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