6 PAF-study: results of a randomized controlled trial 159 Discussion The present study is the first randomized clinical trial of EMG-biofeedback-assisted PFPT for CAF. The results of our study show a significant decrease in mean resting tone of the pelvic floor measured with digital rectal examination and EMG, improvement of healing of the fissure, pelvic floor function, pain, and complaint reduction. These results confirm our hypothesis that PPFT is effective in patients with CAF. Pelvic floor muscle tone measured with EMG-biofeedback decreased from pre-to posttreatment and between groups and has been proven an effective and efficient treatment modality. Biofeedback is a neuromuscular training approach in which patients learn how to appropriately contract or relax muscles, aided by visual or auditory feedback of muscle activity. It is the mainstay in the treatment of anorectal dysfunctions and is commonly utilized in PFPT.35 The efficacy of PFPT including biofeedback on pelvic floor dysfunction has already been proven in randomized control trials,19,36,37 although the success depends on motivation of the patient and skills of the therapist.22 Muscle tone measured with EMG, also improved in the EAS from pre-to post-treatment and compared to controls. These results confirm the role of the EAS in patients with CAF, which correlates with findings of Grimaud.38 In this study, including patients with chronic idiopathic anal pain, biofeedback was used for relaxation of the EAS. A significant decrease in resting pressure was observed in the anal canal measured with manometry, which was accompanied by a relief in anal pain, suggesting that the pain was due to abnormal chronic contraction of the EAS. Pelvic floor muscle tone, based on digital rectal examination significantly decreased from pre- to post-treatment and between groups. A comprehensive careful digital rectal examination is an important topic to obtain information on anorectal anatomy and function.22,26 Besides that, the use of quantified digital palpation to measure muscle tone and dyssynergia, is recommended in clinical guidelines.4,25 Although no normative values on pelvic floor muscle tone exits, it appears that patients with CAF have higher levels of tonic activation of the pelvic floor. Furthermore, tenderness to palpation often accompanied with increased pelvic floor muscle tone is a feature of levator ani syndrome 4,39 and was found in 75% of our patients. Increased tone or spasm of the levator ani, probably leading tot ischemia could be a contributing factor in the pain patients experience.40 Tenderness to palpation is a predicting factor of response to biofeedback treatment.41 Fourteen percent of the fissures were anterior, mainly in women (70%), 35% of whom had had a vaginal delivery. Anterior fissures are associated with low anal sphincter
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