Have you ever gone to a party and realized that two of your best friends know each other quite well and get along great? I recently had that experience, although instead of “friends” it was two areas of my PT practice, and instead of a “party” it was a class I was teaching. So basically, the exact same experience 🙂.
Ok, it’s a little bit of a stretch. But I taught a group of PTs and OTs this fall about chronic constipation, and they asked a lot of questions about how to treat kids with limited mobility and spasticity. To my embarrassment, I was caught a little bit off guard. One of my practice areas is providing specialized positioning equipment for kids and adults with spasticity and immobility. I work with kids with cerebral palsy every day! But I hadn't put a lot of thought into how constipation affects these patients specifically.
Now, thanks to the therapists who attended this course and asked thoughtful questions, I have! And I’m excited to share what I’ve learned with all of you.
Prevalence. The best data I can find indicates that anywhere from 74% to 90% of people with cerebral palsy suffer from chronic constipation. That’s astounding! Here’s why the rate is so high:
- Upper motor neuron injuries can disrupt the feedback loops between the bowel and the brain. This is called neurogenic bowel dysfunction (NBD), and up until now it’s really only been discussed in the pediatric population in terms of spina bifida. But many kids with CP also have NBD.
- Spasticity may affect the smooth muscle of the colon, the involuntary muscles of the rectum and internal anal sphincter, and the voluntary muscles of the pelvic floor and external anal sphincter.
- Baclofen, one of the most common medications for managing muscle tone, has constipation as a significant side-effect.
Treatment. This may not surprise you, but there is not a lot of good evidence on how to treat kids with CP who have chronic constipation. It’s a bummer. I did find one nice article summarizing a treatment approach, and it is not much different than what I outline in The Constipation Game Plan:
- Make sure kids are getting enough water and fruits and vegetables, but don’t add a bulk-forming fiber supplement like Metamucil.
- Discuss with the child’s physician the best laxatives to use to soften the stool. I did not find any research on stimulant laxatives and how they affect spasticity, but I do know that stool softeners such as MiraLax are considered effective.
- If kids are significantly impaired by NBD, they may require assistance to void. This could include digital stimulation of the rectum, suppositories or enemas. These should be done at the same time of day, every day, preferably 15 minutes after eating.
- Abdominal massage has been shown to be effective at reducing constipation in the general population, so these researchers took a “why not” approach to people with spasticity. I will be sending out another newsletter on abdominal massage in the next few weeks, so keep checking your inbox.
- Same goes for parasacral TENS. It seems to be effective at increasing BM frequency in neurotypical patients, so it is worth giving it a go on patients with spasticity. (I have a blog post almost ready to go on this subject, too!)
- Modify the patient’s position for voiding. The primary recommendation? Get the knees higher than the hips! And, standing. Consider using a standing frame.
So, how will this affect my practice? I’m kind of in a list-making mood, so here’s how:
- I will address constipation directly with all of my patients with CP. Just as I do with my bowel and bladder patients (and in The Constipation Game Plan), I’ll “demystify” constipation for these patients and families. Knowledge is power! I’m thinking back on my neuro caseload through the years and can count up a few hospitalizations for disimpaction that might have been prevented if I had educated CP families about constipation the first time I met them.
- I will work with my patients to find an ideal position for having a BM. This may involve a standing frame (I couldn’t find any research on standing frames and bowel health, but I have enough experience to know that standing helps immobile people poop), but it also could involve experimentation: prone on balls, side-lying with knees curled to chest, straddling a peanut ball.
- In terms of timing, I’ll talk with patients and caregivers about trying to track when a patient’s spasticity is lowest. In the morning? After a bath? After stretching? That would be when we would want to put somebody on the toilet or in another modified position for having a BM.
- I’ll most likely teach abdominal massage and will consider parasacral TENS depending on how it goes with some of my non-neurogenic kids.
I hope this gives you some ideas on how to help your own child or a child you care for feel better!