BACKGROUND: Anorectal dysfunction (ARD), especially bowel incontinence, frequently compromises the quality of life in multiple sclerosis (MS) patients. The effect of rehabilitation procedures has not been clearly established. OBJECTIVE: To determine the effect of an individualized rehabilitation approach on bowel incontinence and anorectal pressures. METHODS: MS patients with ARD underwent 6-months of individually targeted biofeedback rehabilitation. High resolution anorectal manometry (HRAM) and St. Mark's Fecal Incontinence Scores (SMIS) were completed prior to rehabilitation, after 10 weeks of supervised physiotherapy, and after 3 months of self-treatment. RESULTS: Ten patients (50%) completed the study. Repeated measures analysis of variance (ANOVA) demonstrated significant improvement in the SMIS questionnaire over time [14.00 baseline vs. 9.70 after supervised physiotherapy vs. 9.30 after self-treatment (p = 0.005)]. No significant improvements over time were noted in any HRAM readings: maximal pressure [49.85 mmHg baseline vs. 57.60 after supervised physiotherapy vs. 60.88 after self-treatment (p = 0.58)], pressure endurance [36.41 vs. 46.89 vs. 49.95 (p = 0.53)], resting pressure [55.83, vs 52.69 vs. 51.84 (p = 0.704)], or area under the curve [230.0 vs. 520.8 vs. 501.9 (p = 0.16)]. CONCLUSIONS: The proposed individualized rehabilitation program supports a positive overall effect on anorectal dysfunction in MS patients.

Department of Health and Human Kinetics Ohio Wesleyan University Delaware OH USA

Department of Internal Medicine 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Rehabilitation and Sports Medicine 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

See more in PubMed

Aw, H. C., Ranasinghe, W., Tan, P. H. M., & O’Connell, H. E. (2017). Overactive pelvic floor muscles (OPFM): Improving diagnostic accuracy with clinical examination and functional studies. Translational Andrology and Urology, 6(Suppl 2), S64–S67. 10.21037/tau.2017.05.41 PubMed DOI PMC

Beer, S., Khan, F., & Kesselring, J. (2012). Rehabilitation interventions in multiple sclerosis: An overview. Journal of Neurology, 259(9), 1994–2008. 10.1007/s00415-012-6577-4 PubMed DOI

Bols, E. M., Berghmans, B. C., Hendriks, E. J., de Bie, R. A., Melenhorst, J., van Gemert, W. G., & Baeten, C. G. (2007). A randomized physiotherapy trial in patients with fecal incontinence: Design of the PhysioFIT-study. BMC Public Health, 7(1), 355. 10.1186/1471-2458-7-355 PubMed DOI PMC

Booth, J., & Bliss, D., International Continence Society NursingCommittee. (2020). Consensus statement on bladder training and bowel training. Neurourology and Urodynamics, 39(5), 1234–1254. 10.1002/nau.24345 DOI

Bywater, A., & While, A. (2006). Management of bowel dysfunction in people with multiple sclerosis. British Journal of Community Nursing, 11(8), 333–334. 10.12968/bjcn.2006.11.8.21665 PubMed DOI

Carrington, E. V., Brokjaer, A., Craven, H., Zarate, N., Horrocks,E. J., Palit, S., Jackson, W., Duthie, G. S., Knowles, C. H., Lunniss, P. J., & Scott, S. M. (2014). Traditional measures of normal anal sphincter function using highresolution anorectal manometry (HRAM) in 115 healthy volunteers. Neurogastroenterology& Motility, 26(5), 625–635. 10.1111/nmo.12307 PubMed DOI

Chia, Y. W., Fowler, C. J., Kamm, M. A., Henry, M. M., Lemieux, M.C., & Swash, M. (1995). Prevalence of bowel dysfunction in patients with multiple sclerosis and bladder dysfunction. Journal of Neurology, 242(2)), 105–108. 10.1007/BF00887825 PubMed DOI

Cotterill, N., Madersbacher, H., Wyndaele, J. J., Apostolidis, A., Drake, M. J, Gajewski, J, Heesakkers, J., Panicker, J., Radziszewski, P., Sakakibara, R., Sievert, K.-D., Hamid, R., Kessler, T. M., & Emmanuel, A. (2018). Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013. Neurourology and Urodynamics, 37(1), 46–53. 10.1002/nau.23289 PubMed DOI

Fox, M., Schwizer, W., Menne, D., Stutz, B., Fried, M., & Thumshirn, M. (2004). The physical properties of rectal contents have effects on anorectal continence: Insights from a study into the cause of fecal spotting on orlistat. Diseases of the Colon and Rectum, 47(12), 2147–2156. 10.1007/s10350-004-0739-0 PubMed DOI

Frank, C., Kobesova, A., & Kolar, P. (2013). Dynamic neuromuscular stabilization & sports rehabilitation. International Journal of Sports Physical Therapy, 8(1), 62–73. PubMed PMC

Gosling, J., Plumb, A., Taylor, S. A., Cohen, R., & Emmanuel, A. V. (2019). High-resolution anal manometry: Repeatability, validation, and comparison with conventional manometry. Neurogastroenterology & Motility, 31(6), e13591. 10.1111/nmo.13591 PubMed DOI

Gulick, E., Namey, M. (2012). Bowel Dysfunction in Persons with Multiple Sclerosis. 10.5772/29317 DOI

Halabchi, F., Alizadeh, Z., Sahraian, M. A., & Abolhasani, M. (2017). Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurology, 17(1), 185. 10.1186/s12883-017-0960-9 PubMed DOI PMC

Heinrich, H., Fruehauf, H., Sauter, M., Steingötter, A., Fried, M., Schwizer, W., & Fox, M. (2013). The effect of standard compared to enhanced instruction and verbal feedback on anorectal manometry measurements. Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society, 25(3), 230–237, e163 10.1111/nmo.12038 PubMed DOI

Hinds, J. P., Eidelman, B. H., & Wald, A. (1990). Prevalence of bowel dysfunction in multiple sclerosis. A population survey. Gastroenterology, 98(6), 1538–1542 10.1016/0016-5085(90)91087-m PubMed DOI

Kang, H. R., Lee, J.-E., Lee, J. S., Lee, T. H., Hong, S. J., Kim,J. O., Jeon, S. R., & Kim, H. G. (2015). Comparison of High-resolution Anorectal Manometry With Water-perfused Anorectal Manometry. Journal of Neurogastroenterology and Motility, 21(1), 126–132. 10.5056/jnm4025 PubMed DOI PMC

Keef, K. D., & Cobine, C. A. (2019). Control of Motility in the Internal Anal Sphincter. Journal of Neurogastroenterology and Motility, 25(2), 189–204. 10.5056/jnm18172 PubMed DOI PMC

Khera, A. J., Chase, J. W., Salzberg, M., Thompson, A. J. V., & Kamm, M. A. (2019). Systematic review: Pelvic floor muscle training for functional bowel symptoms in inflammatory bowel disease. JGH Open: An Open Access Journal of Gastroenterology and Hepatology, 3(6), 494–507. 10.1002/jgh3.1220 PubMed DOI PMC

Kim, Y., Lai, B., Mehta, T., Thirumalai, M., Padalabalanarayanan S., Rimmer, J. H., & Motl, R. W. (2019). Exercise training guidelines for multiple sclerosis, stroke, and Parkinson’s disease: Rapid review and synthesis. American Journal of Physical Medicine & Rehabilitation, 98(7), 613–621. 10.1097/PHM.0000000000001174 PubMed DOI PMC

Kobesova, A., Safarova,, Marcela, R. M., & Kolar,Pavel. (2016). Dynamic neuromuscular stabilization: Exercise in developmental positions to achieve spinal stability and functional joint centration. In Textbook of musculoskeletal medicine. Oxford University Press. http://www.tandfonline.com/toc/rwhi20/

Kopańska, M., Torices, S., Czech, J., Koziara, W., Toborek, M., & Dobrek, Ł (2020). Urinary incontinence in women: Biofeedback as an innovative treatment method. Therapeutic Advances in Urology, 12, 1756287220934359. 10.1177/1756287220934359 PubMed DOI PMC

Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice & Research. Clinical Gastroenterology, 23(4), 531–543. 10.1016/j.bpg.2009.04.012 PubMed DOI

Laycock, J., & Jerwood, D. (2001). Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy, 87(12), 631–642 10.1016/S0031-9406(05)61108-X DOI

Lazarescu, A., Turnbull, G. K., & Vanner, S. (2009). Investigating and treating fecal incontinence: When and how. Canadian Journal of Gastroenterology, 23(4), 301–308. PubMed PMC

Lee, T. H., & Bharucha, A. E. (2016). How to Perform and Interpret a High-resolution Anorectal Manometry Test. Journal of Neurogastroenterology and Motility, 22(1), 46–59. 10.5056/jnm15168 PubMed DOI PMC

Lensch, E., & Jost, W. H. (2011). Autonomic Disorders in Multiple Sclerosis. Autoimmune Diseases, 2011. 10.4061/2011/803841 PubMed DOI PMC

Maeda, Y., Paräs D., Norton, C., Vaizey, C. J., & Kamm, M. A. (2008). Does the St. Mark’s incontinence score reflect patients’ perceptions? A review of 390 patients. Diseases of the Colon and Rectum, 51(4), 436–442. 10.1007/s10350-007-9157-4 PubMed DOI

Majlesi, J., & Unalan, H. (2010). Effect of treatment on trigger points. Current Pain and Headache Reports, 14(5), 353–360. 10.1007/s11916-010-0132-8 PubMed DOI

Marola, S., Ferrarese, A., Gibin, E., Capobianco, M., Bertolotto, A., Enrico, S., Solej, M., Martino, V., Destefano, I., & Nano, M. (2016). Anal sphincter dysfunction in multiple sclerosis: An observation manometric study. Open Medicine (Warsaw, Poland), 11(1), 509–517. 10.1515/med-2016-0088 PubMed DOI PMC

Mazur-Bialy, A. I., Kołomańska-Bogucka D., Nowakowski, C., & Tim, S. (2020). Urinary Incontinence in Women: Modern Methods of Physiotherapy as a Support for Surgical Treatment or Independent Therapy. Journal of Clinical Medicine, 9(4), E1211. 10.3390/jcm9041211 PubMed DOI PMC

Motl, R. W., Sandroff, B. M., Kwakkel, G., Dalgas, U., Feinstein, A., Heesen, C., Feys, P., & Thompson, A. J. (2017). Exercise in patients with multiple sclerosis. The Lancet Neurology, 16(10), 848–856 10.1016/S1474-4422(17)30281-8 PubMed DOI

Munteis, E., Andreu, M., Martinez-Rodriguez, J., Ois, A., Bory, F., & Roquer, J. (2008). Manometric correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis. Multiple Sclerosis (Houndmills, Basingstoke, England), 14(2), 237–242 10.1177/1352458507082606 PubMed DOI

Munteis, E., Andreu, M., Tällez, M. J., Mon, D., Ois, A., & Roquer, J. (2006). Anorectal dysfunction in multiple sclerosis. Multiple Sclerosis (Houndmills, Basingstoke, England), 12(2), 215–218 10.1191/135248506ms1254oa PubMed DOI

Newsome, S. D., Aliotta, P. J., Bainbridge, J., Bennett, S. E., Cutter, G, Fenton, K., Lublin, F., Northrop, D., Rintell, D., Walker, B. D., Weigel, M., Zackowski, K., & Jones, D. E. (2017). A Framework of Care in Multiple Sclerosis, Part 2. International Journal ofMSCare, 19(1), 42–56 10.7224/1537-2073.2016-062 PubMed DOI PMC

Nightingale, G. (2020). Management of urinary incontinence. Post Reproductive Health, 26(2), 63–70. 10.1177/2053369120927112 PubMed DOI

Noelting, J., Ratuapli, S. K., Bharucha, A. E., Harvey, D. M., Ravi, K., & Zinsmeister, A. R. (2012). Normal values for high-resolution anorectal manometry in healthy women: Effects of age and significance of rectoanal gradient. The American Journal of Gastroenterology, 107(10), 1530–1536 10.1038/ajg.2012.221 PubMed DOI PMC

Nordenbo, A. M., Andersen, J. R., & Andersen, J. T. (1996). Disturbances of ano-rectal function in multiple sclerosis. Journal of Neurology, 243(6), 445–451 10.1007/BF00900497 PubMed DOI

Norderval, S., Rydningen, M. B., Falk, R. S., Stordahl, A., & Johannessen, H. H. (2019). Strong agreement between interviewobtained and self-administered Wexner and St. Mark’s scores using a single questionnaire. International Urogynecology Journal, 30(12), 2101–2108 10.1007/s00192-019-03945-6 PubMed DOI

Norton, C., & Cody, J. D. (2012). Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. The Cochrane Database of Systematic Reviews, 7, CD002111. 10.1002/14651858.CD002111.pub3 PubMed DOI PMC

Nusrat, S., Gulick, E., Levinthal, D., & Bielefeldt, K. (2012). Anorectal Dysfunction in Multiple Sclerosis: A Systematic Review. ISRN Neurology, 2012. 10.5402/2012/376023 PubMed DOI PMC

Oblizajek, N. R., Gandhi, S., Sharma, M., Chakraborty, S., Muthyala A., Prichard, D., Feuerhak, K., & Bharucha, A. E. (2019). Anorectal pressures measured with high-resolution manometry in healthy people-Normal values and asymptomatic pelvic floor dysfunction. Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society, 31(7), e13597. 10.1111/nmo.13597 PubMed DOI PMC

Pedraza, R., Nieto, J., Ibarra, S., & Haas, E. M. (2014). Pelvic Muscle Rehabilitation: A Standardized Protocol for Pelvic Floor Dysfunction. Advances in Urology, 2014, e487436. 10.1155/2014/487436 PubMed DOI PMC

Pinter, A., Cseh, D., Sárközi, A., Illigens, B., & Siepmann, T. (2015). Autonomic Dysregulation in Multiple Sclerosis. International Journal of Molecular Sciences, 16, 16920–16952 10.3390/ijms160816920 PubMed DOI PMC

Preziosi, G., & Emmanuel, A. (2009). Neurogenic bowel dysfunction: Pathophysiology, clinical manifestations and treatment. Expert Review of Gastroenterology & Hepatology, 3(4), 417–423 10.1586/egh.09.31 PubMed DOI

Preziosi, G, Gordon-Dixon, A, & Emmanuel, A. (2018). Neurogenic bowel dysfunction in patients with multiple sclerosis: Prevalence, impact, and management strategies. Degenerative Neurological and Neuromuscular Disease, 8, 79–90 10.2147/DNND.S138835 PubMed DOI PMC

Preziosi, G, Raptis, D. A., Storrie, J., Raeburn, A., Fowler, C.J., & Emmanuel, A. (2011). Bowel biofeedback treatment in patients with multiple sclerosis and bowel symptoms. Diseases of the Colon and Rectum, 54(9), 1114–1121 10.1097/DCR.0b013e318223fd7b PubMed DOI

Ramage, L., Qiu, S., Yeap, Z., Simillis, C., Kontovounisios, C., Tekkis, P., & Tan, E. (2019)., Anorectal Manometry Versus Patient-Reported Outcome Measures as a Predictor of Maximal Treatment for Fecal Incontinence. 35(6), 8. PubMed PMC

Rao, S. S. C., Bharucha, A. E., Chiarioni, G, Felt-Bersma, R., Knowles, C., Malcolm, A., & Wald, A. (2016). Anorectal Disorders. Gastroenterology, S0016-5085(16)00175-X 10.1053/j.gastro.2016.02.009. 10.1053/j.gastro.2016.02.009 PubMed DOI PMC

Rao, S. S., Hatfield, R., Soffer, E., Rao, S., Beaty, J., & Conklin, J. L. (1999). Manometric tests of anorectal function in healthy adults. The American Journal of Gastroenterology, 94(3), 773–783 10.1111/j.1572-0241.1999.00950.x PubMed DOI

Remmen, F., & Dindo, D. (2013). [Fecal incontinence—A treatable problem!]. Therapeutische Umschau. Revue Therapeutique, 70(7), 403–406 10.1024/0040-5930/a000425 PubMed DOI

Roos, A.-M., Sultan, A. H., & Thakar, R. (2009). St. Mark’sincontinence score for assessment of anal incontinence following obstetric anal sphincter injuries (OASIS). International Urogynecology Journal and Pelvic Floor Dysfunction, 20(4), 407–410. 10.1007/s00192-008-0784-7 PubMed DOI

Ruiz, N. S., & Kaiser, A. M. (2017). Fecal incontinence—Challenges and solutions. World Journal of Gastroenterology, 23(1), 11–24 10.3748/wjg.v23.i1.11 PubMed DOI PMC

Sanagapalli, S., Neilan, L., Lo, J. Y. T., Anandan, L., Liwanag, J., Raeburn, A., Athanasakos, E., Zarate-Lopez, N., & Emmanuel, A. (2018). Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study. Neuromodulation: Journal of the International Neuromodulation Society, 21(7), 682–687 10.1111/ner.12764 PubMed DOI

Sandalcidi, D. (2016). Pelvic Floor Muscle Strengthening Using Biofeedback for Treatment of Fecal Incontinence in a Patient with Multiple Sclerosis. https://www.semanticscholar.org/paper/Pelvic-Floor-Muscle-Strengthening-Using-Biofeedback-Sandalcidi/a73a5cc1df03662ad76b8e87a985f02c9f3f8a67

Scott, S. M., & Carrington, E. V. (2020). The London Classification: Improving Characterization and Classification of Anorectal Function with Anorectal Manometry. Current Gastroenterology Reports, 22(11), 55. 10.1007/s11894-020-00793-z PubMed DOI PMC

Smania, N., Picelli, A., Munari, D., Geroin, C., Ianes, P., Waldner, A., & Gandolfi, M. (2010). Rehabilitation procedures in the management of spasticity. European Journal of Physical and Rehabilitation Medicine, 46(3), 423–438. PubMed

Teng, M., Kervinio, F., Moutounaïck, M., Miget, G., Charlanes, A,, Chesnel, C., Le Breton, F, & Amarenco, G. (2018). Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies. Annals of Physical and Rehabilitation Medicine, 61(5), 345–351 10.1016/j.rehab.2018.06.006 PubMed DOI

Vaizey, C., Carapeti, E., Cahill, J., & Kamm, M. (1999). Prospective comparison of faecal incontinence grading systems. Gut, 44(1), 77–80. PubMed PMC

Waldron, D. J., Horgan, P. G., Patel, F. R., Maguire, R., & Given, H.F. (1993). Multiple sclerosis: Assessment of colonic and anorectal function in the presence of faecal incontinence. International Journal of Colorectal Disease, 8(4), 220–224 10.1007/BF00290311 PubMed DOI

Wiesel, P. H. (2000). Gut focused behavioural treatment (biofeed-back) for constipation and faecal incontinence in multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry, 69(2), 240–243. 10.1136/jnnp.69.2.240 PubMed DOI PMC

Yumpu.com. (n.d.). Ebooks-download-travell-simons-simons-myofascial-pain-and-dysfunction-the-trigger-point-manual-unlimited. Yumpu.Com. Retrieved June 23, 2021, from https://www.yumpu.com/en/document/view/63118429/ebooks-download-travell-simons-simons-myofascial-pain-and-dysfunction-the-trigger-point-manual-unlimited