The Relationship Between Incontinence, Breathing Disorders, Gastrointestinal Symptoms,

Michelle D. Smith, PhD,* Anne Russell, MMedStat,w and Paul W. Hodges, PhD

Clin J Pain, Vol 30 (2), Feb 2014, 162-7.

July 8, 2015 Pelvic PT Distance Journal Club

Jane Franczak

Summary:

Question asked: Does the presence of 1 disorder increased the risk for another?

Current data suggests/assumes causal pathway from resp. disorder,  incontinence, and GI leads to back pain ,

But it IS POSSIBLE that BP may contribute to development of other disorders.

Background: Factors that influence BP, continence, GI and respiration can be a common basis for dysfunction in these systems. ie. modified trunk ms. activation to protect spine can increase bladder pressure, and restrict chest wall motion ( limiting respir). OR increased spinal load in BP can contribute to additional abdom ms. activity and increase demand on continence)...So..

Goal: test whether presence or development of dysfunction in 1 system ( BP, Incont, breath disorders and /or GI sx) underlies the development of symptoms in another system within this spectrum of disorder.

Longitudinal study :

1. to eval the relationship btw the 4 issues pre-existing and newly developed BP, incont. Resp. dis and GI sx.

2. Determine if presence of disorder in in 1 system increases risk development in another.

Methods:

Data from ALSWH of women, random selection from Australian National Medicare Health Ins. Database in 1996 for a 20 years follow up study.

 3 age ranges 18-23, 45-50 and 70-75.  Survey 1: All 3 ages  initial survey  ( survey1)  . Subsequent surveys  given annually for age group : 2 yr interval to middle age, 3 year interval to older, and 4 yr interval to younger.  This study=survey 1 and 2. ( Not sure how they continued for the next 20 years)

Outcome measures:

Frequency of various sx ( doesn’t say which sx) for the 12 months prior to the survey: never, rarely, sometimes and often.

BP, incont. and breathing mid and older only  classified as present, or absent.

GI sx defined  as present if constipation, hemorrhoids  or other bowel pbms were sometimes or often. Note, for younger, breathing not assessed so they included allergy as breathing problems.

**Previous analysis related to development of BP found the body weight, physical activity, mental health, stress, smoking, asthma, pelvic surgery, # pregnagcies, Osteo, stiff, painful jts, educ, occup, satisfaction with career, work study and providing care for another with disability WERE NOT assoc. with devel. of BP. Also, these factors didn’t affect assoc. btw BP, incont. Resp. pbms. BUT, menstrual pain, and life experience ie major pers. illness and injury did related to devel. of BP in addition to UI, resp. pbm and GI sx. So, they coded menstrual pain as due to BP, incont and breathing pbm and major pers. illness or injury as present or absent.

Between survey 1 and 2, changes in sx were listed as absent-absent, present- present, absent present, present - absent.

Separate analysis used for newly developed sx at survey 2 per each age group. ( exclusion for cancer and recent fx.)

Results (see table 2-5 for PR)

*Preexistence and devel. of 1 sx lead to devel of another

*Incont at baseline -> devel of BP and GI ALL AGES

Preexisting BP, GI, resp.  -> incont.

BP at baseline ->GI sx.  & breathing pbm. ALL AGES.

*PR were greater for those who developed the assoc. condition than for those who has it preexisting. Strength of associations increased with age.

No assoc. btw devel. of condition and improvement of another.

Discussion

Study showed presence or devel of condition  is assoc. with devel of another in this spectrum.

UI is risk factor for devel of BP and vice versa.

Breathing issue present more likely to devel BP and vice versa.

Strengthens premise that conditions have common basis.

Shows importance for understanding the comorbidities and complexity of mgmt.

Mechanisms for the inter relationships:

Altered function of trunk ms. ( generally increased activity ) bad for  spinal health , continence and resp.

1.    = increased spinal loading, dampens dissipation forces of spine and leads to degeneration

2.   increased IAP and bladder P ( challenges bladder)

3.   abdom ms. activity may compromise ribcage and diaphr mvmt ->impaired resp.

4.   Prolonged elevated abdom. Ms. activity impedes GI function ->devel of GI sx in animals. and excessive abdom activity is common in GI pbms due to excessive straining for BM.

So, pathology in a system not due to ms. activity may influence sx manifestation. ( emphysema and altered breathing pattern).

Other explanations:

1.   altered collagen content impairs support of bladder, urethra, lumbars, pelvic, and can contribute to incont and BP ( gene polymorphism/alpha 1 chain/ incont and BP)

2.   viscerosomatic convergence   explains BP and GI( altered pain perception)

conclusions and Implications for use of info:

evidence of assoc. btw BP, incont, resp, GI pbms.

common mechanism for devel of sx across systems.

? recognition of predictive factors and ID increased risk for devel of comorbid conditions. can -> preventative measures , improved mgmt, and decreased cost  assoc.

thoughts for your practice >>>>>>>>>>>>>

Does anyone see Patients you have with these comorbities?

How do you manage these patients?

Does this info lead you to inform coworkers who may have pts with B. resp pbm, to have pelvic floor eval? Or talk to other docs?

How do you decrease overactivity of trunk ms?

Other thoughts?

My reason for this study inclusion was due to challenges with a UI pt, with onset of BP and sciatica... needed research for case study, additional resources for treatment. Called in the Ortho/spine clinical specialist in clinic. Still working on her case.

Jane Francak, PT, MSPT, WCS