A Comprehensive physical therapy approach including visceral manipulation after failed biofeedback therapy for constipation. Archambault-Ezenwa, L. Tech Coloprotology, June 24, 2016.

Journal Club September 7, 2016

Jane O’Brien Franczak, PT, MSPT

Case study of 41 year old female severe constipation, rectal pain, levator ani spasm, 8 year hx. 2x/mo BM from daily use of laxative and enemas/ 4-6 glasses H2O/day, 15g fiber/day. 75% time, strain for BM,  hard stool, difficulty emptying 25% time, 15 min per attempt to evacuate, difficulty initiating urination 10% time, abdom pain 3-5/10, rectal pain with defecation, 5-7/10, suprapubic pain with full bladder and dysuria 3/10.

Bristol stool rating type 2,3,4. 5/7 sx for Rome III criteria for chronic constipation.

PMH : hemorrhoidectomy, cholestystectomy, gastric sleeve, 3 pregnancies with episiotomy,

Prior Treatment by MA of biofeedback, estim, coordination exs, 10 sessions, with resultant improved motor control. No change in bowel function or QOL.

Imaging:  colonic transit study, NL, (r/o slow transit constipation),

Defecography diminished sphincter relaxation, no sigif rectocele, intussesception or enterocele with straining,

Manometry: decreased first sensation 50ml. (11-68ML nl) and unsuccessful balloon expulsion. Suggestive of anal dyssynergia.

PT exam: posture kyphotic, hypomobility of T10-L4, (impaired spinal mobility and assoc. chronic pain may contribute to changes in autonomic functions of viscera). External palpation; Spasm of L iliopsoas,  L glute med, R coccygeus.

Neuro exam: Pudenal Nerve entrapment at L Alcock’s canal.

Visceral and abdom. Exam : Motility ( free ROM) and Mobility (how much an organ can be displaced), decreased motility of small intestine, ..Restriction and decreased mobility of sigmoid

Perineal exam decreased perineal excursion, (due to spasm? Weakness?)

Lacock’s modified Oxford scale: 4-/5, 7 sec endurance, R coccygeus and B lev ani spasm, decreased mobility of L side of urethra and R rectum. Rectal exam burning, dyssynergia confirmed via bearing while contracting TvA.

Assessment: Obstructed defecation due to Dyssynergia, Pain and spasm from scarring, suggested treatment: MFR transvaginally/rectally with dilator protocol. Visceral manip and nerve manip.

 Goals:

1.       Improved relaxation of EAS during bearing

2.       Decreased pain with BM

3.       Decreased abdom bloating and related pain with urination

Intervention

1.       Modify behavior: diet, Increase activity, self-massage, defecation strategy of : utilization of peristaltic wave, listen to urge, No straining, potty posture of hips less than 90*, vibration/dilation of PFM and EAS, visualization of PFM relaxation.

2.       Ther Ex: LE stretches, core without use of PFM ( facilitate co-contraction/relaxation )

3.       Manual: Visceral manip (colon, sigmoid, sm. Intestine, rectum, kidney, bladder, urethra). Pudenal N traction intravaginally near Alcott’s canal, Lymphatic Drainage of perineum toward groin, Spinal mobe of Thoracolumbar area PA, TP/MFR of LA and EAS.

4.       NMRED: PFM contract relax with co-contraction of TvA. Engage PFM, TvA, Bear down with abdoms then release PFM while PT digitally palpates puborectalis to guide relaxation (done on potty seat).

Outcome

                7 sessions over 3 months, =>

•        Pain redux 1-2/10 with defecation and urination 0/10,

•        Decreased Mirilax 50%

•        No use of water enema

•         Normal stool formation, no straining

•        PAC-SYM redux 5 points, PAC-QOL redux 20 pts.