Visceral and Neural Manipulation in Children with Cerebral Palsy and Chronic Constipation: Five Case Reports

Participants

• Number: 5

• Criteria of inclusion: children aged between 2 and 18 years, with a diagnosis of static encephalopathy (cerebral palsy) secondary to brain injury during the first year of life,  non-ambulatory Gross Motor Function Classification System (GMFCS) level IV or V, and constipation according to Rome II criteria modified for children with cerebral palsy.
• Criteria of exclusion: presence of a cast in the pelvis and femur, abnormal coagulation, blood dyscrasia, abdominal aneurysms and major surgery in the six weeks prior to the first visit.
• Descrizione:
  • Case A: an 8-year-old male, born at full term and adopted from China. Undergone a Stroke following heart surgery for tetralogy of Fallot at the age of 15 months, followed by quadriplegia (GMFCS IV), mainly on his left side. Difficulty swallowing and overactive gag reflex. A gastrostomy tube (G-tube) was placed for nutrition, while the reflux was treated with a protein pump inhibitor and erythromycin. Right hip surgery at the age of 4 years and, given the possibility of falls if unsupported, use of a wheelchair with seating supports. Communication occurred mainly through facial expressions, with hypotonus at the level of the trunk and athetosis of the upper limbs. Severe pain in the right hip with limited movement, frequent regurgitation and vomiting, and need for glycerin suppositories to favor intestinal peristalsis.
  • Case B: an 18-year-old male, who had a GMFCS V with spastic quadriplegia with unclear etiology. As a baby he had undergone a Nissen fundoplication and G-tube placement through gastronomy. He was using a wheelchair but could sit by himself in a chair and also walk a few steps if assisted. Low muscle tone in trunk and extremities with posterior pelvic tilt and very stiff hamstrings. Need for a device to communicate as it was non-verbal; however, the parents would understand when he was stressed. At night he did not sleep and was very agitated, perhaps because of pain due to constipation, for which he had been taken to the emergency room many times. Despite he had 7 bowel movements a week he often needed suppositories or enemas.
  • Case C: a 3-year-old male, who had suffered a traumatic brain injury which induced spastic quadriplegia, left occipital contusion, left parietal subdural hematoma, bilateral retinal hemorrhages, cerebral visual impairment (CVI), intractable seizures. He mistrusted anyone other than his parents. His body was “closed” in the fetal position and had a feeding tube placed via a gastrotomy. He depended on his parents for every activity and was in a wheelchair. He was on various medications including protein  pump inhibitors, clonidine, baclofen and keppra. He had two bowel movements a week.
  • Case D: a 7-year-old female, suffered a traumatic brain injury leading to cerebral palsy, cerebral visual impairment, and seizure disorder (GMFCS IV). She underwent a right cranietomy and placement of a ventriculo-peritoneal shunt. One month prior to treatment, she underwent a right derotational femoral osteotomy. although she used a wheelchair on the one hand, on the other hand she had started using a walking aid. Despite a feeding tube she ate orally. When she was in pain, she communicated it clearly. She she had 11 bowel movements a week.
  • Case E, a 4-year-old female, born at 25 weeks of gestation. She was a triplet with GMFCS IV. She was given a ventriculo-peritoneal shunt which was revised 10 times, and a G-tube via gastrotomy. She had a hearing impairment, a cochlear implant and seizure disorder. She was able to eat orally, sit and crawl, had started walking a few steps and could communicate verbally. Central hypotonicity and slight hypertonicity in the extremities (especially on the right). She was constipated, had 6 bowel movements a week, regurgitated frequently, vomited and had head and neck pain. The various medicines she took included keppra.

Interventions and evaluations

• Evaluation, at the beginning of the study, at the end of the treatments and after 3 months, of the quality of life by CPCHILD and of the function by WeeFIM.
• Evaluation, at the beginning of the study and at the end of the treatments, of colonic motility by radiography with radio-opaque markers.
• Daily assessment for one week at baseline and at weeks 8, 16, 24 and 36, of the consistency, colour, size and frequency of intestinal peristalsis (through Modified Bristol Stool Scale) using family diaries especially created for this study.
  • The diaries contained information on interventions for constipation (eg, medications and treatments), appetite, reflux and vomiting episodes, sleep quality and duration, seizure frequency and duration, and pain measured by the Wong Baker Faces Pain Scale.
• 12 sessions of 45 minutes of visceral and neural manipulation every 2 weeks for 6 months.
• Visceral and neural manipulation:
  • treatment centered on the abdomen and nervous system.
  • at the beginning of each session, the therapist assessed what tissue presented the most important tension and shortening.
• The intention of the study was to implement  a personalized therapy for each patient, that acted on his needs (eg, eating habits, bowel habits, communication).
  • • Parents were taught how to touch and massage their children.
• Manipulation performed by a therapist trained in visceral and neural manipulation.

Results

• General results:
  • The WeeFIM scale showed an improvement in function in all participants at the end of the interventions, with 3 subjects maintaining the result in the follow-up.
  • The CPCHILD scale showed an improvement in the quality of life in 4 participants during the treatments, an improvement also seen at the foolow-up for 3 subjects.
  • At the intestinal level, 3 participants increased the number of bowle movements after 8 weeks and 3 participants showed greater peristalsis until the end of the follow-up.
  • Although statistical significance is lacking due to the low number of participants, colonic motility increased for all.
• Specific resulats:
  • Case A no longer needed suppositories, decreased reflux and vomiting episodes and had a continuous increase in function, while quality of life, which improved after 8 weeks, returned to pre-study levels at the end of the follow-up.
  • Case B showed a continuous increase in quality of life, while at the end of the follow-up the function decreased after having increased during the treatments. The frequency of bowel movements increased 11 times a week. An attempt was made to get the boy to overcome an alleged sexual abuse suffered at school.
  • Case C showed an increase with treatment but then a decrease at the follow-up in both quality of life and function. The frequency of bowel movements was increased to 3 per week. She started riding the tricycle and trusting people other than her parents.
  • Case D saw a continuous improvement in quality of life and, despite a decrease during the treatment period, an improvement in function at the follow-up. He also increased his frequency of bowel movements to 13 times a week, and all this despite getting worse because of a hip surgery and subsequent drugs consumption (Valium and Motrin).
  • Case E saw a continuous improvement of both quality of life and function and an increase of bowel movements to 8 times a week.

Discussion

Most participants showed improvements in both function and quality of life as they continued with the treatments, although some improved while others worsened during follow-up.

The main finding, however, was the uniqueness of each case: not only were the degrees of spasticity, with relative repercussions on intestinal motility and pain, very different, but also the pharmacological treatments and above all the emotional, personal and social experiences, were varied. In this regard, several traumas experienced were related to the touch and, therefore, made it difficult for them to relax.

When either the cause or the underlying mechanism of the pain perceived by the participants was treated, a relaxation of the nervous system and an improvement in intestinal motility were seen. The same effect was favored by massages taught to the parents.

In addition to the specific restricted tissues, it was essential to treat the autonomic nervous system, from the skull to the sacral plexus along the vagus nerve.

Finally, it should be noted that excellent palpatory skills and careful attention to body signals are paramount with these patients since they cannot express themselves verbally, therefore the therapist must be able to understand when they are in a state of stress or pain.