or
with electromyography probes, which provides some quantitative data to document
improvement and areas for ongoing therapy.
Reported efcacy of pelvic oor physical
therapy in patients with obstructive defecation
is mixed. A meta-analysis of a total of 38 studies demonstrated signicant heterogeneity
between techniques and approaches, but overall, efcacy ranged from 69% to 75%.
W.Botulinum toxin A (Botox; Allergan; Madison,
NJ) has been shown in small studies to
improve symptoms of pelvic outlet obstruction. A study of 24 patients, in which botulinum toxin (60 Units) was injected under
ultrasound guidance in two sites on either side
of the puborectalis muscle using a 23-gauge
31 Pelvic Outlet Obstruction
243
needle. Patients did not receive sedation or
local anesthetic. Using this technique, the
authors demonstrated symptomatic improvement in 19 patients (79%). The symptomatic
improvement also correlated with increased
anorectal angle on defecography. Given that
the effects of the toxin only last 3months, it is
unclear how often (and how many times) the
injection would need to be repeated for maintenance of long-term results.
X. Intestinal stoma creation should be considered
in select patients who continue to manifest
refractory debilitating symptoms. Patients
should be counseled that the need for a colostomy should not represent “failure,” as it can
be a highly effective approach, and may enable
them to move past their disease, and experience an improved quality of life. Importantly,
patients with evidence of concurrent slowtransit constipation should be considered for
ileostomy and not colostomy. It is important
to note that some patients may require an
intestinal stoma due to their inability to
undergo pelvic oor physical therapy due to
physical or psychological coexisting conditions; it is therefore not necessary to reserve
this option only for those with persistent
symptoms despite non-surgical approaches.
In summary, pelvic outlet obstruction is a
complex disease that can prove to be a signicant diagnostic and therapeutic challenge. The
evaluation begins with a detailed history and
physical exam. Diagnostic workup is individualized and involves ruling out other associated
conditions, such as slow-transit constipation,
pelvic organ prolapse, or internal rectal intussusception. Initially, treatment strategies concentrate on lifestyle and dietary changes, and
also include pelvic oor physical therapy, botulinum toxin injection, and lastly, surgery.
Suggested Reading
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Marmo R, etal. Water supplementation enhances the
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Chiarioni G, Bassotti G, Monsignori A, Menegotti M,
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of the pelvic oor: a pictorial review. Radiographics.
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tion of posterior compartment vaginal prolapse and
obstructed defecation. Ultrasound Obstet Gynecol.
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review. Dis Colon Rectum. 2003;46(9):1208–17.
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Pelvic Floor Conditions: Biofeedback
JenniferS.Beaty andCharlesA.Ternent
32
Refer toAlgorithm in Fig.32.1
Background
The internal anal sphincter is the distal (2.5–
4.0cm) condensation of the circular muscle layer
of the rectum. As a smooth muscle in a state of
continuous maximal contraction, the internal
anal sphincter is a natural barrier to the involuntary loss of stool and gas. The internal anal
sphincter contributes 50–85% of the resting tone.
The external anal sphincter is the elliptical cylinder of striated muscle that envelops the entire
length of the inner tube of smooth muscle which
contributes 25% to 30% of the resting tone of the
anal canal. The deepest portion of the external
anal sphincter is intimately related to the puborectalis muscle. The external anal sphincter is usually inactive at rest. The external anal sphincter
will contract with increased intra-abdominal
pressure and rectal distension for 30–60 s. The
levator ani muscle is the major component of the
pelvic oor and is composed of iliococcygeus,
pubococcygeus, and puborectalis muscles. The
puborectalis is a strong, U-shaped loop of striated
muscle that is the most medial portion of the
J. S. Beaty · C. A. Ternent (*)
Section ofColon andRectal Surgery, CHI Bergan
Mercy Medical Center, Creighton University School
of Medicine, Omaha, NE, USA
e-mail: cat@colonrectalsurgeons.com
levator ani complex. The puborectalis is responsible for the anorectal sling around the anorectal
junction and the anorectal angle, which play roles
in both continence and ability to defecate effectively (Table 32.1).
Pelvic Floor Dysfunction
A. Deranged pelvic oor function encompasses
a variety of conditions that often result in signicantly decreased health related quality of
life. Pelvic oor dysfunction or dyssynergia
(PFD) is one such condition. PFD is also
known as dyssynergic defecation, anismus
and paradoxical anal or puborectalis contraction. PFD is a common entity that can affect
up to one half of patients with constipation.
The etiology of PFD is not clear, but it appears
to represent an acquired abnormal behavior
of increased contraction of the pelvic oor
and anus with strain effort that interferes with
normal defecation. This failure to relax the
puborectalis muscle during defecation produces a functional—not a physical—obstruction. Cardinal symptoms of PFD are straining
at stools and sensation of incomplete evacuation. The diagnostic criteria for dyssynergic
defecation, recently updated in the Rome III
report, include those for functional constipation plus at least two out of three investigations (radiology, manometry and
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making inColorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_32
245
246
J. S. Beaty and C. A. Ternent
Fig. 32.1 Algorithm for pelvic oor biofeedback; Dx diagnosis, FI fecal incontinence, SNS sacral nerve stimulation
electromyography) showing inappropriate
contraction or failure to relax the pelvic oor
muscles during attempts to defecate
(Fig.32.2). Inadequate defecatory propulsion
represents another abnormal pattern of defecatory physiology described in the Rome III
criteria (Romecriteria.org). It is associated
with inadequate abdominal propulsive forces
and decreased Valsalva maneuver with or
without inappropriate contraction or less than
20% relaxation of the anal sphincter during
attempted defecation. Fecal incontinence (FI)
can also be associated with various derangements of pelvic oor function, including:
alteration of innervation of the pelvic oor
and anorectal area. In addition, anatomic
injury can result in decreased anal canal tone
and decreased anorectal sensation which can
lead to FI.
B. A history and physical examination can
help to diagnose and guide the workup of
PFD and FI. A detailed medical history
should identify any ongoing issues with
infrequent bowel movements, excessive
straining with bowel movements and fecal
incontinence. A digital rectal exam should
be performed to assess appropriate contraction of the anal sphincter and pelvic oor at
rest, strain and squeeze. Increased anal
canal tone at strain suggests the presence of
PFD. Decreased anal canal tone at rest or
squeeze may suggest prior anatomic or neurogenic injury in patients with FI.Minimal
or absent abdominal Valsalva effort with
strain can suggest ongoing inadequate defecatory propulsion issues. Anorectal physiology tests such as anorectal manometry
(ARM), electromyography (EMG), defe-
32 Pelvic Floor Conditions: Biofeedback
Table 32.1 Biofeedback therapy components available to address specic needs of patients with outlet obstruction
constipation and fecal incontinence
Fecal incontinence
Specic
pathology
Regimens and
exercise
protocols the
need to be
learned and
practiced
Biofeedback
visualization/
resensitization
modality
Therapy goal Increase anal
Neurogenic or
anatomic anal
sphincter
compromise
Kegel type
rest-squeeze
cycles of varying
time and attempts
to maximize
squeeze
magnitude
ARM or EMG ARM or EMG ARM based rectal
canal tone at rest
and squeeze to
help minimize
frequency and
magnitude of FI
symptoms
Pelvic oor
dysfunction Decreased rectal sensation
Paradoxical/
dyssynergic
defecation unlearned
behavior
Pelvic oor
relaxation
techniques with
defecation/balloon
expulsion practice/
behavior
modication to
avoid squeeze during
straining to defecate
Decrease
paradoxical
contraction of the
pelvic oor with
defecation (strain) to
less than 50% of the
squeeze activity
Decreased rectal call to
urge from encopresis and
chronic rectal stool
distention or neurogenic
factors
For encopresis related
issues start with a bowel
regimen and daily
cleansing enemas. Use
rectal balloon distention
sensory threshold
exercises with patient at
decreasing volumes from
urge and maximum
tolerable balloon
inations
balloon distention
Lower rectal volumes
that are detected by
patients and modify
bowel patterns to help
reinstate call to defecate
with rectal distention
Inadequate defecatory
propulsion
Decreased Valsalva
maneuver with effort
to defecate unlearned
behavior
Increase abdominal
muscle contraction
and coordination of
breathing patterns and
posture and
appropriate intraabdominal pressure
generation with strain
effort to defecate
Multi-channel EMG
of pelvic oor and
abdominal muscles
Re-instate appropriate
abdominal muscle
contraction/Valsalva to
generate appropriate
intra-abdominal
propulsion pressure
for defecation while
relaxing pelvic oor
muscles
247
cography and balloon expulsion test can
provide further evidence for the presence
and magnitude of the pelvic oor problem
(Fig.32.2).
Biofeedback Therapy
Biofeedback is a learning strategy that is based
on “operant conditioning” and “instrumental
learning” techniques. If a behavior—be it a complex human performance such as eating or a simple physiological task such as a muscle
contraction—is reinforced by intrinsic or extrinsic means, its likelihood of being repeated
increases. Miller proposed that autonomic functions could be regulated by the use of observable
and verbal cues. A NATO conference in 1976
called for a broad range of applications for bio-
feedback. In the present practice of medicine
only a few indications can be found for biofeedback therapy and these include the management
of fecal incontinence and obstructive pattern constipation. Interestingly, the literature suggests
that optimal biofeedback treatment may be
through Physical Therapy (PT) specialists as
opposed to the use of devices without proper
training. Also, instruction by a PT may be more
effective than biofeedback alone since both
modalities are mutually additive and facilitate
attaining the nal desired effect. Many insurance
companies will pay for pelvic oor PT, but not
reimburse for biofeedback whether performed by
a physical therapist, medical doctor or other
allied health care provider. In order to maximize
benet from biofeedback, the person administering the therapy should have specialized training.
PT programs teach a semester of modalities,
248
J. S. Beaty and C. A. Ternent
Fig. 32.2 High resolution anorectal manometry showing lack of relaxation of the pelvic oor with strain in a patient
with paradoxical puborectalis activity
including 5–10h on the basic use and interpretation of biofeedback. Specic pelvic oor training
can be obtained from the Section on Women’s
Health of the American Physical Therapy
Association which offers a level 1, 3-day course
consisting of approximately 4 additional hours of
instruction specic to interpreting and instructing
biofeedback for pelvic oor disorders (http://
www.womenshealthapta.org/2017livecourses/).
The Biofeedback Certication International
Alliance (BCIA) (http://www.bcia.org) certies
non-physical therapy providers to use biofeedback (RNs, MDs, Massage Therapists,
Psychologists, etc.). A trained professional
should be able to detect subtle yet important substitutions by patients with ancillary muscles (i.e.,
gluteus muscles) during pelvic oor muscle biofeedback. In addition, a trained professional
32 Pelvic Floor Conditions: Biofeedback
249
should be able to recognize if muscle fatigue is
occurring during a treatment session and use this
as a signal to stop the biofeedback session prematurely to avoid muscle overuse. There are also
differences between the exercises instructed for
strengthening (concentric contractions) versus
downtraining (eccentric contractions) used for
outlet obstructions and pelvic oor pain and tension patterns, respectively. Also, there are different bers that may be recruited with short quick
icks versus long holds. Optimal pelvic oor biofeedback is therefore, a complicated proposition
that entails both directed physical therapy and
visualization biofeedback techniques to help
improve function. The quality of results with biofeedback depends on the skill of the individual
directing the biofeedback and the dedication of
the patient to the program.
C. Sensory training was the rst biofeedback
technique used in clinical practice. It entails
simulated defecation by means of a waterlled balloon introduced into the rectum. The
balloon is slowly withdrawn while patients are
asked to concentrate on the rectal sensation
evoked by the balloon and attempt expulsion.
Variations of this technique involve defecation
of a balloon or simulated stools to improve
defecatory dynamics. This technique of rectal
resensitization and facilitation of rectal evacuation using biofeedback may be especially
useful in patients with decreased rectal sensation, encopresis related outlet dysfunction,
PFD and rectal inertia. It can also be used in
patients with FI with decreased rectal sensation. We routinely add a bowel regimen with a
high/low ber diet and laxatives/anti- motility
agents as needed to promote regular bowel
habits. We also employ strategic use of enemas to the sensory biofeedback technique in
order to help reinstate the physiologic call to
urge that may have been lost. Behavior modication also forms an integral part of treatment for encopresis patients who have lost
rectal sensation and the call to defecate as a
result of chronic abnormal rectal content
retention. The balloon expulsion test with the
ability to gradually increase expulsion vol-
umes provides valuable information on the
progress with rectal sensation and evacuation.
The 2016 American Society of Colon and
Rectal Surgery Practice Parameters for the
Clinical Practice Guidelines for the Evaluation
and Management of Constipation recommend
biofeedback as the main form of therapy for dyssynergic defecation with 1B evidence grading,
corresponding to a strong recommendation with
moderate quality evidence and benets that
clearly outweigh risks and burdens. A prospective randomized trial investigated the efcacy of
biofeedback (manometric-assisted anal relaxation, muscle coordination, and simulated defecation training biofeedback) with either sham
feedback therapy or standard therapy (diet, exercise, and laxatives) in 77 subjects (69 women)
with chronic constipation and dyssynergic defecation. At baseline and after 3months of treatment, physiologic changes were assessed by
anorectal manometry, balloon expulsion, and
colonic transit study, and symptomatic changes
and stool characteristics were recorded using a
visual analog scale and prospective stool diary.
Subjects in the biofeedback group were more
likely to correct their dyssynergia, improve defecation indexes, and decrease balloon expulsion
time. Colonic transit improved after biofeedback
or standard therapy but not after sham therapy.
Biofeedback increased the number of complete
spontaneous bowel movements and decreased
the use of digital maneuvers and was associated
with higher global bowel satisfaction. In this
study, biofeedback relieved constipation and
improved physiologic bowel function in patients
with dyssynergia. A high pretreatment constipation symptom score, a high rectal sensory threshold, and a delayed colonic transit time have been
associated with poor biofeedback treatment outcomes for PFD.
Hardware requirements for biofeedback training are variable and dependent on patient and
provider preference and availability. The positioning of the patient should be that which most
comfortably allows optimal visualization of the
biofeedback tracings by the patient. One description of EMG biofeedback for PFD involves