Physiotherapy Management for Faecal Incontinence in ChildrenAmy ChungMSSc, Dip. (Acupuncture), P.D.PT19 Sept 2009
Contents
• Introduction• Overview of physiotherapy management• Local experience - Continence Program in QEH• Conclusion
Introduction
• Definition:Recurrent uncontrolled passage of gas, liquid, or solid stoolCan be passive incontinence, urge incontinence or faecal seepage
Jackson S.L. et al (1997) Cardozo L. et al (2001)Miner P.B. (2004) Tuteja A.K. (2004)
Introduction
Prevalence• Local: - About 30% children have constipation,
6% to 10% has incontinence of varying degree
- Around 200 new cases per year in 2 local hospitals (QEH & UCH)
• Overseas: - 1.5% of the general population, ~ 3 million Americans were affected
Introduction• Factors associated with faecal incontinence:
- Constipation- Toileting habit- Family problems- Psychiatric problems (e.g. Schizophrenia)- Mental retardation (e.g. Down’s syndrome)- Neurological disease (e.g. Spina Bifida)- Anatomical deviations (e.g. Anorectal
Malformation)Pena A & Hong A (2000)
Bulk-Bunscoten AMW et al (2007)
Anorectal Malformation (ARM)• Prevalence
Affecting 1 in 4000 – 5000 newborns• Classification
Often confusedHigh, intermediate, low anomalies
• ManagementSurgery (30% - 56% patients have significant faecal soiling after surgery)Physiotherapy
Stephens F.D., Smith E.D. (1986)Levitt M.A., Pena A. (2005)
Normal Bowel Function
• Bowel control depends on:– Functional pelvic floor muscles– Functional internal & external anal sphincters– Intact pudendal nerve– Intact rectal sensation– Adequate rectal accommodation – Cognition
Sushmita Bhatnagar (2007)
Function of Pelvic Floor Muscles (PFM)
• Support the abdominal & pelvic contents
• Control bowel & bladder function
• Counteract changes in abdominal pressureMaintain continence
Enck P & Vodusek DB (2006)
Anatomy of Pelvic Floor Muscle (PFM)
Superficial Layer : Figure of 8; sphincters
Deep Layer:Levator Ani & Coccygeus
Anatomy of PFM• Internal Anal Sphincter- Smooth muscle - Autonomous nervous system
Tonically contracted ( 80% of the resting anal pressure)
• External Anal Sphincter- Striated muscle- Pudendal nerves (S2-4)
Partially contracted at rest (20% of the resting anal pressure)
Overview of Physiotherapy Management
• Biofeedback– Electromyography (EMG)
• Peri-anal or Intra-anal• Electrical Stimulation (ES)• Pelvic Floor Muscles Training (PFMT)
Beddy P et al (2004), Palsson et al (2004)Ozturk R et al (2004), Dobben AC et al (2006)
Leung MWY et al (2006), Terra MP et al (2006)
Biofeedback• Originated in the late 1960s• Use monitoring instruments to feed back to
patients with physiological information which they are normally unaware of
• Visual / auditory display• Facilitation / inhibition • Labor-intensive, safe, effective, inexpensive,
long term effect
Ozturk R et al (2004)Terra MP et al (2006)
Electromyogram (EMG)
• H. Piper – the first investigator (1912)
• Needle & surface EMG• Intra-anal & peri-anal• Record muscle action
potentials with skin surface electrodes
Kiersch SE et al (1993)Merletti R & Parker P A (2004)
Terra et al (2006)
Feedback loop
Brain
Spinal Cord
Muscle
EMG Signal
Decomposition
Motor Unit Action Potential
Electrical Stimulation (ES)• Low frequency current ~ 20 – 50 Hz• Nerve or muscle stimulation• Strength & endurance• Parameters: frequency, pulse width, hold time &
rest time, current intensity & duration• Synchronized with biofeedback to maximize
effect on voluntary motor control
Dobben AC et al (2006)Leung MWY et al (2006)
Terra et al (2006)
Pelvic Floor Muscles Training
• Essential to prevent or treat incontinence• Improve strength and endurance• Comprehensive assessment• Initial stage: ES and PFM exercises• Progression: in conjunction with biofeedback• Wean off ES & EMG biofeedback, continue with
pelvic floor muscles training
Johnson VJ (2001)Hay-Smith J et al (2008)
Local Experience –Physiotherapy Management for Faecal
Incontinence for Children with Anorectal Malformation in QEH
• Collaborated with Department of Surgery, QEH since 2001
• Structured physiotherapy program by a team of paediatric physiotherapists
• 6 months department-based program, followed by 6 months home-based program with monthly FU
Aims of Physiotherapy Management for Faecal
Incontinence• Improve strength & endurance of pelvic floor muscles• Educate coordination of pelvic floor muscles• Improve control of sphincters• Train faecal-continence function• Improve awareness• Bowel habit re-education• Life-style modification, coping strategies and skin care• Psychological and emotional support• Improve social life and quality of life
Objectives of Program
• To improve patients’ functional outcomes and empower patients’ home management.
• To evaluate the effectiveness of physiotherapy intervention in faecal incontinence.
Target Clients
• Inclusion criteria:– Children presented with faecal incontinence
after surgery for ARM – Age: 5 years or above– Good mental status
• Exclusion criteria:– Children with learning difficulty
Framework of Treatment Program
0-3 months 4-6 months 7-12 months
Phase 1 Phase 2 Phase 3
Department-based
Intensive regular treatment sessions + home exercise
Weaning ↓frequency of treatment sessions, more emphasis on home program
Home-basedwith regular home exercise and Re-assessmentmonthly
Assessment at Initial, 6th month and 12th month
1) EMG biofeedback
2) Rintala continence score
3) Soiling rank
T1 T2 T3
Treatment Program Treatment program outline:
- Biofeedback training- Electrical stimulation for muscles re-
education and strengthening- Pelvic floor muscles training- Home exercise
EMG Biofeedback
• Position: crook lying• Surface electrodes over perineum, ground
electrode over sacrum
EMG Biofeedback
• Facilitating audio sound • Visual feedback• Hold for 5 sec• Rest for 5 sec• 99 repetitions
EMG Biofeedback
Relax Maximal Contraction
Electrical Stimulation (ES)
• Electrodes are placed around the perineal area similar to that with biofeedback
• Intensity: as tolerated, usually 18 – 20mA• Hold for 5 seconds• Rest for 5 seconds• Duration: 20 to 30 minutes• EMG trigger + ES
(Low & Reed 2000)
Pelvic Floor Muscles Training
• Active muscle contraction• Use of ball to facilitate training:
enhance sensation of perineal muscle contraction
• Long-term home-based training: maintain strength & prevent atrophy
• Carry over in daily living at all times
Home exercise log book:- Record no. of
times of bowel open- No. of episodes of
incontinence- Duration and
frequency of exercise- Use of enema
Outcome Measures
-EMG biofeedback – strength of the PFM-Rintala questionnaire score – bowel function
-Soiling rank
EMG Record
• Measure the mean voltage during active contraction / relaxation
• Work average in micro-volts• Rest average in micro-volts
Rintala score:- Ability to hold- Urge to defecate- Frequency of defecation- Frequency of soiling- Frequency of accidents- Degree of constipation- Social problems
Max = 20 marks
Soiling Rank
Ranks from 1 to 5:1. More than 7 times per week2. 4 – 7 times per week3. 2 – 3 times per week4. Less than twice per week 5. Nil soiling
Data Analysis
• Statistical method:Paired t-test for EMG studyWilcoxon signed ranks test for Rintala questionnaire score study and soiling rankAll analyses were done using SPSS version 17.0
Results
Subjects for statistical analyses:19 boys and 10 girls
29 subjects completed the 1-year programme 10 subjects continue the programme
39 subjectsage ranging from 5 to 19
6 subjects withdrawn with reasons:Mental retardation and authistic features,
medical, financial probelmsor lack of parents support
March 2001-200945 subjects recruited
Improvement in Pelvic Floor Muscle Strength as Reflected by EMG Study
Improvement in Overall Bowel Function as Reflected by Rintala Score Study
Decreased in Soiling Frequency as Reflected by Soiling Rank Study
Discussion
Long term effect:• Improvement was maintained with home-based
program as reflected by data at 1-year FU.
Discussion
Problems encountered:• Lengthy (1 year program)• Time-consuming (~ 1 hour per session)• Active children with low concentration• Fluctuated hygiene consciousness
Discussion
• Six children were withdrawn– mental retardation and autistic features – defaulted since inadequate family support– other medical problem; financial problem
DiscussionKey for success:• Age >/= 5 years old• Good mental/cognitive function• Good compliance to treatment regime, drugs, diet• Good medical & family support
Conclusion
• Faecal incontinence: – multi-factorial– multi-disciplinary approach
• Devoted team
Conclusion• As a pioneer hospital to launch this service, we
found all positive findings including:– physical parameters – psychosocial aspect
• Clean pants• Able to go swimming• Less embarrassment• Enjoy normal life & growth
Acknowledgement
• Dr. Polly Lau, JP, Cluster Manager (Physio), KCC• Ms. Jocelyn Cho, Senior Physiotherapist, QEH• Mr. Gary Fan, Physiotherapist II, QEH• Mr. Stephen Chan, Physiotherapist II, QEH
Thank You
References
• Beddy P et al. Electromyographic Biofeedback Can Improve Subjective and Objective Measures of Fecal Incontinence in the Short Term. Journal of Gastrointestinal Surgery. 2004; 8: 64-72
• Bulk-Bunschoten AMW et al. A Guideline for Children with Functional Fecal Incontinence. 2007 http://www.pediatriconcall.com/fordoctor/diseasesandcondition
• Bhatnagar S. Bowel Control. 2007 http://www.caremycolostomy.org/bowel.htm
• Cardozo L., Khoury S., Weiri A. Proceedings of the second international consultation on incontinence. 2001; Health Publication Ltd, Plymouth
• Dobben AC et al. Functional Changes after Physiotherapy in Fecal Incontinence. Int J Colorectal Dis. 2006; 21:515-21.
• Enck P & Vodusek DB. Electromyography of Pelvic Floor Muscles. Journal of Electromyography & Kinesiology 2006; 16: 568-77.
References
• Hay-Smith J., Morkveds S., Fairbrother K.A., Herbison G.P. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women (review) 2008 Issue 4; The Cochrane Collaboration, John Wiley & Sons Ltd.
• Jackson S.L., Weber A.M., Hull T.L. et al. Faecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynaecol. 1997; 89:423-427
• Johnson VJ. How the Principles of Exercise Physiology Influence Pelvic Floor Muscle Training. JWOCN. 2001; 28(3): 150-55.
• Kirsch SE, Shandling B, Watson SL et al. Continence following Electrical Stimulation and EMG Biofeedback in a Teenager with Imperforate Anus. Journal of Paediatric Surgery. 1993; 28: 1408-09.
• Leung MWY et al. Electrical Stimulation and Biofeedback exercise of Pelvic Floor Muscle for Children with Faecal Incontinence after Surgery for Anorectal Malformation. Paediat Surg Int 2006; 22: 975-78.
References
• Levitt M.A., Pena A. Outcomes from the correction of anorectal malformations. Curr Opin Paediatr 2005; 17:394-401
• Merletti R & Parker P A . Electromyography – Physiology, Engineering, and Nonincasive Applications. 2004.
• MF van der et al. The prevalence of encopresis in a multicultural population. Journal of Paediatric Gastroenterol Nutrition. 2005; 40:345-8.
• Miner P.B. Economic and personal impact of faecal and urinary incontinence. Gastroenterology. 2004; 126:S8-13
• Ozturk R et al. Long-term Outcome and Objective Changes of Anorectal Function after Biofeedback Therapy for Faecal Incontinence. Alimentary Pharmacological Therapy. 2004; 20: 667-74.
• Palsson et al. Biofeedback Treatment for Functional Anorectal Disorders: A Comprehensive Efficacy Review. Applied Psychophysiology and Biofeedback. 2004; 29(3) 153-73.
References
• Pena A & Hong A. Advances in the Management of Anorectal Malformations. Am J Surg. 2000; 180: 370-76.
• Stephens F.D., Smith E.D. Classification, identification and assessment of surgical treatment of anorectal anomalies. Paediatr Surg Int (1995); 1: 200-205
• Terra et al. Electrical Stimulation and Pelvic Floor Muscle Training with Biofeedback in Patients with Fecal Incontinence: a Cohort Study of 281 Patients. Dis Colon Rectum 2006; 49: 1149-59.
• Tuteja, A.K., RAO, S.S.C. Review article: recent trends in diagnosis and treatment of faecal incontinence. Alimentary Pharmacology & Therapeutics. 2004; 19(8): 829-840
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