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Table 2 Additional interventions at each session for group 2

From: Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: study protocol for a randomised controlled trial

a. Biofeedback balloon and catheter/probe will be connected to the manometry system and linked to the computer monitor. Patient lying in lateral position facing computer screen (supine if unable to lie in lateral position). Probe taped or held into position

b. Resting and squeeze pressure noted

c. Rectal balloon inflated with air at 2 mL/s to assess first sensation, urge sensation and maximum volume tolerated. Volumes noted. Maximum fill to 360 mL

d. Recto-anal inhibitory reflex (RAIR) elicited with 50-mL aliquots using rapid balloon inflation with air at 30 mL/s. Volume to first urge and effect on resting pressure noted, maximum 150 mL

e. Participant will receive coaching to evacuate with 60 mL water (one syringe full) in the balloon. Participant will attempt balloon expulsion while the effect on anal pressure is noted

f. The therapist will monitor attempts to relax while pushing and attempting to expel the balloon. Instruct participant to push and breathe, emphasising the need to push from the waist while relaxing the anus. Note propulsive effort. A minimum of 3 and no more than 10 attempts in total, with coaching (therapist observes abdominal and anal activity and advises), or until balloon is expelled (not essential). Therapist will advise on correct pushing technique

g. High-resolution anal manometry (HRaM) can also be used to coach pelvic floor exercises if indicated (e.g. evident perineal descent on pushing)

h. Participants undergoing biofeedback may have rectal hypersensitivity or hyposensitivity. At each interventional visit, these participants will undergo sensitivity training. The goal will be to increase (hypersensitive) or decrease (hyposensitive) tolerated balloon volume by gentle progressive distension or progressively lower volume of air