Dawn Sandalcidi, PT, RCMT, BCB-PMD can be found online at https://kidsbowelbladder.com/. Dawn is a long time instructor with Herman & Wallace and has generously shared her recent blog with The Pelvic Rehab Report. "Stool Withholding And Core Activation" can be found in its original post on her website here: https://kidsbowelbladder.com/stool-withholding-and-core-activation/.

What do they have in common?
About 9-12% of children suffer from functional constipation, which is the vicious cycle of retained stool causing rectal distention and subsequent loss of sensation and urge to defecate, which results in further stool retention. The exact physiologic causes for functional constipation are not completely understood.

We know the bowel absorbs water constantly. The longer stool sits in the rectum, the harder it becomes. For some children, this leads to very large stools that are uncomfortable or difficult to eliminate. In turn, these children may practice something called stool withholding (which may be the reason stool was sitting in the rectum too long in the first place).

There are many other reasons a child may withhold their stools beside the standard issues that functional constipation presents. Some other reasons for stool withholding include:

• Inability to generate intraabdominal pressure
• Availability, likes, and dislikes of the toilet
• Fear of having a bowel movement
• Perineal sensation issues
• Psychological concerns
• Pain with defecation
• Dietary contribution
• Illness or infection
• Medications
• And more

No matter how or why a child began withholding stools, it’s vital to treat the problem as soon as possible. When withholding and constipation go untreated, they can cause lifelong issues. In this article, we will explore the relationship between constipation and core control, specifically the child’s ability to generate intraabdominal pressure.

What are the Symptoms a Child May have When Practicing Stool Withholding?
Normally, when enough stool enters the rectum and it’s time for a bowel movement, the rectum will send messages to the brain to make you aware that it’s time to have a poop. Ideally, when you receive this message and become aware of your body’s need to defecate, you find a toilet and do so.

When a child regularly withholds stools, the stool may become retained in the rectum and cause rectal distention and a subsequent loss of sensation. Because the rectum isn’t able to sense its fullness, the messages are never sent to the brain, and the sense of urge to poop disappears.

Although children who withhold stools may not have the urge to poop, they can have other physical symptoms if their stool withholding causes stool retention.

Physical symptoms of stool retention include:

• Abdominal pain
• Offensive body odor
• Stools that clog the toilet
• Decreased appetite
• Urinary incontinence or frequency
• And more

Children who withhold stools do not always have retention, however, and sometimes will simply withhold stools due to their environment (such as being at school during the day), and poop as soon as they get home.

How Might Core Strength Relate to Stool Withholding?
I treated a 6-year-old child once who had a bowel movement every single day, but only after he fell asleep in his parents' arms. His parents hadn’t been able to transition him out of diapers because of this. His bowel movements were so predictable that his parents would wait for him to poop, then clean him up and put him back to bed.

This child was also autistic and did have issues with low tone. I discovered during examination of the child that he had a difficult time voluntarily contracting his core muscles. Rotational and balance activities were difficult for him to perform as well due to his lack of core control.

You may be wondering what the core has to do with constipation, or stool withholding specifically. For starters, you need adequate core strength in order to sit upright on the toilet. Without proper core control, children may develop poor toileting postures which can lead to difficulty with defecation.

Correct toileting posture involves first being able to have enough hip extension, back extension, and side-to-side control to balance in a seated position on the toilet seat. Seats of differing heights add to the complexity of good toileting posture.

Proper Body Position for Toileting
Ideally, your feet should be supported, not dangling (which is a common occurrence for our children using adult-sized toilets). Forearms should be resting on the thighs, and the hips should be bent to at least 90 degrees of flexion. The spine should be in a neutral position (no posterior pelvic tilt).

This position allows for the pelvic floor muscles to relax appropriately, and for the core muscles to activate enough in order to produce appropriate intraabdominal pressure.

Without appropriate intraabdominal pressure generation, it will be difficult for a child to push out their poop. This is precisely what we discovered with my patient who was withholding until she got into bed. When in her parents' arms she was flexed, it was easier for her to generate enough intraabdominal pressure to poop, and so she did!

Knowing the reason for his withholding allowed us to target treatment planning where he needed it the most.

How to Address Core Strength in Children who Withhold Stools
Once you’ve determined that core activation is a root issue, you’ll need to address it in order to see any change with your patient’s bowel habits. Parents are usually at their wit’s end and are looking to you for answers. Your physical exam is your best tool in identifying root causes of stool withholding.

Many children attending physical and/or occupational therapy do suffer from low tone. As we’ve learned, this can compound constipation issues and even lead to stool withholding.

With the child above, we worked on core activation exercises first in supine, then in prone on an incline, and gradually added challenge to his exercises until she was able to generate enough intraabdominal pressure to poop on the toilet independently.

Even if your patient does not suffer from low tone, core activation and training may still be indicated. Some children have difficulty with coordinating or timing appropriate muscle contraction and relaxation. Be sure to evaluate the core when treating patients who suffer from constipation and stool withholding.

These children may have difficulty crossing midline as well. Age-appropriate exercises to engage the core while also incorporating diagonal and midline-crossing motions will be beneficial for those patients.

Additionally, you’ll want to assess the rib cage. Oftentimes I find children who have difficulty with core control also have a wider rib angle and hence need upper abdominal engagement exercises.

Lastly, many of the children you’ll treat will need help with rotation. This is a common finding during examination and without addressing rotation, you’ll see much slower progress.

Treating Stool Withholding and Core Issues is Possible
So many children with constipation will not receive appropriate treatment during childhood and their problems will persist into adulthood. It’s our job as pediatric therapists to identify children in need of help. Many children with bowel and bladder problems will be seen in your clinics for other issues, and unfortunately never even bring up the bowel or bladder concerns.

I put together a list of 5 Screening Questions you can ask your patients to determine whether they might be suffering from bowel or bladder issues and not even know it. This is a quick and easy way to identify patients in need of pediatric pelvic floor therapy.

It’s a great idea to get in touch with your local pediatric pelvic floor specialist to be able to easily refer these patients. You can also become a pediatric pelvic floor therapist yourself by taking my online courses! I believe this patient population is severely underserved and have made it easier than ever to learn how to best support these children.

My courses are held live in various locations around the world throughout the year, but I also offer online options for you to be able to work at your own pace from the comfort of home. Inside my online courses, there is space in every module to leave comments or ask questions and they go directly to me.

Sign Up For the Pediatric Functional Gastrointestinal Disorders Remote Course.

I’ve also created a group online where those who have taken my courses can collaborate, receive my mentorship, and discuss any issues that come up along their pediatric pelvic floor therapy journey. The group is called KBB Professional Village.

Learn More about KBB Professional Village.

Pediatric Functional Gastrointestinal Disorders

Course Dates:
November 12-13, 2022
May 20-21, 2023
November 4-5, 2023

Price: $600
Experience Level: Intermediate
Contact Hours: 15

Description:  This two-day, remote course is offered on Zoom and is the next step for therapists who focus on the pediatric pelvic floor patient population. It is designed to expand your knowledge of the development of normal bowel patterns in children, introduce the new Rome IV criteria (Zeevenhoovenet al. 2017), and review the anatomy and physiology of the GI system with emphasis on Pediatric Functional Gastrointestinal Disorders (FGID).

This course will delve into the most common types of functional constipation and the tests and measures used to assess it. Special emphasis on constipation with the coexistence of fecal incontinence (Nurko, Scott. 2011) and the psychological effects of these disorders will also be presented. Additionally, participants who have not yet been trained will learn external and internal anorectal PFM evaluation of the pediatric perineum. Indications for rectal balloon training and determining the appropriate patient will be instructed with lab. Functional defecatory positions for breathing and PFM relaxation, manual therapy techniques of the abdominal wall and viscera will be taught. 

Dawn Sandalcidi PT, RCMT, BCB-PMD is known as the go-to expert in the field of pediatric pelvic health. She has been practicing for 40 years this May and has concentrated on the pediatric pelvic floor for 29 of those. When it comes to pediatric pelvic floor issues, there is so much more than bedwetting, and often the practitioner needs to look beyond the pelvic floor.

Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served. This can cause undue stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Many of the techniques used in pediatric pelvic therapy can be translated to the adult population. The question is ‘who’s the driver?’ In pediatrics, it is typically a bowel issue.

The Standard American Diet involves food that is high in calories, saturated fats, trans fats, added sugars, and sodium. It is also lacking in the intake of essential nutrients for the body like fiber, calcium, potassium, and vitamin D. This lack of dietary fiber can cause issues with the digestive tract as well as the colon leading to constipation. Bowel dysfunction including constipation can contribute to urinary leakage and urgency (1). Constipation accounts for approximately 5% of visits to pediatric clinics (2) proving that there is a need for practitioners to know how to treat these pediatric issues.

Dawn focuses much of her pediatric knowledge on her two courses: Pediatric Incontinence and Pelvic Floor Dysfunction (PEDs) and Pediatric Gastrointestinal Disorders (PEDsG). Pediatric pelvic floor basics are covered in PEDs, including instruction in anatomy, physiology, development of normal voiding reflexes and urinary control, and learning how to talk with child patients. Biofeedback and ultrasound (which Dawn fondly calls jelly belly) are also covered and can be helpful as less invasive procedures for children.

PEDsG goes beyond the pelvic floor and opens up the door to look at the big picture of the whole child. Dawn shares that almost 80% of her kiddos with chronic constipation present with diastasis rectus abdominus. They can also have hyperextension in the thoracic spine, and the rib cage is postally rotated – where the kids don’t know how to bring it down.

Dawn is also on the threshold of writing a pediatric pelvic pain course that she expects to be ready later this year. Pediatric pelvic pain is becoming more prevalent, and it can’t be treated the same way as in adults. Dawn explains that “children don’t understand, so we’re actually creating a pediatric pain neuroscience protocol. It is a bio-psycho-social approach, and we use fun things.”

Research tells us that 15% of kids per year will outgrow bedwetting. Children who suffer from bedwetting can feel ashamed and embarrassed, have self-esteem issues, or even act out. There are 5 basics of where you start with a pediatric patient that are taught in PEDs. Dawn also shares 5 basics in her e-book, BEDWETTING BOOTCAMP(3):

1. Avoid things that can irritate the bladder
2. Avoid drinking anything just before bed
3. Drink throughout the day
4. Empty your bladder throughout the day
5. Avoid constipation and straining

Everything in Pediatric Incontinence and Pelvic Floor Dysfunction builds into Pediatric Gastrointestinal Disorders, and everything in PEDsG builds into Pediatric Pelvic Pain. The more practitioners who learn about the pediatric pelvic floor means that more kids get treated and the fewer adults that will have pelvic floor dysfunction. To learn more about treating pediatric pelvic health register for one of Dawn Sandalcidi’s upcoming courses:

Pediatric Incontinence and Pelvic Floor Dysfunction: August 27-28th

Pediatric Gastrointestinal Disorders: May 14-15, November 12-13

References:

1. Sandalcidi (Spring 2018). Paediatric incontinence and pelvic floor dysfunction. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, 122, 5–8.
2. Thibodeau B. A., Metcalfe P., Koop P. & Moore K. (2013) Urinary incontinence and quality of life in children. Journal of Pediatric Urology 9 (1), 78–83.
3. Dawn Sandalcidi PT, RCMT, BCB-PMD. BEDWETTING BOOTCAMP Frustrated by Bed Wetting? The 5 Ways to Speed Starting Up Dry Tonight! www.kidsbowelbladderPMD.com. https://cdn.fs.teachablecdn.com/YfP5rUfiRtOJxXZSZUso

This week The Pelvic Rehab Report sat down with senior teaching assistant and author, Mora A Pluchino, PT, DPT, PRPC, to discuss her new book “The Poop Train”. Mora works at the Bacharach Institute for Rehabilitation and in 2020, she opened her own "after hours" virtual practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016, as well as a TA with Herman and Wallace since 2020 with over 150 hours of lab instruction experience!

What or who inspired you to write this book?

My nine-year-old daughter has had issues with constipation since she was two. Our household is no stranger to talking about poop and all things related to poop to manage her tummy issues. I always tried to explain to her the purpose of habits like eating fiber and drinking water, as well as how poop moves through the body. One day my daughter started telling me that her “poop train wasn’t ready to leave the station” and I got the idea for the story!

Can you tell me about your book and the title?

I wanted a title that would be silly but interesting to a child. My goal was to create a book to be easy to read and understand the story about how food enters and leaves our body with resources within and after the book for parents to help manage their child’s bowels. I wanted it to be something that would be fun to read while on the potty, preparing for potty training or if a child is having an issue.

What does your daughter think of “The Poop Train”?

I just asked her and she took my computer over to answer. “I think that you are crazy and you talk about poop way too much! I also think that your book is super cute and even kind of funny. Kids and adults alike are going to love it because it talks about all the parts it needs to but it is not creepy or embarrassing.” - Nina P.

What’s your favorite thing about your book?

I am honestly in love with the illustrations. I had this idea for a few years and couldn’t do anything with it because I’m not good at drawing. I finally connected with the sister of a dear friend who shares my love poop talks and happens to be a talented artist. She brought my idea to life in adorable, inclusive, and simple images!

How do you think writing this book has impacted you as a PT and parent?

Taking Pelvic Floor Level 1 changed my life as a parent. This career path gave me the tools to help my daughter manage her constipation and resultant pelvic floor issues like post-void dribbling and bed-wetting. I wrote this book to help other parents who had similar struggles.

Were there any surprises along this book journey?

Funny story, I proofread my book multiple times along with my husband and a friend. My daughter read the book for the first time and found a TYPO! At that point, it was too late so my book became practically perfect. Hint - the typo is in the resource section!

What advice do you have for other PTs who are interested in writing?

I’d encourage anyone interested in writing something to go for it. Take your idea and nurture it until you can create it! Talk to others if you get stuck. I did this and found the illustrator of my dreams shortly after. And proofread a million times!

Do you think you’ll write another book?

I am finalizing the manuscript for my second pelvic health book. I was so happy with how Elizabeth Wolfe was able to capture the style I wanted that I asked her to work on a second project a few days after we finished our first. “Practically Perfect Pelvic Health 101: A Visual Tour of the Pelvic Floor” will be going to print soon!

How do I get a copy of this book?

“The Poop Train” is available in paperback on Amazon! I am also happy to send copies to fellow pelvic health professionals at a discount. I can be contacted by email at This email address is being protected from spambots. You need JavaScript enabled to view it.!

Mora Pluchino (She/Her)

practicallyperfectpt.com

@practicallyperfectpt

Deb Gulbrandson, PT, DPT, along with Frank J Ciuba DPT, MS, is the author and instructor for a new course on osteoporisis that is launching remotely this month. Join Deb in Osteoporosis Management: A Comprehensive Approach for Healthcare Professionals!

Osteoporosis is a disease of increasingly porous bones that are at greater risk for fracture. The normal “bone remodeling” of breaking down and building up bone as we age is out of balance. Similar to a bank account with withdrawals outpacing deposits, as time goes on there is more breaking down than building back up. This leaves the bone more vulnerable for fracture.

We tend to think of Osteoporosis as an old person’s disease and in fact age is certainly a risk factor. We see a sharp decline in bone density the first few years following menopause; a withdrawal from the “bone bank account.” But let me share a startling statistic. At the age of 20 we have 98% of the bone density we will ever achieve. We achieve Peak Bone Mass by age thirty when our bones have reached their maximum strength and density.

Factors affecting Peak Bone Mass include both Non-modifiable and Modifiable. Among the non-modifiable factors are gender (peak bone mass is higher in men), race (peak bone mass is higher in African Americans), and hormonal factors (early onset of menstruation and use of oral contraceptives tend to have higher peak bone mass). A family history of osteoporosis is another important factor.

Modifiable factors include nutrition (adequate calcium in the diets of young people), physical activity during the early years (specifically weight bearing and resistance exercises). Poor lifestyle behaviors (smoking, high alcohol intake, and sedentary lifestyle) have all been linked to low bone density in adolescents.

The American Physical Therapy Association website includes a section on “Container Baby Syndrome” (CBS). CBS is the name used to describe a range of physical, cognitive, and developmental conditions caused by a baby or infant spending too much time in containers such as baby carriers, strollers, and Bumpo seats. Bone mass can certainly be affected by reduced movement and weight bearing activities. Due to the SIDS scare, many young parents are fearful of allowing their children to spend time on their abdomens. Educate and share the “Supine to Sleep, Prone to Play” mantra.

The graph below shows a comparison of the Peak Bone Mass of males to females and to individuals with suboptimal lifestyle factors. You can see that the suboptimal group never catches up and enters the osteoporosis stage at around age 40.

According to the Department of Human Services “Osteoporosis is a pediatric disease with geriatric consequences. Peak bone mass is built during our first three decades. Failure to build strong bones during childhood and adolescent years manifests in fractures later in life.”

What can we do?
• Start early: Encourage young children (and their parents) to move more and sit less.
• Spread the word: Speak to Young Mothers’ Clubs, Girl Scout Troops; anywhere to influence adolescent and teens about the importance of proper exercise and good nutrition.
• Write a blog: Share this information in newspapers, social media, and on your website. Get the word out! Because the bones of our future generation depend on it.

NIH Osteoporosis and Related Bone Diseases National Resource Center
Department of Human Services
American Physical Therapy Association

The following post comes from Dawn Sandalcidi PT, RCMT, BCB-PMD author and instructor of the Pediatric Incontinence and Pelvic Floor Dysfunction course, and the more recent follow-up course, Pediatric Functional Gastrointestinal Disorders. Dawn has developed a pediatric dysfunctional voiding treatment program in which she lectures on nationally. She has further studied pediatric conditions in post graduate work at Regis University. Dawn has published articles in the Journal of Urologic Nursing, the Journal of Manual and Manipulative Therapy, and the Journal of Women’s Health Physical Therapy.

Growing up, I was blessed to be around children with Cerebral Palsy (CP), which stimulated my desire to become a physical therapist, a career that I love more now than when I started nearly 38 years ago!

Did you know….

The incidence of Cerebral Palsy in Nepal is estimated to be over 60,000. The Self -Help Group for CP estimate that 80% of children (and adults) also present with bowel and bladder leakage which significantly affects their quality of life and leads to infections and other medical complications. Additionally, a recent pilot study revealed an incidence of urinary leakage in school children aged 10-16 years at 73%, as compared to 6-13% in developed countries. This has shown me a clear and meaningful need to help CP kids in Nepal who are tragically affected.

Pictures from http://www.cpnepal.org/about.html

Through a partnership with the University in Nepal, I will be training Nepali Physical Therapists how to treat children with bowel and bladder issues. Nepal currently does not have any trained providers - this training will provide sustainability as these providers will be able to treat multiples of children with bowel bladder issues, in addition to strategies for prevention. The plan is also to visit several villages with a Self-Help Group for Cerebral Palsy children to educate families and caregivers how to manage incontinence and constipation in these children.

I need your help to accomplish this!

I will be donating a 3-day training for PT’s and several caregiver trainings for this project. With your help I can secure needed supplies, bring physical therapists from remote villages to the course and help with travel expenses.

The Prometheus Group has generously donated an entire biofeedback system with pediatric animation to the hospital, but additional lead wires and electrodes are needed to run the system.

What’s needed?

• Supplies for treatments
• Electrodes for 1 child $4.60 x 100 =$460
• Additional lead wires and adaptors - $340 per set – 2 sets per year= $680.00
• Airfare and Travel Expenses (Hotel, etc.) to help offset the costs of - $3,750.00

My goal is to raise approximately $6,000 to help improve the quality of life for these children.
Your Support Will Make a Great Impact:

• $50 will help pay for electrodes for 10 children
• $150 will bring a physical therapist from a remote region to the course
• Any $ amount will help me educate the therapists in Nepal to sustain the program and treat thousands of children = PRICELESS

A donation of any size will make a difference and will be tremendously appreciated. Please consider donating an amount that feels comfortable to you and know that you are impacting the health, well-being and quality of life for Nepalese children.

This is a personal mission - I’m asking for a personal donation (which unfortunately is not tax-deductible) to help me make a difference in the lives of these children. My hope is to train the physical therapists in Nepal who will in turn continue to train others. Training the trainers is the most sustainable way for me to begin this grass-roots process.

I need to be funded by February 29!

3 Options for donations
1. Venmo @Dawn-Sandalcidi- no fees
2. https://fundly.com/nepal-2020-1 (fees apply)
3. Mail a check directly (no fees) to:
 3989 E. Arapahoe Rd #120
 Centennial, CO 80122

Thank you so much for your consideration!
Dawn Sandalcidi

For over 25 years my practice has had a focus on children suffering from bloating, gas, abdominal pain, fecal incontinence and constipation. Functional Gastrointestinal Disorders (FGID) are disorders of the brain -gut interaction causing motility disturbance, visceral hypersensitivity, altered immune function, gut microbiota and CNS processing. (Hyams et al 2016). Did you know that children who experience chronic constipation that do not get treated have a 50% chance of having issues for life?

The entire GI system is as amazing as it is and complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. In her book GUT, Giulia Enders talks about Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great (Chase et el 2018). Last year an 18-year-old patient of mine had to decline a scholarship to an Ivy League University because she needed to live at home due to her bowel management problem.

Unfortunately, FGID conditions can lead to suicide and death. Over 15 years ago my children’s pediatrician told me about an 11-year-old boy who hung himself because he had encopresis. In 2016 a 16-year-old girl suffered a cardiac arrest and died because of constipation.

The problems with children are different than for adults and need to be addressed with a unique approach.

How do physical therapists treat pediatric FGID?

• Have a solid foundation in the gastrointestinal system
• Coordinate muscle functions from top to bottom!
• Identify common childhood patterns
• Learn treatment techniques and strategies to address the issues specifically

Study and understand gastrointestinal anatomy, physiology, function and examination techniques. The entire GI system is as amazing as it is complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great.

What do the Pelvic Floor Muscles (PFM) have to do with it?

Encopresis leads to a weak internal/external anal sphincter and pelvic floor muscles and constipation leads to pelvic floor muscles that can’t relax. Confused? When the Rectal Anal Inhibitory Reflex or RAIR fails from bypass diarrhea the sphincter muscles relax, and feces leaks out. This constant leakage leads to weak sphincter and pelvic floor muscles. When it happens on a regular basis most children don’t feel it, however their peers smell it and life changes.

My course, Pediatric Functional Gastrointestinal Disorders, teaches how to coordinate the muscle function based on the tasks required.

How did this start?

One painful bowel movement can lead to withholding for the next due to fear of the pain happening again. The muscles of the pelvic floor then tighten to hold the poop in. This actually does not make the muscle strong but instead makes it confused. The muscle then is controlled by the consistency of poop being too hard and painful to let out or too loose and not able to hold in.

Managing functional GI disorders is a process. It takes the bowel a long time to re-train and it requires patience and skill to know how to do it. Many therapists and patients themselves get frustrated and compliance fails. This is mostly due to lack of knowing how to titrate medications and give the bowel what it needs (other than proper nutrition that is!) It's like retraining a person to walk after a stroke, the brain needs to relearn normal bowel sensations.

Most families don’t realize how severe constipation can be. It is an insidious problem that gets ignored until it is too late.

Typically, what I hear from parents is their child was diagnosed with constipation and was advised to take a daily laxative. So, which one is the best one? How do they all work? Once leakage occurs again the laxative is discontinued as we think the bowel must be empty and this medication is causing the leaks which is counterproductive. Now the frustrating cycle of backing up or being constipated begins again. The constipation returns, the laxative is restarted, the loose stool leaks out and the laxative is stopped and that is the REVOLVING DOOR or what I refer to as children riding the “Constipation Carousel”. The bowel is an amazingly beautiful, smart but also sensitive organ that does not like this back and forth and therefore will not learn how to be normal. In the meantime, they experience distended abdomens and dysmorphia ending up in eating disorder clinics. I had an 11-year-old girl taking Amitriptyline for abdominal pain all because of a pressure problem in the gut not knowing how to work the pelvic floor with the diaphragm and her core.

No two children are the same and no two colons are the same. Laxatives need to be titrated to the specific needs of your child’s colon and motility of their colon not their age or body weight.

The success in getting children to have regular bowel movements of normal consistency without any fecal leaks is based not only teaching how to titrate laxatives but also how to sense urge, become aware of the pelvic floor muscles and learn how NOT to strain to defecate, retrain the core and diaphragm with the ribcage and integrate developmental strategies for function. Teaching Interoception- what my body feels like when I have an urge- is an important part of this course. This is especially important for those children born with anorectal malformations or congenital problems such as imperforate anus or Hirschsprung’s Disease.

In this class we use visceral techniques, manual therapy techniques, sensory techniques and neuromuscular reeducation and coordination to retrain the entire system.

Come and explore the amazing gut with me and learn how to improve the health and well-being of your patients, in Pediatric Functional Gastrointestinal Disorders!

1. Hyams, JS, et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology volume 150, 2016;1456-1468.
2. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and rome IV. Gastroenterology 2016;150:1262-1279
3. Robin SG, Keller C, Zwiener R, et al. Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria. J Pediatr 2018; 195:134.
4. Koppen IJN, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, Di Lorenzo C, Benninga MA, Tabbers MM. Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr. 2018 Jul;198:121-130.e6. doi: 10.1016/j.jpeds.2018.02.029. Epub 2018 Apr 12.
5. Zar-Kessler C, Kuo B, Cole E, Benedix A, Belkind-Gerson, J. Benefit of pelvic floor physical therapy in pediatric patients with dyssynergic defecation constipation. 2019 Dig Dis https://doi.org/10.1159/000500121/
6. Chase J, Bower W, Susan Gibb S. et al. Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children’s Continence Society. J Ped Urol (2018) 14, 98e107

“What's wrong with children?”

As pelvic health physical therapists we take care of people suffering from bladder and bowel incontinence and/or dysfunction as well as pre-natal/ post-partum back pain, weak core muscles and pelvic pain. I was approached over 30 years ago by a urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” It’s been a whirlwind of learning since that day!

Pediatric pelvic floor dysfunction is common and can have significant consequences on quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?

Bed-wetting is also a pediatric issue with significant negative quality of life impact for both children and their caregivers, with as much as 30% of 4-year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes considerable stress and anxiety for children (Austin, 2014; Neveus, 2010).

Additionally, bowel dysfunction, such as constipation, is a contributor to urinary leakage or urgency. With nearly 5% of pediatric office visits occurring for constipation (Thibodeau 2013, NIDDK, 2013), the need to address these issues is great!  And, since pediatric bladder and bowel dysfunction can persist into adulthood, we must direct attention to the pediatric population to improve the health of all our patients.
Children suffer from many diagnoses that affect the pelvic floor including (Austin et al, 2014);

• Voiding dysfunction
• Enuresis (Bedwetting)
• Daytime urinary incontinence
• Urinary urgency and frequency
• Vesicoureteral reflux (Backflow of urine into the kidney)
• Pelvic pain (yes pelvic pain!)

The most common diagnoses I treat are voiding dysfunction and constipation. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral muscles while emptying the bladder. (Austin et al, 2014); The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and vesicoureteral reflux. Frequently, constipation is a culprit or cause. (Austin et al, 2014; Hodges S. 2012); Managing constipation can have a very positive effect on voiding dysfunction.
 

“What do we do to teach the pelvic floor (Kegel) muscles to work?”

Common questions I am asked include:

• Can I use biofeedback with children?
• Do we complete internal assessments on pediatric patients?
• How do we teach kids so they can understand?
• Do kids have the ability to learn strengthening versus relaxation?
• How do you teach a child to become aware of their pelvic floor and coordinate it?

If you have pondered these questions, let’s delve in! I see children as young as 4 who have been able to master biofeedback and recite back to me how their pelvic floor works with bowel and bladder function! Children are so eager to please and they love working with animated biofeedback sessions. The research supports the potential benefit of biofeedback training for children with pelvic floor dysfunction (DePaepe et al. 2002, Kaye 2008, Kajbafzadeh 2011, Fazeli 2014). The children are engaged and learn how to isolate their pelvic floor muscles (PFM) through positioning and breathing. The exercises are fun and easy to do. We also incorporate the core! What a wonderful opportunity we have to educate the younger population on these vital muscles as well as proper diet and bowel/bladder habits!

It is not typical to complete an internal pelvic muscle assessment on children, as this would not be appropriate.

“How do I treat it?”

In the literature on pediatric bowel and bladder dysfunction you will often come across the word "Urotherapy". It is, by definition, a conservative management-based program used to treat lower urinary tract (LUT) dysfunction. (Austin 2014)

Basic Urotherapy includes education on the anatomy, behavior modifications including fluid intake, timed or scheduled voids, toileting postures and avoidance of holding maneuvers, diet, avoiding bladder irritants and constipation. Parents are often not aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs.

Urotherapy alone can be helpful however a recent study (Chase, 2010) demonstrated a much greater improvement in those patients who received pelvic floor muscle training as compared to Urotherapy alone.

The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy (Austin et al, 2014). This includes biofeedback of the pelvic floor muscles by a trained professional who can teach the child how to alter pelvic floor muscle activity specifically for voiding. Cognitive behavioral therapy and psychotherapy are also important and can be a needed in combination with biofeedback in specific cases.

As you can see, PFM exercise combined with Urotherapy is a safe, inexpensive, and effective treatment option for children with pediatric voiding dysfunction.

Do bladder and bowel problems cause psychological problems or is the reverse true?

When we think of pediatric bowel and bladder issues, we primarily focus on what is happening to cause the bowel or bladder leakage and treat it accordingly. It is imperative to teach a child that she/he did not have an “accident”, but their bladder or bowel had a leak. It makes the incident a physiological problem and not something they did. See my blog post on “Accident” for more information.

It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In other more recent studies (Joinson et al. 2006a, 2006b, 2008, Kodman-Jones et al, 2001) it was noted that elevated psychological test scores returned to normal after the urologic problem was cured.

I frequently get testimonials from my patients. I would say the common denominator is the child and/or caregivers report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.
You can learn more about treating pediatric patients in my courses,

Pediatric Incontinence and Pelvic Floor Dysfunction and Pediatric Functional Gastrointestinal Disorders.

Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.
Chase J, Austin P, Hoebeke P, McKenna P. The management of dysfunctional voiding in children: a report from the standarisation committee of the international children’s continence society. 2010; J Urol183:1296-1302.
Constipation in Children. (2013)retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
DePaepe H., Renson C., Hoebeke P., et al: The role of pelvic- floor therapy in the treatment of lower urinary tract dysfunctions in children. Scan J of Urol and Neph 2002; 36: 260-7.
Farahmand, F., Abedi, A., Esmaeili-dooki, M. R., Jalilian, R., & Tabari, S. M. (2015). Pelvic Floor Muscle Exercise for Paediatric Functional Constipation.Journal of Clinical and Diagnostic Research : JCDR, 9(6), SC16–SC17. http://doi.org/10.7860/JCDR/2015/12726.6036
Fazeli MS, Lin Y, Nikoo N, Jaggumantri S1, Collet JP, Afshar K. Biofeedback for Non-neuropathic daytime voiding disorders in children: A systematic review and meta-analysis of randomized controlled trials. J Urol. 2014 Jul 26. pii: S0022-5347(14)04048-8.
Hinman, F. Nonneurogenic neurogenic bladder (the Hinman Syndrome)-15 years later. J Urol 1986;136, 769-777.
Hodges SJ, Anthony E. Occult megarectum:a commonly unrecognized cause of enuresis. Urology. 2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Hoebeke, P., Walle, J. V., Theunis, M., De Paepe, H., Oosterlinck, W., & Renson, C. Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Urology 1996; 48, 923-927.
Joinson, C., Heron, J., von Gontard, A. and the ALSPAC study team: Psychological problems in children with daytime wetting. Pediatrics 2006a; 118, 1985-1993.
Joinson, C., Heron, J., Butler, U., von Gontard, A. and the ALSPAC study team: Psychological differences between children with and without soiling problems. Pediatrics 2006b; 117, 1575-1584.
Joinson, C., Heron, J., von Gontard, A., Butler, R., Golding, J., Emond, A.: Early childhood risk factors associated with daytime wetting and soiling in school-age children. Journal of Pediatric Psychology2008; e-published.
Kajbafzadeh AM, harifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. (2011) Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol;186, 2379-2385.
Kaye JD, Palmer LS (2008) Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol 180, 300-305
Kodman-Jones, C., Hawkins, L., Schulman, SL. Behavioral characteristics of children with daytime wetting.  J Urol 2001;Dec(6):2392-5.
Neveus, T, Eggert P, Evans J, et al. Evaluation of the treatment for monosymptomatic enuresis: a standarisation document from the international children’s continence society. J Urol 2010; 183: 441-447
Rushton, H. G. Wetting and functional voiding disorders. Urologic Clinics of North America, 1995; 22(1), 75-93.
Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.
Thibodeau, B. A., Metcalfe, P., Koop, P., & Moore, K. (2013). Urinary incontinence and quality of life in children. Journal of pediatric urology, 9(1), 78-83.
Urinary Incontinence in Children. (2012). Retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, Vacic N. (2012). Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European Journal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.

In some families, puberty is not only a time to have to deal with all the physical, hormonal, and emotional changes that are occurring, but it is a time to have to worry about and check for spinal abnormalities that can run in families. Adolescent idiopathic scoliosis is an abnormal curvature of the spine that appears in late childhood or adolescence. The spine will rotate, and a curvature will develop in an “S” shape or “C” shape. Scoliosis is the most common spinal disorder in children and adolescents. It is present in 2 to 4 percent of children between the ages of 10 and 16 years of age. There is a genetic link to developing scoliosis and scientists are working to identify the gene that leads to adolescent idiopathic scoliosis. Adolescent girls are more likely to develop more severe scoliosis. The ratio of girls to boys with small curves of 10 degrees or less is equal, however the ratio of girls to boys with a curvature of 30 degrees or greater is 10:1. Additionally, the risk of curve progression is 10 times higher in girls compared to boys. Scoliosis can cause quite a bit of pain, morbidity, and if severe enough can warrant spinal surgery.

A recent article in Pediatric Physical Therapy by Zapata et al. assessed if there were asymmetries in paraspinal muscle thickness in adolescents with and without adolescent idiopathic scoliosis. They utilized ultrasound imaging to compare muscle thickness of the deep paraspinals at T8 and the multifidus at L1 and L4. They found significant differences in muscle thickness on the concave side compared to the convex side at T8 and L1 in subjects with scoliosis. They also found significantly greater muscle thickness on the concave side at T8, L1, and L4 in patients with adolescent idiopathic scoliosis compared to controls. This is very interesting to me, and exciting to think about the possibilities of how we therapists might can use this information! My first question is, is the difference in muscle thickness a cause or result of the curvature of the spine? My next question is if we trained the multifidus on the convex side, the side that is thinner, would it make a difference in supporting the spine and therefore help prevent some of the curvature? Would strengthening the multifidus in a very segmental manner comparing right versus left and targeting segments and sides that are weaker than others help prevent rotation and curvature in individuals who have a familial predisposition to developing idiopathic scoliosis? I hope so! I hope this group continues to study scoliosis and provides some evidence-based treatment that can help decrease the severity of curvature.

Assessing the multifidus thickness and strength, and differentiating it from the paraspinal muscles can be tricky. The best way to do this is the same way the authors of this article did, using ultrasound imaging. Ultrasound imaging gives unparalleled information on muscle shape, size, and activation of the muscle. Learning to use ultrasound imaging will change your practice! You will see dramatic differences in how you treat patients as well as the results you get when training the local core musculature. It also may open doors to treating different patient types than you are treating now, like adolescents with scoliosis. Join me in Spokane, WA on October 20-22 to further discuss how ultrasound can change your practice and perhaps help you reach out to a new population that you may not be treating now!

Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:343–52.
Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:353–65.
Zapata KA, Wang-Price SS, Sucato DJ, Dempsey-Robertson M. Ultrasonographic measurements of parspinal muscle thickness in adolescent idiopathic scoliosis: a comparison and reliability study. Pediatr Phys Ther. 2015; 27(2): 119-25.

After my Dad’s 3rd trip to the emergency room not being able to breathe because of his sleep apnea and congestive heart failure, his cardiologist recommended he ”just relax” when his suffocating feelings occurred. Of course, not being able to catch his breath would always heighten anxiety, which made it even more difficult to inhale and exhale. Ultimately, what my Dad needed to learn was mindfulness to deal with his relatively benign inability to breathe, since the focus of mindfulness is acceptance of rather than control over your circumstances.

The concept of mindfulness has been studied in adults, but it is gaining popularity among the pediatric population. Ruskin et al., (2017) used a prospective pre-post interventional study to assess how children with chronic pain respond to mindfulness-based interventions (MBI’s). For 8 weeks, 21 adolescents engaged in group sessions of MBI. Before, after, and 3 months post-treatment, the authors collected self-report measurements for a variety of factors such as disability, anxiety, pain quality, acceptance, catastrophizing, and social support. Subjects were highly satisfied with the treatment, and all would recommend the group intervention to friends. From baseline to 3-month follow-up, pain acceptance, body awareness, and ability to cope with stress all improved in the subjects. Further randomized controlled studies are needed, but the initial conclusion was MBI’s were received well by adolescents.

A feasibility study performed by Anclair, Hjärthag, and Hiltunen in 2017 considered the effect of mindfulness and cognitive behavioral therapy for the parents of children with chronic conditions, looking at Health-Related Quality of Life (HRQOL), measured with Short Form-36 (SF-36), and life satisfaction. Ten parents received group-based cognitive behavioral therapy (CBT), and 9 participated in a group-based mindfulness program (MF). Treatment was implemented for 2-hour weekly sessions over the course of 8 weeks. The CBT treatment was based on the Acceptance and Commitment Therapy, focusing on changing thoughts and emotions about stressful issues as well as behaviors. They avoided the acceptance aspect, as it would overlap the MF intervention. The MF therapy used the Here and Now Version 2.0 (including daily themes on knowing your body, observing breathing, acceptance, meditation, coping, understanding thoughts versus facts, and self-care reinforcement). The parents in each group significantly improved their Mental Component Summary (MCS), Vitality, Social functioning, and Mental health scores. The MF group even showed notable improvement in Role emotional and some of the physical subscales (Bodily pain, General health, and Role physical). The CBT group showed improved satisfaction with Spare time and Relation to partner, and CBT and MF groups improved life satisfaction Relation to child. The authors conclude CBT and MF may positively affect HRQOL and life satisfaction of parents with chronically ill children.

Whether young or old or in between, how we perceive stressful situations and chronic pain can impact our health. The neurodevelopmental aspect of mindfulness is still being studied. The “Mindfulness Based Pain Treatment” course applies the concept to treating chronic pain patients. This approach brings to mind the Serenity Prayer by Reinhold Niebuhr: “Lord grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

Ruskin ,DA, Gagnon, MM, Kohut SA, Stinson JN, Walker KS. (2017). A Mindfulness Program Adapted for Adolescents With Chronic Pain: Feasibility, Acceptability, and Initial Outcomes. The Clinical Journal of Pain. http://www.doi:10.1097/AJP.0000000000000490
Anclair, M., Hjärthag, F., & Hiltunen, A. J. (2017). Cognitive Behavioural Therapy and Mindfulness for Health-Related Quality of Life: Comparing Treatments for Parents of Children with Chronic Conditions - A Pilot Feasibility Study. Clinical Practice and Epidemiology in Mental Health : CP & EMH, 13, 1–9. http://doi.org/10.2174/1745017901713010001