Abdominal massage for the treatment of idiopathic constipation in children with profound learning disabilities: a single case study design

Transcription

1 ORIGINAL ARTICLE Abdominal massage for the treatment of idiopathic constipation in children with profound learning disabilities: a single case study design Lucy Moss, Melanie Smith, Sarah Wharton and Annette Hames, Benton House, 13 Sandyford Road, Newcastle upon Tyne, NE 1QE, UK. ( annette.hames@nap.nhs.uk) Accessible summary Summary This report describes how abdominal massage was provided to five children, to see if it would help with their constipation. Children and adults with learning disabilities often have long-term constipation that is treated with. The abdominal massage was not effective for all the children. However the parents enjoyed doing the massage and all thought that it was a helpful and enjoyable experience for them and their children. Chronic constipation is a common problem in people with learning disabilities. Treatment often involves dietary changes or long-term laxative use. The aim of this study was to examine the effectiveness of abdominal massage. The participants were five children with profound learning disabilities and additional physical difficulties. Their long-standing idiopathic constipation was managed by. Intervention lasted up to 35 weeks, during which participants received min of massage at least twice daily. Parents were asked to maintain stable use of during the intervention phase, although some chose to withdraw during abdominal massage intervention. Abdominal massage appeared to result in stools of a more normal consistency in some cases. However, no significant differences were found in stool frequency. Parents reported that abdominal massage was a positive experience. In addition, they believed that massage was an effective treatment for constipation. As a result, laxative use was reduced in some cases, apparently with no ill-effects. These subjective beliefs were not, however, generally borne out by the objective results. Keywords Abdominal massage, children, constipation, learning disabilities Introduction Constipation is the subjective complaint of the passage of abnormally delayed or the infrequent passage of dry, hardened stools, often accompanied by pain (Croffie & Fitzgerald ). Constipation in children accounts for about 3% of all general paediatric referrals (Gallagher et al. 199). Soiling, the involuntary passage of stools into the child s doi:1.1111/j x

2 L. Moss et al. underwear, is one consequence of chronic constipation. Chronic constipation is believed to be the cause of faecal soiling in 95% of children presenting with this problem (Loening-Baucke 1997). Many factors can contribute to constipation: poor diet, insufficient fluid intake, lack of exercise, reduced mobility, constipation-causing medication, anxiety, depression, continually ignoring the urge to defecate, and organic causes such as cerebral palsy (Rogers 3). Constipation is believed to be more common in high-dependency populations, including learning disabilities (Von Wendit et al. 199). Constipation with no physiological, anatomical, radiological or histological abnormalities is described as idiopathic (Gordon et al. ). Children with idiopathic constipation are often recommended changes in diet, along with increased physical activity. However, where constipation persists, long-term laxative therapy tends to be employed (Rogers 3). More invasive interventions may include enemas, suppositories, manual removal and surgery. These techniques are distressing and especially so for children with learning disabilities, who may not understand why they are necessary. Other recently favoured treatment approaches include biofeedback and behavioural therapy. Biofeedback training uses instrument-assisted exercises to improve physiological control. Despite initially positive reports, a review by Brooks et al. () concluded that there is no evidence to support the routine use of anal sphincter biofeedback. Many studies have demonstrated the effectiveness of behavioural treatment approaches in children in the general population as well as those with learning disabilities (Smith ; Smith et al. 199), with treatment success reportedly around 7% (Bosch 19; Dawson et al. 199). Abdominal massage is an alternative, non-invasive technique that may be useful in the relief of constipation. Ernst (1999) carried out a systematic review of studies reporting the use of abdominal massage as a treatment for chronic constipation. He concluded that abdominal massage therapy might represent a useful and effective treatment for chronic constipation. Furthermore, it is perceived as agreeable by most patients and it could be used to enhance the therapeutic relationship. Similarly, Richards (199) noted that abdominal massage was a pleasant and relaxing experience, which enhanced the communication and social interaction of the people involved. Despite the widespread interest in the application of abdominal massage to the treatment of constipation, there is little objective evidence as to its efficacy and few studies of its application to constipation in children with learning disabilities. Therefore, a pilot study was designed to explore the effects of abdominal massage on a small group of children with profound learning disabilities, all of whom had idiopathic constipation. Ethical approval was obtained for this study from the local research ethics committee. Method Design A single case methodology was used in this study across baseline and two phases of intervention. Single case design was chose as it allows the complexities of the relationship between the individual participant, their constipation, his/ her learning disability and the intervention to be elucidated. The study therefore does not aim to look at group differences. Cases were chosen in no predetermined order, started consecutively, every 3 weeks. Participants One boy and four girls from a special needs school for children with severe and profound learning difficulties were involved (see Table 1). Their ages ranged from to 9 years (mean =.). All had a significant developmental delay; none could walk with ease, none could use phrase speech, and their only self-help skill was that four could self-feed with a spoon. Some had additional physical or sensory disabilities. All had idiopathic constipation as confirmed by their general practitioner. Procedure Baseline recording (Bristol Stool Scale, Heaton 1999), stool size, use of artificial elimination aids and amount of abdominal massage were recorded daily at home and school, prior to and during intervention. Intervention was implemented on a child by child basis, thereby reducing the likelihood that environmental factors, such as school holidays, might account for any changes observed in the dependent variables. Baseline measures were recorded for at least five weeks (maximum = 11 weeks; mean = 7. weeks). Teaching the massage Massage was administered at home once in the evening, twice at weekends and during holidays by parents, and on a daily basis at school by special needs assistants. A nurse practitioner who is highly experienced in abdominal massage began the treatment phase by demonstrating the techniques to parents and special needs assistants on a daily basis. She then observed the parents and special needs assistants, carrying out the massage, until she felt that they were competent. Following this, she visited the parents and school weekly to monitor massage treatment and to collect recordings. Base massage oil, rather than essential oils, was used in order to ensure that symptom improvement was

3 Abdominal massage with children with learning disabilities 3 Table 1 Participant information Participant Number Age Gender Diagnosis Medication Additional problems 1 7 Female Spastic tetraplegia Chloralhydrate Atenol Vallegan Senokot Female Left hemiplegia Sodium volporate Epilepsy. Lactulose 3 Male Unknown Movecol Thyroxin Visual impairment. Gastrostomy. Heart defect Visual impairment. Limited mobility Hypothyroidism. Low muscle tone but mobile. Significant behavioural problems 7 Female Unknown Lactulose Limited mobility 5 9 Female Angelman syndrome. Epilepsy. Sodium valporate Chloralhydrate Melatonin Lactulose Senna syrup. Fluid retention Hyperactive behaviour Limited mobility related to the massaging action itself and not the essential oils. effect on their child s constipation, and any additional benefits. Massage treatment recordings During intervention, recordings continued for a mean of 9. weeks (shortest = weeks, longest = 35 weeks). The parents were asked not to alter their child s laxative use during the intervention to ensure that any subsequent changes in bowel function could be attributed to the massage and not change in laxative use. Qualitative interviews Each participant s family was interviewed about the massage, how it fitted in with their routines, their views of its Results Figure 1 shows the stool frequency for all participants while Figs. compare the stool frequencies alongside laxative use for each individual participant. Statistical analyses Randomization tests were used to assess whether massage led to an increase or reduction in stool frequency. The randomization test requires that each individual is 3 5 Stool trequency 15 1 P1 P P3 P P No. of weeks Figure 1 of participants, Participant 1, baseline = 7 weeks, Participant, baseline = 11 weeks, Participant 3, baseline = 5 weeks, Participant, baseline = 5 weeks, Participant 5, baseline = 1 weeks.

4 L. Moss et al. Participant 1 Stool frequency/no N N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Figure and laxative use during baseline and intervention for participant 1. 1 Participant /no. 1 1 N N N N N N N N N N N Y N Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y N N Y N N N N N N Figure 3 and laxative use during baseline and intervention for participant. 3 Participant 3 /no N N N N N Y Y Y Y Y Y N N N N N N N N N Y Y Y Y Y Y Y N Y Y Y Y N N Y Y N N N N N Figure and laxative use during baseline and intervention for participant 3. 1 Participant /no. 1 N N N N N Y Y Y Y Y N N N N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N Figure 5 and laxative use during baseline and intervention for participant. randomly allocated to the point at which treatment is introduced. This increases the likelihood that any changes observed in the dependent variable are due to implementation of intervention and not to some coincidental factor in the environment. For each participant, the probability of a different randomly selected starting point producing the same results as those observed can be calculated. A chi-squared test of independence was used to identify whether the frequency of soft, normal and hard stools (according to the Bristol Stool Scale) was independent of intervention as a whole, or (in a second analysis) dependent on the phase of massage treatment, where intervention was

5 Abdominal massage with children with learning disabilities 5 1 Participant 5 Figure and laxative use during baseline and intervention for participant 5. /no. of 1 N N N N N N N N N N N N Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y N N N N N N Table Summary of the outcomes of the statistical analyses reported in the text Participant Stool Frequency (exact p) (comparison 1 v ) (comparison 1 Asymp. p) (comparison v ) (comparison Asymp. p) < < Comparison 1 is the test of baseline vs intervention and comparison is the test of baseline versus intervention separated into phases one and two as described. split into two equal halves ( treatment phase 1 and treatment phase ). statistically significant. There was no change in laxative use. Participant one Weekly stool frequency was fairly stable in the baseline phase (mean = 5.33). During intervention, there was a statistically significant reduction in weekly stool frequency (P =.5) (see Table ). Although stool frequency increased towards the later weeks, the overall effect of treatment was a reduction (mean = 3.5). Laxative use was largely stable across baseline and intervention. In contrast to what might be expected, treatment led to an increase in hard stools, not normal stools [v () =.5, P =.3]. There was no difference between baseline and the first and second halves of treatment [v () = 9.7; P =.59], suggesting that bowel function did not change significantly as intervention progressed. Participant Baseline stool frequency was somewhat variable, with a mean of 3.. During intervention, weekly stool frequency increased to a mean of 5.9, though this difference was not There was generally no difference in stool type between baseline and treatment, although normal stools increased in the second half of the treatment [v () = 11.7; P =.]. Participant 3 Overall, there was no significant difference in stool frequency between baseline and intervention. was stable during baseline (mean = 1.). When the massage was introduced (weeks 7 11), frequency increased slightly (mean = 1.17). During weeks 1, massage was not administered due to the school summer holidays. When intervention re-started, stool frequency was very variable. Overall, this period produced the fewest stools per week (mean = 11.). Simultaneously during weeks 1, were also in regular use. This participant had not used any during the baseline or intervention up to week 11. Normal stools increased during intervention [v (1) = 9.575; P <.1]. When treatment was split into two halves,

6 L. Moss et al. analysis showed that treatment led to an increase in normal stools during the second phase [v () = 9.3; P <.1]. Participant increased during baseline recording (mean =.). This appeared to coincide with a slight increase in laxative use in weeks and 5. Intervention during weeks 1 showed an apparent increase in stool frequency (mean = 5.), but there was also an increase in the number of used during these weeks. This, together with the upward trend during the baseline period, makes it difficult to assess the effect of the intervention under study. Again, data were missing for the school summer holidays. When massage was restarted, there was a large increase in weekly stool frequency (mean = 7.5), even though no were used during this period. Overall, there was no significant difference in stool frequency. All five parents enjoyed doing the massage. Three of the parents described how they also felt that their child enjoyed receiving the massage. Three parents felt that the massage was difficult to learn at first. All five parents reported that they felt the massage was effective in relieving constipation in their child, and four said that they thought the massage was more effective than laxative treatment. Interesting/important findings 1. The acceptability of the massage treatment is high, an important factor from the parents points of view.. Subjective parental impressions of improvement in constipation were not always borne out by the objective data: although there was some evidence of improved consistency in three of the five participants, there was no evidence of increased stool frequency. 3. Three of the participants stopped/reduced laxative use during the study (despite being asked to maintain stable laxative use throughout) and subsequently reported no adverse effects. Overall, there was no statistical difference in stool type between baseline and treatment, or between baseline and treatment phases one and two. Participant 5 Overall, there was no significant difference in stool frequency. varied considerably prior to intervention, which may have been a reflection of variability in laxative use. During intervention, were withdrawn, with little discernible effect on stool frequency before week, possibly due to missing data. After week, a fairly stable increase in stool frequency was observed. Normal stools increased significantly with intervention [v () = 9.71; P =.7], this effect being greater during the first phase of treatment [v () = 1.9; P =.]. Qualitative interviews Interviews were conducted with parents at the end of the study period. Questions investigated whether the parent and the child enjoyed the massage, what they most liked/ disliked, how easy they found the massage, whether they thought that it was effective and how it compared to other treatments. Discussion Constipation is multi-faceted in origin and little is known about its aetiology in the field of learning disability. Group experimental designs, while answering questions about the relative efficacy of different treatments or one intervention compared to no intervention, are inappropriate where a particular intervention has been little investigated, where it is not possible to control for relevant variables, or indeed where relevant variables are unknown. Single case design therefore allows the process of treatment to be studied for each individual across baseline and treatment. Although generalizations to the wider population cannot be made, single case design enables us to identify particular individuals for whom treatment has been effective, helps us formulate questions about the characteristics of those for whom the intervention was and was not successful, and permits any emerging themes to be identified. The results reported here do not support an increase in stool frequency during abdominal massage. However, the proportion of stools of normal consistency increased in three of the five participants. Caution must, however, be advised as laxative use was not stable throughout. Previous research into abdominal massage has produced inconsistent results with regard to stool frequency. The present study found no evidence of increased stool frequency, but some evidence of improved stool consistency. This finding is consistent with the clinical experience of the nurse practitioner, who has noted that the massaging action may soften stool consistency, making them easier to pass even although frequency does not improve. However, stool consistency is often not reported in other studies.

7 Abdominal massage with children with learning disabilities 7 Consistent with findings from previous studies are the positive experiences reported by those performing the massage and, also, reportedly experienced by the recipient of the massage (Emly et al. 199; Richards 199). Parents in the present study felt empowered by the massage to help their child with an unpleasant condition. Many felt that the daily one-on-one time brought them closer to their child. This may explain why the parents unanimously perceived abdominal massage to be an effective treatment for constipation, even though this was not borne out by the objective evidence. A number of methodological difficulties were encountered in the present study. Laxative use proved to be a variable that was difficult to control. Another difficulty arose when treatment was suspended for two participants during the school summer holidays. The participation of profoundly disabled children in research will always present practical problems such as illness or other environmental changes which impact on treatment integrity. Future studies of abdominal massage for children with learning disabilities would benefit from group designs using larger sample sizes, comparing control groups or groups receiving alternative interventions. Single case methodology could use reversal designs (though these are not popular with parents, who are generally reluctant to withdraw treatment if they feel it is effective). In addition, consideration should be given to the better-controlled use of or their withdrawal prior to the start of the study in order to demonstrate treatment effects more clearly. References Bosch J.D. (19) Treating children with encopresis and constipation: an evaluation by means of single case studies. In: Emmelkamp P., Eveaerd W., Kraaimat F., van Son M.J.M., editors. Advances in theory and practice in behaviour therapy. Amsterdam, Swets and Zeitlinger: 1 3. Brooks R.C., Copen R.M., Cox D.J., Morris J., Borowitz S. & Sutphen J. () Review of the treatment literature for encopresis, functional constipation, and stool toilet ing refusal. Annals of Beh Med, : 7. Croffie J.M.B. & Fitzgerald J.F. () Idiopathic constipation. In: Walker W.A., Durie P.R., Hamilton J.R., Walker-Smith J.A., Watkins J.B., editors. Pediatric gastrointestinal disease, 3rd edn. Hamilton, ON, Canada, Decker: 3 3. Dawson P.M., Griffith K. & Boeke K.M. (199) Combined medical and psychological treatment of hospitalized children with encopresis. Child Psychiat Hum Dev, : Emly M., Cooper S. & Vail A. (199) Colonic mobility in profoundly disabled people. Physiotherapy, : Ernst E. (1999) Abdominal massage therapy for chronic constipation: a systematic review of controlled clinical trials. Res Complement Med, : Gallagher B., West D., Puntis J.W. & Stringer M.D. (199) Characteristics of children under five referred to hospitals with constipation: a one year prospective study. Int J Clin Prac, 5: Gordon J., Reid P., Thompson C. & Watford C. () Ideopathic constipation management pathway. NT Plus, 9: 5. Heaton K. (1999) The Bristol Stool Form Chart. In Understanding your bowels, Family Doctor Series. London, BMA. Loening-Baucke V.A. (1997) Fecal incontinence in children. Am Fam Phys, 55: 9 3. Richards A. (199) Hands on help. N Times, 9: Rogers J. (3) Management of functional constipation in childhood. Brit J Comm Nurs, : Smith L.J. () A behavioural approach to the treatment of nonretentive encopresis in adults with learning disabilities. J Intel Dis Res, : Smith L.J., Franchetti B., McCoull K., Pattison D. & Pickstock J. (199) A behavioural approach to retraining bowel function after longstanding constipation and faecal impaction in people with learning disabilities. Dev Med and Child Neur, 3: 1 9. Von Wendit L., Simila S., Niskanen P. & Jarvelin M-R. (199) Development of bowel and bladder control in the mentally retarded. Dev Med and Child Neur, 3: 515.