重症脳損傷児の便秘への運動療法

m･}･tzaza*eg

20

_gag

1℃

-

24-- 32

fi

(1993

tf{)

$&thm

Defecation

Treatment

for

Constipation

in

Children

Severe

Brain

Damage*

with

Masamichi

FURUSAWAi),

Matsuo

SHINB02),

Mineshige

MISAWA3>,

Koji

MATSUMOTO`),

Michiko

OMUROi),

Tatsuyuki

KANEK05)

and

Tomio

OUCHI6)

Abstract

The purpose of thisarticle istoreport on the result of a new treatment forconstipation in

children with severe

brain

damage.

Conventionat

rnethods forthetreatment of constipation

in-clude the use of

taxative,

enema, abdominal massage, and

dietary

control. However, _these

treatments

have

not

been

markedly effective.

With

thisnew treatment, the postural tune

is

firstnormalized and then a stretch refiex isinduced inthe intestinalwaLl by squeezing out the

fecalbolus retained inthe descending colon.

Manual

manipulation

by

a

_physical

therapist

fa-cilitates theevacuation. The stretch reflex _{prc)ducesperistalsis,}which allows these children to learn the desireto defecate. The _physical therapist also

has

the chiidren experience an in-crease

in

intra-abdominal

pressure by

fiexing

their

lower

trunk

forward

while maintaining both

Legsinabduction and flexion,This

defecation

treatment was incorporated intothetherapeutic

exercise of 32 children with severe brain damage

(exporimental

_group),and 23 children under-went therapeutic exercise witheut defeeationtreatment

(control

group).

The

change in their

condition was assessed as remarkable, moderate, slight, or no improvement.

The

experimental _group was treated

for

a _periodof up to1month or

3

years and 9 months

(mean

7.0

±

8,4

months), and the control group

for

a _period of

3

months or

7

years and

6

months

(mean

23.2±26.9 months). The improvement inconstipation was significantiy

great-er

(p<O.OI)

in

theexperimental group than in thecontrol group.

In

the experirnental group,

adjunct measures such as laxativeswere used in25 of Lhe children at the initialassessment,

but were only required

in

7

{p<O.05)

for

the

final

assessment.

In

the control group, adjunct

measures were being used in 20 of the children on the initialassessment and were still

required at the finalassessment in17of thechildren

(p>O.05).

The outcome was favorable in

9 of the children in whom defecationtreatment was commenced

before

theage of 1year, with

a remarkable

improvement

being

observed

in

7

of them and a moderate

improvement

being

noted in2.Therefore, defecationtreatme-t should be

incorporated

early into the therapeutic

prograrn to prevent chronic constipation. Because anticonvulsants are likelyto induce con-stipation as a side effect, thisshould be noted early and _prompt initiationof defecation

treat-ment started.

Key words

Chiidren

with severe

brain

damage,

Constipation,

Therapeutic

exercise

*Il･2]3)41,

E{ittEE'lft'MYt!oifiEif-Novaetrkza

Bobath Mernoria] Hospital

JuntendoUniversityHospital

Yokohama MunicipalRehabilitationCenter

SuitaMunicipal Health Center

5) _{Surnida Health}

and Welfare Center fer the

Handi-capped

6>_{SakaiMunicipalAkebono Ryoiku Center}

{Receivecl

:September21,1991,XAccepted:October 12, 1992)

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysicalTherapy Association

Defecation Treatment for

Constipation

inChildren

1.

Introduction

Inthe management of children with severe

brain

damage, the physical therapist

is

respensible

for

vital

function

probiems.

Management

of

con-stipation, which

is

often chronic

in

these children,

must censtitute a part of thetreatment regimen.

Intake of vegetable drinksand fibrousfood is en-couraged as a dietary measure to _prevent chronic

constipation in children with severe brain

damagei)'3).However, their oral motor dysfunction usually restricts ingestion Qf foeds, and dietary therapy has been found tobe an unsatisfactory

so-lutionto this_problern. The use of laxatives and

enema, digital removal of feces4),abdominai

massage5]6), and acupuncture7)B) have also

been

attempted,

Drugs

are often ineffective,because

drug

resistance

is

tikeEy

to

develop.

Furthermore,

abdominal massage

does

not significantly promote

defecatien,inthese children whom

postural

tones are abnormal.

Furusawa

(1982)9)

previousiy advocated

thera-peutic exercise Lo suppress the abnormal postural

tone in reflex inhibiting

_patterns,

to increase the desiretodefecate,and to facilitatestraining. Inthe

present study,

32

children with severe

brain

damage were treated by this method and compared

with 23 controls who

did

not receive

defecation

treatment.

Significantly

better

results were

ob-tainedintheexperirnental group.

2.

Methods

The

chi]dren with severe

brain

damage

who visited the outpatient clinics of Bobath

Memorial

Hospital,

Sakai

Municipal

Akebono

Ryoiku

Center

for

Handicapped

Children

in

Osaka,

Juntendo

Uni-versity

HospitaL

and

Tokyo

Women's

Medical

Col-lege

Hospital

in

Tokyo between April,1982 and

Oc-tober, 1989 were assessed.

Constipation

was

defined

as the absence of

defecation

for

3-4

days

or

longer.

Thirty-two children consisting of 22 males and

10 femaies in whom defecation treatment was

with

Severe

Brain Damage 25

corporated into the therapeutic exercise were

followed up as the experimental _group. The

defeca-tjon

treatment

commenced frorn the age oi

2

months to 12 years and 6 months with a mean of

2.8=I2.8 _years. The

diagnosis

was cerebral _palsy

in22,rnicrocephatus in8,braindysfunction as a

se-quela of _pneumonia in 1,and sequela of meningitis

in 1, According to a classification

by

the postural

tone,20

had

spastic _{quadriplegia,}6

had

athetosis,

and 6

had

fiaccidity.

Six

of the children

(18.7%)

on the initialassessrnent and 8

(25%)

at the final assessment retained some means of mobility, which

was creeping in2,crawling in2,rolling over in2, and properling themselves

in

thesupine position by

pushing

on the

heels

in

2.

Moderate

or severe

intel-lectualhandicap was noted in 28

(87.5%),

and 22

children were complicated by epilepsy

(71.9%}.

Twenty-three children with severe

brain

damage

consisting of

10

males and

13

iemales

treated at the outpatient clinics of the same institutions

with-out

defecation

treatment were

followed

up as the

controL _group. Inthis _{group, therapeutic} exercise

commenced

from

the age 3 months to 12years and

8

months with a mean of

4.2

±

3.5

years. The

di-agnosis was cerebral palsy

in

12,microcephalus in

8,

sequela of meningitis

in

2,

and sequela of

Japa･

nese encephalitis in 1.According toa class{fication

by

the _postural tone spastic _quadriplegia was

ob-served in 16, athetosis in 5, and flaccidityin

2.

Three

_(13.0%)

had a means of tnobility, which was

by creeping. InteLLectualhandicap was observed

in

19

<82.796),

and epilepsy was noted in16

(69.6%).

The subjects in both the experimental and

con-trol_groups were treated tonormalize _posturaltone, so as toacquire the antigravitational control oi the head and neck, and toIearnto sit.iO)']2)

Defecation

treatment was _given in addition to these

treat-ments

in

the

children of

the

experimental group.

Figure I shews a 21-month-old male with

dystonic athetosis due to microcephalus.

In

the

photograph, thischitd istrying to defecate,but he

shows an opisthotonic posture with a strong

26

-\dezatla.

and adducted.

his

anus

is

closed.

Therefore,

his

opisthotonus must

be

inhibitedfirst

(Fig.

2,above).

Fo[lowing

this,the therapist

helps

the child to

learnthe antigravitational control of the head and

neck in the midline and sitting _position

(Fig.

2,

below). The head and neck control

in

the midline

isimportant for facilitatingclosure of the vocal

Fjg･1.

A

21-month-old

child with dystonic

o$is. As the child straine(l

for

defecation,

opisthotonus and adduction of the

legs

intensified

due

to associated reacLions,

resulting inclosure of hisanus.

Fig. 2.Fig, 2.above

I

Inhibition

of opisthotonus.

below 1Long sitting. Spasticityof the bi-lateralhipadduct.ors

is

suppressed by

ab-ducting

the

legs

toensure opening of the

anus

for

defecation.

ca

2o

_tsee

1

-g

cords

during

straining for

defecation.

In

the

supine

position,fecalboluses retained in the descending colon are squeezed slowly towards

the

sigmoid

colon and the rectum while inhibitingopisthotonus

and relaxing the

intra-abdominal

pressure.

This

is

to

induce

stretch refiexes

in

the

intestinal

wall

_CFig.

3,above) and, thus,to _produce the desireto

cate. Sincestraining fordefecation tends toinduce

an associated reaction, which adducts the legs,the

therapistincreaseschild's intra-abdominal pressure

by bending histrunk with the legsabducted and

helps

the child experience proper straining

(Fig.

3,

･

below). The therapist confirms sLraining by the

child and opening of hisanus,

Thc

therapist

teaches

the

mother _these

proce-Fig.

Fig.

3. above IThe _physica! therapist squeezes

with

fingers

the fecalbolusesretained in

the dcscending colon toward thesig'moid

colon. This

induces

stretch reflexes inthe descending and sigmoid colons and

duces

the

desire

to

defecate.

3.

below

l

_The

intra-abdominal _pressure is

increasqd by fiexing the trunk while

abductingthe]egs.

Thephysicaltherapist

confirrns elicitation of straining and

Japanese Physical Therapy Association

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JapanesePhysicalTherapyAssociation

Defecation Treatment forConstipation

dures which are

practiced

for 5-10 mmutes daily

with therapeutic exercise. The treatment should,

however,

be

avoided within

1

hour

after meals.

In

both

groups, thechildren who

have

oral motor

dys-function

are also provided with an eating therapy

programi3)'i6)

by

the speech _therapist.

The change

in

constipation ivas assessed

accord-ing

to a

4.-grade

scale of remarkable, moderate,

slight, and no

improvement

(Table

1),and the

results were compared

between

the experimental

Table

1.

inChildren with SevereBrain Damage 27

and the control _groups, Statisticalanalysls was made

by

thechi-square test.

3.

Results

Defecation

trcatment was continued

for

up to

1

month to

₃

_years and

9

months

(mean

_7.0±_8,4

months) intheexperimental group.

Figure

4

sumrnarizes

findings

in

theexperimental

and control groups. Inthe experimental group,

re-markable

improvement

in

constipation was

ob-Assessment criteria

for

constipation.

Classification

Criterion

Remarkable

Improvement

Defecation

once

measures.

every one or two

days

without any adjunct

Moderate

Improvement

Defecation

once every

ures once a fortnight.one

or

two

days,

but

with adjunct

meas-SlightImprovernent

Change

infrequency of

defecation

from once every four or more

days toonce every two or threedays,with no more than

oceasion-al use of adjunct measures,

No

Improvement

No essential

menced,changefrom

the time therapeutic exercise

com-(1

Remarkable

ImprovementModerateIrnprevementSlight

No

Improvement Irnprovement Fig. 4.Comparison between theexperimental and control

28

vaYdetu*

served

in

19

of the children

(59,4%),

moderate

improvement in

7

(21

.8%),

slight improvement in

3

(9,4%),

and no

improvernent

in

3

(9.4%).

Inthe

control _group, remarkable improvement was ob-served

in

4 of the children

(17.4%},

and no

im-provement

in

19

{82.6%).

The

improvement

inthe experimental group was significantly _greater

(p<

O,Ol)than forthoseinthe control _group.

Many mothers used adjunct measures such as

enema,

laxative,

digital

removal of

feces,

and

stimu-lationof the anus with a cotton swab to relieve

constipation

in

theirchildren.

On

theinitial assess-ment, adjunct measures were used

in

25

chj]dren

{78.1%)

ef the experimentat group,

but

this

number was reduced significantly

{p<O.05)

to

7

(21.9%)

at the

final

assessment.

In

thecontrol group, adjunct measures were used

in20 of the children

(87.0%)

on the

initial

assess-ment and in17children

(73,9%)

at thefinal assess-ment with no significant difference

{p>O.05).

The change inconstipation ef the experimental

(%)1098

ooo70605040302010o

D

RemarkableImprovement

ua

Moderate Irnprevement

eellli

SlightImprove'ment

ee

No lmpruvement AthetoidType(n:=6>SpasticQuadriplegia

{n

;- 20) FlaccidType(n=6} 'fi' i'"20

_tseg

1

."b-group was assessed according toa cLassification

by

the postural tonei7)

(Fig,

5).

Remarkable

improve-ment was ob$erved

in

all

6

children with athetosis,

but

in those with spastic _{quadriplegia,}remarkable

improvement

was observed in9,moderate

improve-ment

in

6,

slight

improvernent

in

2,

and no

im-provement in 3 of the 20 children. Of the 6

'dren

with flaccidity,4showed remarkable

improve-ment, 1 moderate improvement, and 1 slight

im-provement. However, no significant

difference

was

observed inthe changes among these three

classifi-catlons,

Improvement

in

the experimental group was

analyzed according _to age

<Fig.

6).

The median age

of the children

in

thisgroup was

25

months, and

we compared the 16 _younger children under 25

months of age with the

16

children aged

25

months

or older.

No

significant

difference

was observed of

change in constipation between the two groups.

Defecation treatment commenced _prior to

the

age

vf 1 year in9 children of the experimental _group

(Fig.

7)

showed favorable results, with

7

showing

remarkable improvement and 2 moderate

impreve-ment.

D

fi:,M.l.i.",Ce,M,:"k,e.f

.T,re2aK"r.e.".t,b.e.fgr: M,.th.

ua

Commencement of Treatmentafter 2Yearsand 1Month.

109 43 3 21 o Remarkable ]mprovement

{N=19)

Moderate].rnprovement

(N

--

7} S]ight No Improvement Improvement

(N=3)

CN

=t 3)

Fig. 5. Comparison of changes in

stipaLion among three

tions

in

the experimental group.

Fig.6. Comparison according toage

in

Lhe

Japanese Physical Therapy Association

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JapanesePhysicalTherapy Association

Defecation Treatment forConstipation in

7

2

Children

with SevereBrain Damage

DEFECATiON

29

o

{N=

9)

o Remarkable Moderate Slight No

Improvement Improvement Improvement Improvement Fig.

7.

Change

in

the constipated condition of

children younger than

1

year in

mental group.

4.

Discussion

Without appropriate management, constipation

may cause anorexia and abdominal pain,reduce

at-tention span, and

induce

epilepsyiS),

pyelone-phritisi9),hemorrhoids, ileus,and flatu]ence,posing

major heatthand social problems.

The improvement in constipation was

signi-ficantlygreater

in

the experimental group than

in

the control _group. Since the descending colon

shows no marked _pendular segmentatien, or

peri-staltic movement20), tecesare Iikelytobe retained at thissite inchildren with severe brain damage, in

whom the

level

of _physical activity is lew,

Clinically,

retention of fecalboluses inthe

descend-ing

colons of such children can often

be

cenfirmed

by

_palpation.

Hirst

and

McKirdy2i}

induced

the stretch reflex

in

the smeoth muscle of theco]on

by

insertinga

bal-loon intothe guinea pig colon and infiatingit,and

confirmed that the afferent excitation returned to

the colon via autonomic nerve _ganglias to induce

peristalsis.

Squeezing of

fecal

boluses retained in the

descending

colon toward thesigmoid colon and the

rectum using thetherapist'sfingersisconsidered te

elicita similar stretch reflex and _promote

peristal-sis. In healthy individuals,

esophago-proximal-colonic reflexes are

induced

by ingestion of food,

followed by a _{gastro-intestinal}refiex and

gastro-CLOSURE

OF

GLOTTIS

INTRA--ABDOMINAL

PRESSURE

PERISTALSIS

CEREBRUM

BRAIN

STEM

STRETCH

REFLEXES

IN

COLON

Fig. 8. Mechanism of defecation.

colonic refiex, which _produce the desire to

defecate22)'26)

(Fig.

8).Inchildren with severe brain

damage,

however,

restriction in food intake

due

to

oral motor dysfunction isconsidered to be related

to a lack of desiretodefecate. Even ifthereisthe

desire,the cerebral area thatreceives thissensation may

be

suppressed

in

itsresponse.

In these chjldren, a stretch reflex was elicited by

squeezing out the

fecaL

boluses

in

the

intestine

with

the

fingers

of the ±

herapist

and the resultant

peri-stalsi$ was considered to have served as sensory

stimuLi, which eLicited the desire todefecate from

thecerebrum.

The

physical therapist needs to modify the in-struction of straining according tothe types of

cer-ebral _palsy. In the children with spastie

quad-riplegia or those with dystonic athetosis, crossing of the legs and hyperextension or torsion of the

trunk must

be

inhibited,and the symmetry of

the

body

be

maintained during _the training for

strain-ing.

In athetoid children showing unstable and

fluctuating_postura] tone, _{the therapist}must

first

stabilize the postural tone and then teach them to

continue straining without interruption. In

chil-dren with flaccidity,cocontraction of the neck and

trunk muscles isenhanced firstin order to help

them resist gravity. This isconsidered as having

30

ffijZfith\

volving straining.

AIL6 children with athetosis showed remarkable

improvement,

probably

because

the principal

motility27), which

is

considered to be relatively

intact

in

such children,

is

related to

defecaLional

maneuvers. The lack of a significant differencein

the changes among the three types of children may

be

ascribed

to

the

limitednumber of cases ineach

group,

In order

to

increase

the

intra-abdorninal_pressure

by means of closing the vocal cords during

strain-ing,

the

therapist

repeatedly

interrupted

the

breath

of the children

by

applying strong vibrations with

the hands tothechest. as well as teaching them to

hold

the

head

and neck

in

midline

for

various

body

positions. This type of handling was considered to

have been helpfulinthe_process of learninghow to straln.

Daily repetition of this

defecation

treatment as

part of the therapeutic exercise was considered as

inducing the development of perception by the

cer-ebrum for

the

desire

to

defecate

as well as of the physical ability tostrain. Itistherefore very

im-portant

to

understand that constipation

is

a result

of sensorimotor impairment. The physical thera-pistmllst recognize

that

the

therapeutic

exercise to promote defecation

is

by

treatment of the

sensorimotor regions of the centraL nervous system.

Contents

and number of meals and water

intake

must be assessed on Lhe basisof thisapproach in connection with the sensorimotor system.

Constipation is more likely to take a chronic

course

in

older children and

is

more

dilficult

to

treat

(Fig.

6),but easier and lesslikelytorecur in

infants

_(Fig.

7). Therefore, defecation treatment

should be initiatedearly ifthereisany sign of con-stipation.

Children

with severe brain

damage

are often

complicated

by

epilepsy. Anticonvulsant

drugs

were administered to

18

of the

22

children with

ep-ilepsy

inthe experimenta] _group and to 15of _the

17

children with epilepsy

in

the

control group. These

drugs

have a side effect olsuppres$ing

intes-eg

20

_igeg

1Il;

Fig. 9.

Holding

thechild ina _positionto

promote

defecation.

tinal _peristalsiswhich is a cause of

constipa-tion28)29).

Therefore,

caution is necessary when

the children with severe brain damage are taking

these drugs,

The

_physical therapist isexpected

to

prevent constipation

by

introducing

defecation

treatment early when the signs of constipation are noted.

Recurrence of constipation

is

more likely

during

summer when perspiration

increases,

and

during

winter when activity

is

reduced

due

tocold

weath-er. Iti$thereforeimportant forthe therapisttoask

the parents at the times whether their children

have

any sign of constipation.

Along

with the

defecation

treatment,

it

is

recorn-mended toteachmothers theway toholdthechildren

in

a _position that

increases

the

intra-abdominal

pressure

(Fig.

9).

Presently,more than 60% of _preschool children

who go to day care centers for the handicapped

have severe disabilitiesand are dependent for

put-ting on and taking off clothes, eating, toiletting,

social mobility, and communication3D). Therefore,

many children encounter the problem of con-stipation, and itsmanagement by the _parents with

such measures as was

introduced

here

is

needed.

Japanese Physical Therapy Association

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JapanesePhysicalTherapy Association

Defecation Treatment forConstipation inChildren with

Severe

Brain

Damage

31

forthat matter, many _physical therapiststend to

think

that

the

management of constipation isnot a

part of their responsibility. Therapists shouLd

make a cornbined effort with the mothers in the

treatrnentof constipation so as to_prevent its per-slstence.

5.

Conclusion

Constipation

improved

significantly

in

the experi-mental _group, in which the

defecation

treatment

was

incorporated

with the therapeutic exercise.

This treatment may

_produce

satisfactory results

when

it

is

initiated

early at the

first

signs of con-stipation,

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32

理 学 療 法 学　第

20

巻第 i号 ＜要 旨〉 重 症 脳 損 傷 児の便 秘へ の運動療法 占 澤 正 道1） 新 保松 雄2） _{三 沢} 峰茂の 松 本 浩 二4）

　　　

小室美智 子D

　

金 子 断 行5） 大内 富夫6）

1

）ボバ

ー

ス記 念 病 院 2） 順 天 堂 医院

3

）横浜市 総合リハ ビリテ

ー

シ ョ ンセ ンタ

ー

4） 吹 田 市 立 保 健セ ンタ

ー

5

） すみ だ福祉保健セ ンタ

ー

6） 堺 市 立 あけ ぼの療 育セ ンタ

ー

　

重 症 脳 性 麻 痺 児の_便秘を解決する た めの運 動 療 法 を考 案 した

，

背 臥 位で患 児の両下肢を屈曲外転しな が ら下行結腸の便 塊 を 理 学 療 法 士の_手指で_押し出した

．

_次に両大 腿で腹 部を圧 迫し

，

腹 圧を高めて力み 方を経 験させた

．

全 身 的な運 動 療 法に この_{排便 訓練}を取り入れ た

32

名の 重 症 脳 性 麻 痺 児を実 験 群

，

排 便 訓 練を取り入れ ない 23名 を 対 照 群とした

，

変 化を著効， 改善， 軽度改善， 無 効で判 定 した

．

実 験 群 の変 化は対照群に比べ _{有 意に高か} っ た

　

（P＜ 0

．

Ol）

．

実験群で は緩下剤等の補助 手 段 を25名 が 用いて い た が

，

最 終 的には

7

名が使用して いた （P＜ 0

．

05）

．

対 照 群で は

20

名が用い て い た が， 最終評価 時に 17 名 が 使 用 して いた （P＞ 0

．

05）

，

1 歳米満に_排便 訓練を取り入れた 9名は

，

著 効

7

名

，

改善 7名で

，

成 績が良 好で あっ た

，