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Transabdominal electrical stimulation increases colonic propagating pressure waves in paediatric slow transit constipation

Journal of Pediatric Surgery (2012) 47, 2279–2284 Transabdominal electrical stimulation increases colonicpropagating pressure waves in paediatric slowtransit constipation☆,☆☆,★ Melanie C.C. Clarke a, Anthony G. Catto-Smith a,b,c, Sebastian K. King a,c,Phil G. Dinning d, Ian J. Cook d, Janet W. Chase a, Susan M. Gibb a,b,Val J. Robertson e, Di Simpson b, John M. Hutson b,c, Bridget R. Southwell a,c,⁎ aMurdoch Childrens Research Institute, Melbourne, AustraliabRoyal Children's Hospital, Melbourne, AustraliacDepartment of Paediatrics, University of Melbourne, AustraliadSt George Hospital, and Department of Medicine, University of New South Wales, Sydney, NSWeUniversity of Newcastle, Australia Received 31 August 2012; accepted 1 September 2012 Background and aims: In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children.
Methods: Eight children (8–18 years) with confirmed STC had 24-h colonic manometry using awater-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas.
They then received 12 sessions (20 min/3× per week) of IFC stimulation (2 paraspinal and 2abdominal electrodes), applied at a comfortable intensity (b40 mA, carrier frequency 4 kHz,varying beat frequency 80–150 Hz). Colonic manometry was repeated 2 (n=6) and 7 (n=2) monthsafter IFC.
Results: IFC significantly increased frequency of total PS/24 h (mean ±SEM, pre 78±34 vs post210± 62, p=0.008, n=7), antegrade PS/24 h (43± 16 vs 112± 20, p=0.01) and high amplitude PS(HAPS/24 h, 5± 2:10± 3, p=0.04), with amplitude, velocity, or propagating distance unchanged. Therewas increased activity on waking and 4/8 ceased using antegrade continence enemas.
☆ Authors have no financial conflict of interest to disclose.
☆☆ Funding source: National Health and Medical Research Council, Australia (Project Grants 384434, 546432, Senior Research Fellowship 436916-BRS), Murdoch Childrens Research Institute Theme Investment Grants, and supported by the Victorian Government's Operational Infrastructure Support Program.
★ Ethics approval: Royal Children's Hospital Ethics Committee (HRC 23040 C), Clinical Trial Registration ANZCTR: ACTRN12610000418077.
⁎ Corresponding author. Gut Motility Laboratory, Surgical Research Group, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia, 3052. Tel.: +61 3 9345 5069.
0022-3468/$ – see front matter 2012 Elsevier Inc. All rights reserved.
Conclusions and inferences: Transcutaneous IFC increased colonic PS frequency in STC children witheffects lasting 2–7 months. IFC may provide a treatment for children with treatment-resistant STC.
2012 Elsevier Inc. All rights reserved.
Many children with chronic constipation respond to medical therapy and behavioural modification programmes,but 1/3 remain constipated into adulthood . Constipation Briefly, physiotherapists were provided with IFC may be caused by slow colon transit (slow-transit constipa- machines (Vectorsurge 5 VS470, Metron Medical, Carrum tion, STC), diagnosed via radio-nuclear or sitz (plastic) Downs, Victoria, Australia) that delivered two channels of marker colon transit studies In STC, soiling and fecal alternating current. One at a fixed frequency (4 kHz), impaction have significant social and emotional conse- whilst the other varied from 4080 to 4150 Hz, producing a quences for the child and family, resulting in a low quality of varying beat frequency of 80 to 150 Hz. The current (b40 mA) was applied via 4 self-adhesive conducting Children with STC can be managed by antegrade electrodes (40 mm × 40 mm, Verity Medical Ltd, Hamp- continence enemas (ACE) , and we have previously shire, England),with 2 paraspinal (T9-L2), and the paired reported the analysis of colonic motor activity performed by electrodes positioned diagonally opposite on the anterior inserting the manometry catheter via the appendix stoma abdominal wall below the costal margin . Current was . Significant abnormalities in colonic motor function applied just at the sensory level and sub-motor intensity so were identified, including reduced frequency of antegrade children felt no more than low sensory stimulation and no propagating sequences (PS) and lack of response to meals skeletal muscle contractions occurred. IFC stimulation was given for 20 min, ×3/week for 4 weeks.
Transcutaneous electrical stimulation using interferential current (IFC) has been used for pain management and urinary incontinence, with diarrhoea reported as a sideeffect . IFC increased defecation frequency inchildren with chronic constipation and reduced Eight children had 24-h colonic manometry immediately colonic transit times in STC . Symptom improve- before electrical stimulation and 2 months (n=6, 5 male, 9– ment lasted 3–6 months in 1/3 and more than 2 years in 1/3 19 years) or 7 months (n=2, 1 male, 16–18years) after of patients . The aim of this study was to determine completing stimulation. Patients ceased washouts 5 days the effects of IFC upon colonic PSs. Specifically, we before and during the manometry. Manometry was performed hypothesised that IFC increases the frequency of PS in as previously described Briefly, an 8-channel multi-lumen catheter with 7.5 cm sidehole spacing, was inserted via theappendix stoma and advanced anally with bisacodyl infusion(2.5 ml of 0.5 mg/ml solution). The catheter position wasestablished by fluoroscopy. Water was perfused at 0.25 ml/ min. Polygram software (Medtronic Australasia, Gladesville,NSW, Australia) was used for recording, commencing 24 h Children (n = 62) with STC were recruited during a larger after bisacodyl with children remaining in bed for 24 h.
randomised control trial (Ethics: HEC 23040C) .
They drank water and ate a meal of 17% protein, 34% Thirteen of these children had appendix stomas, and 8/13 carbohydrate and 48% fat, with 1255 kJ for breakfast, 4184 kJ volunteered for colonic manometry forming the cohort of for lunch and 4184 kJ for dinner. They completed an event diary recording eating, postural changes, sleep/waking, urine All 8 children had N2 years chronic constipation that had and defecation, abdominal sensation and flatus. After 24 h, 20 not responded to medical therapies (diet, laxatives, behaviour min of electrical stimulation was applied.
modification). STC was diagnosed by radionuclear transit Colonic motility studies were examined and analysed studies (defined by retention of radioisotope in the visually, as previously described to identify antegrade ascending/transverse colon) performed within the previous PS, retrograde PS and high amplitude PS, the latter defined year . Patients had existing appendix stomas placed more as N116 mmHg in 3 adjacent channels (shown as ‘extent’ than 6 months before the study. All had long-standing in Frequency, amplitude and velocity of PS and constipation (6–19 years of symptoms). Half had symptoms distance travelled were compared before and after since birth. Most had soiling but only 2 had daily soiling. For stimulation for each patient (paired t-test). Linked PSs management, they performed antegrade continence enemas were identified. Sequential PSs were defined as being to wash out their colons every second day and recorded 3–4 ‘regionally-linked’ if they started at different side-holes, were in the same direction and had overlapping side-hole Frequency, extent and velocity of propagating sequences.
D. Frequency of total colonic propagating sequences activity If 3 or more regionally-linked PSs occurred sequentially, this was defined as a ‘colonic complex’.
Waking and postprandial responses were analysed using Samples were tested for normality and then compared pre and post TES using students t-test. P b0.05 was considered statistically significant. For one patient, recording stopped initiation moved from the splenic flexure before stimulation, during the 2nd session and this patient was not included to the rectosigmoid after stimulation. Pre-treatment 4/5 patients had antegrade and 2/5 had retrograde coloniccomplexes, whilst post-treatment all 5 had antegrade and 3/5 had retrograde colonic complexes. There was no change in percent of antegrade linked-sequences (pre-treatment 65% ±8%, mean ± SEM, post-treatment 56% ± 4.5%), but unexpect-edly, there was a significant decrease in retrograde linked- Children had colonic manometry before and 2 months sequences (61% ± 4.5%, 33% ± 9.8%, p = 0.04 t-test).
(n = 6) or 7 months (n = 2) after 1 month of IFC stimulation.
Data on responses to meal and waking were available for Data from one time period (9 am to 5 pm) from one child 4/6 patients given the second manometry 2 months after IFC 2 months after stimulation were lost, and this child is not and 2/2 patients 7 months after IFC. None of these 6 patients had an increase in high amplitude PS activity on waking Following stimulation 5 patients had an increase in before stimulation. Two months post-stimulation, there was antegrade, high amplitude and retrograde PS, with the an increase in the number of subjects showing a waking antegrade:retrograde PS ratio becoming greater than 1.0 (1.4 response (0/4 and 0/2 pre, 3/4 and 1/2 post). At 2 months to 4.6, One patient (#5) had no change in antegrade post-stimulation, there was also a small increase in patients or high amplitude PS, a doubling in retrograde PS and with an increase in high amplitude PS after a meal (3 meals, 4 reduction in antegrade:retrograde PS ratio. Another patient subjects, 3/12 pre, 6/12 post). There was an increase in total (#6) had a three-fold increase in antegrade and retrograde PS motility index but no greater response after a meal in the 2 but a reduction (halving) in high amplitude PS. Results were patients at 7 months post-treatment.
similar for patients at 2 or 7 months post-stimulation. All patients were using ACE to washout the colon every shows the change in frequency of PS in 7 children, 2 months 2–3 days for management. There was no difference in the after stimulation (n = 5) and 7 months after stimulation (n = 2).
number of defecations/week in the pre-treatment (mean± In the combined group (n = 7), there was a significant SEM, 3.6±0.6), treatment (3.1±0.4), 1st month post treatment increase in frequency of antegrade, high amplitude and total (4.6±0.5) or 2nd month post treatment (3.3±0.4). However, PS, with a non-significant increase in frequency of retrograde 2/6 patients were able to defecate without the use of antegrade PS (). Increases were into the normal range enemas 2 months after stimulation as were the 2 patients with If data for two months after stimulation were assessed 7 month follow up. Continuing to defecate without needing separately, there was still a significant increase in the washouts suggests their constipation symptoms were gone.
frequency of total PS (/24 h mean ± SEM, pre 89 ± 47: post221 ± 80, p = 0.03, n = 5), antegrade PS (/24 h, 49 ± 22:115 ±18, p = 0.03) and high amplitude PS (/24 h, 5 ± 3:11 ± 3, p =0.06), compared with activity before stimulation (paired t-test). There was a non-significant increase in retrograde PS(/24 h, 40 ± 25 pre, 107 ± 70, p = 0.22). There was no apparent In a long-term follow-up of patients in an RCT of IFC to change in velocity or propagating distance.
treat paediatric STC, 1/3 of patients had no improvement, 1/3 The most common site of initiation of propagation of of the patients had improvement that lasted more than 2 years antegrade PS was the cecum, both before and after and 1/3 had improvement lasting 3–6 months . In this stimulation. For retrograde PS, the most common site of study we examined a subset of these patients and demon- Frequency of propagating sequences (PS). (A) Total, antegrade (Ant), high amplitude (HAPS) and retrograde (Ret) PS. Mean (SEM) values of all 7 patients. (B) HAPS values of all 7 patients.
strated that transcutaneous electrical stimulation using IFC patients with daily stimulation for more than 2 months increased frequency of colonic PS in 5/7 STC children. There support that symptoms continue to improve with more was also a 3-fold increase in high amplitude PS frequency.
stimulation Patients are accustomed to using laxatives or Four of 8 patients stopped using ACE, as soiling stopped. The ACE, and graded removal of these treatments may need to be increased activity persisted for 7 months in the 2 patients who planned and measured as specific outcomes.
were followed for the longer period.
Unfortunately the numbers studied are small, as each Colonic PS and high amplitude PS are temporally study requires the family and child to spend 3 days in the associated with both defecation and luminal transit in hospital and few are able to do this twice. Because of the healthy controls. More frequent high amplitude PS after difficulties of doing this assessment, we did not attempt an morning waking or a high calorie meal can also be used as a RCT. We cannot discount that these changes in bowel measure of a “normal’ colonic response to physiological activity could occur as a placebo or due to time. As we think stimuli Adults and children with STC have an absent or it would be very difficult to perform an RCT, large animal diminished response to such stimuli An absent colonic studies may be necessary to perform an RCT.
response has been reported by some to be an indicator of an Children with STC have reduced antegrade PS. Transcu- intrinsic neuropathy/mesenchymopathy Therefore as taneous IFC 3-times a week for 1 month increased the the majority of our patients demonstrated an increased frequency of colonic PS 3–5 fold in most of the children and frequency of PS and high amplitude PS after treatment with increased colonic motor activity on waking and after meals.
IFC, these data are likely to be of clinical significance.
The effects persisted 2–7 months after stimulation. Further The mechanism of action of IFC remains unclear. With studies on larger numbers of patients are warranted to the electrode positions used, the current could affect local determine if IFC can provide a treatment for children with sensory and motor nerves in the skin, spinal nerves (sensory and motor, T9 to L2), sympathetic (thoraco-lumbar) and parasympathetic nerves, enteric nerves,pacemaker cells (interstitial cells of Cajal) or smooth muscle cells in the intestinal wall. The stimulation was justat the sensory threshold and did not produce striated muscle [1] van Ginkel R, Reitsma JB, Buller HA, et al. Childhood constipation: contraction or pain, so was not stimulating A-δ or C longitudinal follow-up beyond puberty. Gastroenterology 2003;125: (nociceptor/pain) fibres. The effects took months to develop [2] Benninga MA, Buller HA, Tytgat GN, et al. Colonic transit time in and lasted for months, suggesting it was changing nerve constipated children: does pediatric slow-transit constipation exist? circuits or overall neuronal health, rather than causing J Pediatr Gastroenterol Nutr 1996;23:241-51.
[3] Hutson JM, Catto-Smith T, Gibb S, et al. Chronic constipation: no We have previously reported on the use of IFC to treat longer stuck! Characterization of colonic dysmotility as a new disorder chronic constipation and STC in children in children. J Pediatr Surg 2004;39:795-9.
[4] Gutierrez C, Marco A, Nogales A, et al. Total and segmental Other groups have demonstrated that IFC increased colonic transit time and anorectal manometry in children with gastrointestinal motility producing diarrhoea im- chronic idiopathic constipation. J Pediatr Gastroenterol Nutr 2002; proved gastric emptying , improved functional dyspepsia symptoms and increased rate of swallowing [5] Clarke MC, Chow CS, Chase JW, et al. Quality of life in children with Dinning et al. performed 24-h colonic manometry in 8 adults slow transit constipation. J Pediatr Surg 2008;43:320-4.
[6] King SK, Sutcliffe JR, Southwell BR, et al. The antegrade continence with STC during direct stimulation of sacral nerve S3 and enema successfully treats idiopathic slow-transit constipation. J Pediatr showed there was increased pancolonic PS .
The electrical parameters used in this study were those [7] King SK, Catto-Smith AG, Stanton MP, et al. 24-Hour colonic previously used for bladder stimulation. Stimulation was manometry in pediatric slow transit constipation shows significant performed by physiotherapists with patients visiting clinics 3 reductions in antegrade propagation. Am J Gastroenterol 2008;103:2083-91.
times a week. Following 1 month of IFC, symptoms [8] Stanton MP, Hutson JM, Simpson D, et al. Colonic manometry via improved over the following 2 months after stimulation, appendicostomy shows reduced frequency, amplitude, and length of with more improvement at 7 months (both patients had propagating sequences in children with slow-transit constipation. J stopped using their appendix stomas and doing washouts, and were defecating regularly with no impaction). We have [9] Robertson VJ, Low J, Reed A, et al. Electrotherapy explained: principles and practice4th ed. ; 2006.
previously reported the long-term follow-up of the rando- [10] Emmerson CA. A preliminary study of the effect of interferential mised control trial and crossover treatment and this therapy on detrusor instability in patients with multiple sclerosis. Aust showed that symptom improvement lasted 3–6 months or more than 2 years and that 2 months' stimulation produced [11] Kajbafzadeh AM, Sharifi-Rad L, Baradaran N, et al. Effect of pelvic greater improvement than 1 month. Following the release of floor interferential electrostimulation on urodynamic parameters andincontinency of children with myelomeningocele and detrusor battery-operated machines, daily stimulation at home was overactivity. Urology 2009;74:324-9.
tested and this produced increased defecation suggest- [12] Chase J, Robertson VJ, Southwell B, et al. Pilot study using ing a dose response. Further studies on larger numbers of transcutaneous electrical stimulation (interferential current) to treat chronic treatment-resistant constipation and soiling in children.
colonic propagating pressure waves in severe constipation. Neurogas- J Gastroenterol Hepatol 2005;20:1054-61.
troenterol Motil 2010;22(12):e340-9.
[13] Ismail KA, Chase J, Gibb S, et al. Daily transabdominal electrical [20] van den Berg MM, Hogan M, Caniano DA, et al. Colonic manometry stimulation at home increased defecation in children with slow- as predictor of cecostomy success in children with defecation transit constipation: a pilot study. J Pediatr Surg 2009;44: disorders. J Pediatr Surg 2006;41:730-6 [discussion 730–736].
[21] Clarke MC, Chase JW, Gibb S, et al. Improvement of quality of life in [14] Clarke MC, Chase JW, Gibb S, et al. Decreased colonic transit time children with slow transit constipation after treatment with transcutaneous after transcutaneous interferential electrical stimulation in children electrical stimulation. J Pediatr Surg 2009;44:1268-72 [discussion 1272].
with slow transit constipation. J Pediatr Surg 2009;44:408-12.
[22] Weinkauf JG, Yiannopoulos A, Faul JL. Transcutaneous electrical [15] Leong LC, Yik YI, Catto-Smith AG, et al. Long-term effects of nerve stimulation for severe gastroparesis after lung transplantation.
transabdominal electrical stimulation in treating children with slow- J Heart Lung Transplant 2005;24:1444.
transit constipation. J Pediatr Surg 2011;46:2309-12.
[23] Koklu S, Koklu G, Ozguclu E, et al. Clinical trial: interferential electric [16] Yik YI, Ismail KA, Hutson JM, et al. Home transcutaneous electrical stimulation in functional dyspepsia patients — a prospective stimulation to treat children with slow-transit constipation. J Pediatr randomized study. Aliment Pharmacol Ther. 31:961-8.
[24] Furuta T, Takemura M, Tsujita J, et al. Interferential electric stimulation [17] Sutcliffe JR, King S, Hutson JM, et al. What is new in radiology and applied to the neck increases swallowing frequency. Dysphagia pathology of motility disorders in children? Semin Pediatr Surg [25] Dinning PG, Fuentealba SE, Kennedy ML, et al. Sacral nerve [18] Dinning PG, Szczesniak MM, Cook IJ. Spatio-temporal analysis stimulation induces pan-colonic propagating pressure waves and reveals aberrant linkage among sequential propagating pressure wave increases defecation frequency in patients with slow-transit constipa- sequences in patients with symptomatically defined obstructed defecation. Neurogastroenterol Motil 2009;21:945-e975.
[26] Leong LC, Yik YI, Catto-Smith AG, et al. Long-term effects of [19] Dinning PG, Zarate N, Hunt LM, et al. Pancolonic spatiotemporal transabdominal electrical stimulation in treating children with slow- mapping reveals regional deficiencies in, and disorganization of transit constipation. J Ped Surg 2011;46(12):2309-12.


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