Physiotherapy Management for Faecal Incontinence in Children

Amy Chung MSSc, Dip. (Acupuncture), P.D.PT 19 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 stool Can 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. Downs 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 confused High, intermediate, low anomalies Management Surgery (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 pressure Maintain 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)
Brain

Spinal Cord

Muscle

Feedback loop EMG Signal Decomposition

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)

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

Department-based Intensive regular treatment sessions + home exercise Weaning frequency of treatment sessions, more emphasis on home program Home-based with regular home exercise and Re-assessment monthly

Phase 1 0-3 months

Phase 2 4-6 months

Phase 3 7-12 months

T1

T2

T3

Assessment at Initial, 6th month and 12th month 1) EMG biofeedback 2) Rintala continence score 3) Soiling rank

Treatment Program
Treatment program outline: - Biofeedback training - Electrical stimulation for muscles reeducation 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 week 2. 4 7 times per week 3. 2 3 times per week 4. Less than twice per week 5. Nil soiling

Data Analysis
Statistical method:
Paired t-test for EMG study Wilcoxon signed ranks test for Rintala questionnaire score study and soiling rank All analyses were done using SPSS version 17.0

Results
March 2001-2009 45 subjects recruited 39 subjects
age ranging from 5 to 19
6 subjects withdrawn with reasons: Mental retardation and authistic features, medical, financial probelms or lack of parents support

29 subjects completed the 1-year programme Subjects for statistical analyses: 19 boys and 10 girls

10 subjects continue the programme

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

Discussion
Key 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: 200205 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