Pelvic floor behavioral treatment for fecal incontinence and constipation in quiescent inflammatory bowel disease.

BACKGROUND AND AIM: Refractory bowel symptoms in quiescent inflammatory bowel disease (IBD) are common but evidence for effective management is limited. We aimed to determine whether behavioral treatment, including pelvic floor muscle training, decreases the severity of functional bowel symptoms in patients with quiescent IBD. Secondary aims were to evaluate the treatment effect on quality of life, psychological well-being and pelvic floor muscle function. METHODS: This prospective study included IBD patients in remission with persistent symptoms of fecal incontinence or constipation who received up to six sessions of behavioral treatment at monthly intervals. The primary outcome was patient-rated symptom improvement on a 7-point Likert scale (1 = substantially worse, 7 = substantially better). Secondary outcomes included validated symptom scores, quality-of-life, psychological measures, and transperineal ultrasound assessment of pelvic floor muscle activity. RESULTS: Thirty-four patients (median age 38 years; 24 females; 18 ulcerative colitis, 13 Crohn's disease, 3 ileo-anal pouch) were included. Twenty-one of the 29 (72%) patients who completed treatment, or 21 of all 34 (62%) patients, reported moderate or substantial improvement (patient rating of 6 or 7). Symptom scores (p < .001), IBD-specific quality of life (p = .008) and illness perception scores (p = .003) significantly improved. General quality of life, and anxiety and depression scores, did not change significantly. Transperineal ultrasound pelvic floor measures did not correlate with patient-rating of symptom improvement. CONCLUSION: Significant symptomatic improvement occurred in a majority of patients with quiescent IBD. Behavioral treatment should be considered for patients with quiescent IBD and ongoing functional bowel symptoms of fecal incontinence, fecal urgency, or constipation.

Trunk strength and mobility changes in children with slow transit constipation.

BACKGROUND AND AIM: It appears that there are no published reports on childhood slow transit constipation (STC) that have considered the state of the musculoskeletal components of the trunk in these children. The present study aimed to determine whether children with STC have different trunk musculoskeletal characteristics that might be related to their defecation difficulties, compared to controls. METHODS: With the aid of computer-analyzed photographs and clinical testing, 41 children with STC and 41 age-matched controls were examined for Marfanoid features, sitting posture, spinal joint mobility and trunk muscle strength. The latter was assessed by measuring maximum voluntary abdominal bulging and retraction in sitting, and active trunk extension in prone-lying. Levels of general exercise and sedentary activities were evaluated by questionnaire. RESULTS: STC subjects were more slumped in relaxed sitting (P < or = 0.001), less able to bulge (P < or = 0.03) and less able to actively extend the trunk (P = 0.02) compared to controls. All subjects sat more erect during abdominal bulging (P < or = 0.03). CONCLUSION: The results show that STC children have reduced trunk control and posture, which indicates that clinicians should include training of trunk muscles and correction of sitting posture. There was no evidence that children with STC exercised less than the controls.

Connective tissue disorder--a new subgroup of boys with slow transit constipation?

PURPOSE: Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls. METHODS: Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more = hypermobile). This project received ethical approval by the human research ethics committee. RESULTS: Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls (P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile (P < .01). CONCLUSIONS: These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.

Effects of experimentally-induced anterior knee pain on knee joint position sense in healthy individuals.

PURPOSE: The ability to sense the position of limb segments is a highly specialised proprioceptive function important for control of movement. Abnormal knee proprioception has been found in association with several musculoskeletal pathologies but whether nociceptive stimulation can produce these proprioceptive changes is unclear. This study evaluated the effect of experimentally induced knee pain on knee joint position sense (JPS) in healthy individuals. STUDY DESIGN: Repeated measures, within-subject design. METHODS: Knee JPS was tested in 16 individuals with no history of knee pathology under three experimental conditions: baseline control, a distraction task and knee pain induced by injection of hypertonic saline into the infrapatellar fat pad. Knee JPS was measured using active ipsilateral limb matching responses at 20 degrees and 60 degrees flexion whilst non-weightbearing (NWB) and 20 degrees flexion single leg stance. During the tasks, the subjective perception of distraction and severity of pain were measured using 11-point numerical rating scales. RESULTS: Knee JPS was not altered by acute knee pain in any of the positions tested. The distraction task resulted in poorer concentration, greater JPS absolute errors at 20 degrees NWB, and greater variability in errors during the WB tests. There were no significant correlations between levels of pain and changes in JPS errors. Changes in JPS with pain and distraction were inversely related to baseline knee JPS variable error in all test positions (r=-0.56 to -0.91) but less related to baseline absolute error. CONCLUSION: Knee JPS is reduced by an attention-demanding task but not by experimentally induced pain.

Physiological quadriceps lag: its nature and clinical significance.

A study of the limit of active and passive knee extension in 64 healthy adults revealed a physiological quadriceps lag; that is, in most subjects the active limit of knee extension fell short of the passive limit. With the subjects seated, for the passive test the examiner lifted the heel until the relaxed knee sagged into full extension under its own weight. The active test component comprised maximum active extension held for at least 5 sec. Videotaped reference markers on the lateral aspect of the limb were computer-analysed to derive the active and passive test positions. The active limit of knee extension was less than the passive limit by an average 2.5 degrees at the instant of maximum active knee extension, and by 2.9, 3.5, 4.0, 4.5 and 5.0 degrees 1, 2, 3, 4 and 5 sec later. At 0 and 5 sec, 16% and 41% of the subjects manifested a quadriceps lag of at least 5 degrees. There was no correlation between the magnitudes of passive knee extension and quadriceps lag. Since clinicians typically take several seconds to estimate visually or otherwise measure knee extension, account should be taken of the duration of maximum active contraction, as well as other details of test methodology, if quadriceps lag tests are to produce valid and reliable results.

Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury.

PRIMARY OBJECTIVE: The aim of this study was to assess the effect of Botulinum toxin A in the management of spastic equinus resulting from traumatic brain injury. RESEARCH DESIGN: A before-after intervention design was used without controls. METHODS AND PROCEDURES: Subjects were seven patients suffering from traumatic brain injury of average duration 14 (4-38) months as a result of motor vehicle trauma, who had spastic equinus interfering with gait. EXPERIMENTAL INTERVENTION: The patients were treated with injections of Botulinum toxin A into the spastic calf muscles: gastrocnemius, soleus and tibialis posterior. Assessments were made pre-injection and at 2 weeks and 3 months post-injection. MAIN OUTCOME AND RESULTS: At the end of the 3-month period, all patients showed a significant improvement in gait velocity, cadence and stride length. CONCLUSIONS: The findings suggest that Botulinum toxin A may be useful in the management of spastic equinus following traumatic brain injury.

Abnormal knee joint position sense in individuals with patellofemoral pain syndrome.

The purpose of this cross-sectional study was to compare knee joint position sense (JPS) in 20 individuals with and 20 without patellofemoral pain syndrome (PFPS). Five active tests with ipsilateral limb matching responses were performed at 20 degrees and 60 degrees flexion under non-weightbearing conditions, and at 40 degrees flexion under uni- and bi-lateral weightbearing conditions. The response errors were calculated as the difference between each target and response position (accuracy) and the standard deviation of these differences (reliability). JPS was: (i) significantly less accurate and less consistent in the knees with PFPS during both the non-weightbearing and weightbearing tests when compared to the control subject knees; (ii) less accurate when the symptomatic and asymptomatic knees of the 12 uni-lateral PFPS subjects were compared and (iii) less accurate in the asymptomatic knees of the uni-lateral PFPS subjects and knees of the control subjects. The maximum intensity of pain experienced during each knee JPS test was not correlated to any of the JPS test results. The results confirm abnormal knee joint proprioception in individuals with PFPS. Although it cannot be determined whether the abnormality precedes or follows the development of PFPS, the results support including proprioceptive reeducation in management of PFPS.

Use of a video time display in determining general gait measures.

By superimposing a video time display (VTD) onto videotapes of patients walking, and using pause-motion replay, precise measures of walking speed, cadence and stride length may be obtained. Five groups of 10 subjects were used to investigate VTD-based gait analysis under different test conditions. An additional 20 healthy subjects were retested on two occasions on average 10.2 weeks apart. These subjects demonstrated moderate reliability for cadence and poor reliability for speed and stride length. It is recommended that progress be assessed by serial testing with regular time intervals. The results from healthy subjects were comparable with results from studies using other instruments. VTD-based gait analysis is a simple, accurate and inexpensive test procedure under a variety of clinical conditions.