Comparison of the efficiency of transcutaneous electrical nerve stimulation and manual therapy in children with cerebral palsy with lower urinary system dysfunction- a randomized prospective trial

Abstract

Introduction

Neurological defects in children with cerebral palsy (CP) not only affect their motor skills but also lead to bladder and bowel problems. Although most children with CP have achieved urinary control, more than 50% of cases experience lower urinary tract symptoms (LUTS). Common LUTS complaints observed in CP include delayed toilet training, urinary incontinence, increased frequency of urination, urgency, urinary hesitancy, and recurrent urinary tract infections.

Objective

This study aimed to prospectively evaluate and compare the effectiveness of two different physiotherapy approaches, sacral Transcutaneous Electrical Nerve Stimulation (TENS) and massage, on lower urinary tract dysfunction in children with CP.

Method

A total of 54 children with CP who had the Dysfunctional Voiding Scoring System (DVISS) of 8.5 or higher were included in the study. Children were randomized to the TENS (TG; n = 27) and Manual Therapy (MG; n = 27) groups. TENS application was performed 2 sessions in a week for 20 min for a total of 12 weeks. The electrodes used during the application were adhered bilaterally to the parasacral region (S2–S4). 4 electrodes of 5 × 5 cm were used. Classical bowel massage was applied to the MG with the friction massage technique twice a week for 12 weeks. Manual therapy applications were performed in the form of abdominal, colon, and friction massage, twice a week for 20 min by the physiotherapist. Massage was applied to the abdominal region between the lower subcostal border and the anterior superior iliac spine.

Questionnaires were applied before and after treatment interventions: DVISS, functional bladder capacity (FBC), frequency of voiding, and urinary incontinence episodes evaluated by bladder diary, Bristol Gaita Scale, and Pediatric Incontinence Quality of Life Scale (PIN-Q) used.

Results

The decrease in the episodes of incontinence was higher in the TG (p = 0.037; p < 0.05). FBC increased after treatment in both groups, but there was no statistically significant difference between the groups (p = 0.683; p > 0.05). Manual therapy was more effective in improving constipation symptoms. In both groups, DVISS and PIN-Q values decreased after treatment, but the decrease in TG was statistically significant in the evaluation made between groups (p = 0.001; p < 0.01).

Conclusion

Both parasacral TENS and massage provided a significant improvement in LUTS, constipation, and quality of life but TENS showed a bigger improvement. We suggest adding these interventions to the treatment of bladder and bowel problems in CP children.

Summary table. Pre and Post Evaluation Values of The Scales.

Variables	Groups	Pre-intervention	Post-intervention	P Valuea
DVISS, mean (SD), (point)	TG (n = 27)	14.41(3.52)	6.81(2.02)	0.001∗∗
MG (n = 27)	14.67 (3.66)	9.52 (2.17)	0.001∗∗
P Valueb	0.81	0.001∗∗
PIN-Q, mean (SD), (point)	TG (n = 27)	33.07 (6.63)	15.96 (4.06)	0.001∗∗∗
MG (n = 27)	29.89 (5.12)	18.44 (5)	0.001∗∗
P Valueb	0.055	0.043∗
Voiding diary
Functional bladder capacity, mean (SD), (mL)b	TG (n = 27)	175.74 (68.51)	208.33 (84.98)	0.001∗∗
MG (n = 27)	185.19 (61.98)	202.04 (64.74)	0.001∗∗
P Valueb	0.466	0.683
Voiding frequency, mean (SD), (number/day)	TG (n = 27)	7.65 (1.02)	6.35 (0.6)	0.001∗∗
MG (n = 27)	7.43 (1.14)	6.15 (0.66)	0.001∗∗
P Valueb	0.293	0.208
Frequency of incontinence episodes, mean (SD), (number/day)	TG (n = 27)	4.3 (1.07)	0.81(1.08)	0.001∗∗∗
MG (n = 27)	3.78 (0.8)	1.59 (1.15)	0.001∗∗
P Valueb	0.037	0.037∗
Urge symptom, n (%)	TG (n = 27)	19 (70.37)	10 (37.03)	NA
MG (n = 27)	16 (59.25)	8 (29.62)	NA
P Valuec	0.393	0.999

TG: transcutaneous electric stimulation group, MG: manual group, SD: standard deviation, BGS: Bristol gaita score.

a

Wilcoxon test p < 0.01∗∗.

b

Mann Whitney U test p < 0.05∗.

c

Chi-square test p < 0.01∗∗∗; NA, not applicable.