Role of Physical Therapy for Relieving Constipation in Children with Spastic Cerebral Palsy

Abstract

BACKGROUND Bowel and bladder problems in CP children negatively affect children and their families. Constipation along with other problems like reduced mobility decreases the quality of life (QOL) by causing depression, anxiety and affecting social participation of children. Routine physical therapy may contribute in relieving constipation in CP children by improving mobility. OBJECTIVES OF THE STUDY  To determine the effectiveness of physical therapy in relieving constipation in spastic cerebral palsy children. MATERIAL & METHODS Single blinded randomized crossover study design was used to test the hypothesis. There were two groups Progressive Physical Therapy (PPT) and Maintenance Physical Therapy group (MPT). This study was conducted in Physiotherapy Department of Al-Nafees hospital Isra University Islamabad and National Institute of Rehabilitation Medicine, Islamabad. A total of 35 children with spastic cerebral palsy having constipation were recruited through non-probability convenience sampling. The inclusion criteria were spastic CP children between ages 2-12 years of both genders, who were on oral feeding; above 1+ grade (MAS, 0-4 grades) and functional activity level of subjects was between 2-5 grades on Gross Motor Function Classification System (GMFCS). CP children with other systemic co-morbidities, physical deformity in GIT and intellectual disability were excluded from the study. The data was collected through general demographic questionnaire, defecation frequency (DF), constipation assessment scale (CAS) to determine the severity of constipation, Modified Ashworth Scale (MAS) to determine the level of spasticity and Gross Motor Function Classification System (GMFCS) for functional independence in Cerebral Palsy. For betweengroup cross-sectional comparison, independent samples t-test was used and for within group longitudinal comparison repeated measures analysis of variance (RM-ANOVA) was used. To determine association among spasticity, dietary status and constipation regression analysis was used. RESULTS Progressive physical therapy group showed significant improvement in the spasticity throughout the treatment duration with mean difference of 0.9 (f=466.51, p<0.001). The defecation frequency also significantly improved throughout the treatment duration from once a week to almost daily with mean difference of 1.38 (f=1156.43, p<0.05), except at the end of 4th week no significant improvement found as shown by p=0.34. The total score of severity of constipation assessment scale improved significantly with mean difference of 5.1 (f= 241.03, p<0.001). The results showed that spasticity was significantly but negatively correlated(r= -0.81, p<0.001) to defecation frequency. It was also observed that spasticity had significant positive correlation with total score of constipation severity on constipation assessment scale (r=0.45, p<0.001). The results showed that dietary intake is not significantly correlated with defecation frequency (p-value >0.05) but calories(r=0.37, p=0.02), fat(r=0.40, p=0.01) and protein(r=0.41, p=0.01) in diet showed positive significant correlation with small volume of stool. The results also showed that low sugar intake was associated with bowel movements (r=-0.35, p=0.03) and oozing of stool (r=-0.49, p=0 .00) in spastic CP children CONCLUSION It is concluded that physical therapy significantly improves defecation frequency and constipation severity in spastic cerebral palsy children. The change in spasticity level due to administration of physical therapy, to maintain or improve symptoms, is significantly improved defecation frequency and reduces constipation severity among children with spastic cerebral palsy. Furthermore, increase in defecation frequency contributes in decreasing constipation severity. The study also concludes that in spastic CP children dietary status is not significantly associated with constipation in spastic cerebral palsy children. The study shows that even with increase calories, volume of stool was low due presence of spasticity.