Determination of variables affecting constipation severity in children with cerebral palsy: A cross-sectional study

Authors

Abstract

Aim Constipation is common in children with cerebral palsy (CP). Therefore, it is of great importance to determine the factors associated with constipation in individuals with CP and to develop specific strategies for these factors. This study aims to investigate the factors associated with the severity of constipation in children with CP using a cross-sectional analysis.
Materials and Methods This cross-sectional study was carried out in a total of 79 children with CP. Sociodemographic and clinical characteristics of children with cerebral palsy were recorded. Key domains, including constipation severity, pain, motor function, spasticity, posture, sleep quality, daily fluid intake, and physical activity, were assessed using validated measurement tools. Hierarchical regression analysis was conducted to identify the predictors of constipation severity.
Results Hierarchical regression analyses were conducted to identify factors associated with constipation severity in children with cerebral palsy. In Model 1, motor function, posture, and spasticity explained 18.0% of the variance in constipation severity, with only motor function (β = -0.283, p = 0.035) emerging as a significant predictor. In Model 2, sleep status, fluid intake, and physical activity were added, increasing the explained variance to 37.1%. Sleep problems (β = 0.296, p = 0.006), lower fluid intake (β = -0.332, p = 0.009), and lower physical activity (β = -0.402, p = 0.023) significantly predicted greater constipation severity. In Model 3, pain was added, and the model explained 45.6% of the variance. Pain (β = 0.317, p = 0.004) became one of the strongest predictors alongside sleep, fluid intake, and physical activity.
Discussion This study showed that greater fluid consumption, higher levels of physical activity, lower pain severity, better sleep patterns, and better motor function were significantly associated with lower severity of constipation in children with CP. These factors can be utilized in interventions aimed at maintaining and improving the gastrointestinal health of these children.

Keywords

Introduction

Constipation is a common gastrointestinal symptom in patients with cerebral palsy (CP), with a prevalence ranging from 25% to [1]. In this patient population, the pathophysiology of constipation is a combination of several factors; changes in neural modulation, musculoskeletal deformations, muscle tone changes, polypharmacy, low physical activity levels, and low fiber diet are among the risk factors that cause constipation in children with CP [2].
Constipation is an important condition affecting the quality of life in children with CP [3]. Children with CP already experience a lower quality of life than their healthy peers, and constipation can further exacerbate these challenges. In particular, the quality of life is seriously affected by discomfort, pain, and other symptoms caused by constipation [4]. Therefore, in order to improve the quality of life in children with CP, it is important to determine the factors associated with constipation in detail and to develop effective strategies for constipation management.
The severity of constipation varies depending on the intensity of the symptoms and the level of discomfort experienced by the person [5]. In mild cases, the person can alleviate symptoms by consuming certain foods and beverages or making lifestyle changes. However, in severe cases of constipation, the person may experience severe difficulties during defecation, may feel pain, and their general health status may be negatively affected [6]. Therefore, the determination of the conditions affecting the severity of constipation is important for determining appropriate treatment approaches for patients. To the best of our knowledge, no previous study has examined the factors associated with the severity of constipation in children with cerebral palsy. Therefore, in this study, we aimed to determine the factors affecting the severity of constipation in individuals with CP. Our hypothesis was that clinical and functional variables, including sleep quality, pain severity, motor function level, spasticity, posture, fluid intake, and physical activity, would significantly predict constipation severity in children with cerebral palsy.

Materials and Methods

This study involved children with cerebral palsy who were enrolled in a physiotherapy program at a specialized education and rehabilitation center in Bartın. Since the study was conducted in children under the age of 18, their legal guardians were informed about the purpose of the study, and written informed consent was obtained from the guardians of all children participating in the study. Demographic information of children with CP was obtained from their guardians.
A total of 79 children with CP aged 2-18 years participated in the study. The inclusion criteria were: volunteering to participate in the study, being between the ages of 2-18 years, and being diagnosed with CP. Children who had undergone surgery related to bowel health, who had chronic infectious bowel disease, who had congenital bowel anomalies, and who had received Botox in the last six months were not included in the study.
Outcome Measures
Sociodemographic and clinical characteristics of children with CP were recorded. The questionnaires were answered by the families or careers of the children. The Modified Constipation Assessment Scale (MCAS) evaluated the severity of constipation. It consists of 9 questions that measure the presence and severity of constipation, with a worsening score between 0-18 points [7]. Pain severity related to constipation was assessed using the Six Faces Pain Scale (FPS-6). This scale uses even- numbered scores ranging from 0 (no pain) to 10 (maximum pain), with each facial expression representing a progressive increase in pain intensity. Motor function was assessed using the Gross Motor Function Measure (GMFM-88), administered by trained physiotherapists. The GMFM-88 evaluates five dimensions of gross motor function (lying/rolling, sitting, crawling/kneeling, standing, and walking/running/jumping) through 88 items scored on a 4-point Likert scale (0-3). Total scores were converted to percentages (maximum 100%), with higher scores indicating better motor function. The scale demonstrates excellent reliability (ICC = 0.95-0.99) and validity for children with cerebral palsy [8]. Spasticity was assessed using the Modified Ashworth Scale (MAS) for both upper and lower extremities. The evaluation involved rapid passive movement of joints (shoulders, elbows, hands, hips, knees, and feet), with scores ranging from 0 (no increase in muscle tone) to 4 (rigidity). The final spasticity score was calculated as the average of all joint assessments [9]. Spinal Alignment and Range of Motion Measurement (SAROMM) is a clinical measurement tool used to assess posture and range of motion in individuals with neuromotor disorders. The measurement consists of two main components: spinal alignment and range of motion. The spinal alignment component assesses postural alignment in the cervical, thoracic, and lumbar spine regions, while the range of motion component measures the functional range of motion of the hip, knee, ankle, and upper extremity joints. Each item on the SAROMM, consisting of 26 items, is scored from 0 to 5 according to the individual’s postural correction and mobility. A score of 0 indicates “no impairment” (optimal alignment/full range of motion), while a score of 5 indicates “severe impairment” (marked postural deviation/limitation of movement) [10]. Sleep quality was assessed using the Pediatric Sleep Questionnaire (PSQ) developed by Ronald Chervin et al. The PSQ comprises 22 items, which are scored across three subscales: attention deficit, snoring, and insomnia, as well as a total sleep score. Higher scores indicate greater sleep disturbances [11]. Daily fluid intake was measured using the Beverage Intake Questionnaire (BEVQ), developed by Hedrick et al. This tool quantifies consumption of various beverages, including water, soft drinks, fruit juices, coffee, tea, alcohol, and other drinks. The BEVQ assesses the frequency, volume, and types of beverages consumed over a specified period, typically ranging from one day to one month. [12]. Physical activity levels were assessed using the Physical Activity Questionnaire (PAQ), a validated tool with age-specific versions for different populations. The pediatric versions include the Pre-PAQ, PAQ-C (for children), and PAQ-A (for adolescents) [13].
Statistical Analysis
All analyses were performed with SPSS, Version 26.0 (SPSS Inc., Chicago, Illinois). The normal distribution was confirmed using the Kolmogorov-Smirnov test. Continuous data were presented as mean (SD) and categorical data as numbers and percentages.
The Pearson test was used for correlation analysis. Hierarchical linear multiple regression analysis was performed to investigate the magnitude of the relationship between constipation severity and GMFM score, SAROMM score, spasticity severity, sleep status, beverage consumption, physical activity level, and pain severity. Before the regression analysis, it was checked whether the dependent variable, constipation severity, had a normal distribution and whether there were multicollinearity problems in the independent variables. R2 was evaluated to determine the proportion of variance explained after the entry of each block. p <0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Bolu Abant İzzet Baysal University Non-Interventional Research Ethics Committee (Date: 2018-08-09, No: 278).

Results

A total of 79 children with CP were included in this study. The mean age of children with CP was 10.47 (4.60). Clinical and demographic information of the children is given in Table 1.
Hierarchical regression analysis was conducted in three steps to identify the predictors of constipation severity. In Model 1, GMFM, SAROMM, and MAS were included. In Model 2, PSQ, BEVQ, and PAQ were added to the variables in Model 1. In Model 3, FPS-6 was included as an additional predictor.
The results of the univariate correlation analysis are demonstrated in Table 2. Significant relationships were found between constipation severity and all independent variables.
Table 3 shows the results of the hierarchical regression analyses. All models reached statistical significance (Model 1 F = 5.404, p < 0.05; Model 2 F = 6.994, p < 0.05; Model 3 F = 8.375, p < 0.05). In the first model, GMFM, SAROMM, and MAS 18.0% of the variance in the severity of constipation. In this model, only GMFM (β =-0.014, p = 0.035) was found to contribute significantly to constipation severity. Children with CP who had higher GMFM scores had lower constipation severity. Sleep status, physical activity, and beverage consumption variables were added to Model 2. Pain variable was added to Model 3. In model 2, PSQ, PAQ, and BEVQ scores explain 37.1% of the variance in the severity of constipation. In this model, PSQ (β = 0.207, p = 0.006), BEVQ (β = -0.002, p = 0.009), and PAQ (β = -0.142, p = 0.023) were found to contribute significantly to constipation severity. These findings show that the severity of constipation decreases as physical activity level and beverage consumption increase, and sleep problems decrease in children with CP. The variables in Model 3 explain 45.6% of the variance in the severity of constipation. In Model 3, PSQ, PAQ, and BEVQ were significant predictors for the severity of constipation. The newly added pain variable (β = 0.958, p = 0.004) was one of the most important predictors. The severity of constipation was also high in children with SP, with high pain levels.

Discussion

The results of this study showed that GMFM score, pain level, physical activity level, amount of beverage consumption, and sleep problems contributed to the severity of constipation in children with CP. However, in our sample, spasticity level and posture disorders had no effect on the severity of constipation. In our first model, the important factor affecting the severity of constipation was the GMFM score. According to our findings, an increase in GMFM score contributes to a decrease in the severity of constipation. One of the many factors affecting constipation is motor problems [14]. Considering that GMFM is a test that evaluates gross motor function in children with CP, it would not be wrong to say that the higher the score, the higher the activity level of the children. Elbasan et al.’s study on children with cerebral palsy and constipation showed that higher GMFM scores were associated with less severe constipation, consistent with our findings [15].
In our second model, physical activity level was found to be effective on the severity of constipation. There is limited data in the scientific literature about the effects of regular physical activity on constipation in children with CP. It was determined that the studies were mostly conducted in healthy children. Sarı et al. (2012) evaluated factors increasing constipation symptoms in 192 healthy children and found that lack of physical activity was a key contributor [16]. Driessen et al. used accelerometry to investigate constipation and physical activity in 347 healthy preschool children. Reduced physical activity was found to be associated with the risk of functional constipation [17]. In our study, a negative correlation was found between the severity of constipation and physical activity scores in individuals with CP. It is very important to increase the awareness of individuals with CP and their parents/caregivers about the development of physical activity and its relationship with constipation. Physical activity should be included in family education and individual-specific education programs to be developed by physiotherapists.
Another factor influencing the severity of constipation in our second model was sleep status. The relationship between constipation and sleep disturbance was analyzed in healthy adults or in adults with pathology, mostly in people with Parkinson’s disease [18]. In adults with functional gastrointestinal disorders, insufficient sleep, delayed sleep onset, and poor sleep quality are common and contribute to increased abdominal pain and gastrointestinal symptom severity simultaneously and the next day [19]. However, the available evidence provides little or no information about this relationship in children with neurodevelopmental disorders, with the majority focusing on incontinence problems. In epidemiological study conducted by Ono et al. in 2005 on healthy female individuals, it was found that sleep health was worse in individuals with intestinal health problems compared to those without such problems [20]. In a study conducted in 2008 using more objective tools such as actigraphs that can record sleep-wake times for the same purpose, he stated that poor intestinal health may be a risk factor for sleep disorders [21]. In conclusion, there is no study in the literature examining the relationship between the severity of constipation and the sleep status of children with CP. Our study will make an important contribution to the literature in this respect.
Another factor influencing the severity of constipation in our second model was the amount of beverage consumption. Although low fluid intake is likely to play a role in the occurrence of constipation in children, there is little scientific evidence on the role of low fluid intake on constipation, a literature review found that four out of six published papers showed an association between lower fluid intake and constipation [22]. In a study conducted by Favero et al. in 2018 in 40 severely affected children with CP, lower fluid consumption was determined in individuals with constipation symptoms [23]. While the studies in the literature examined the relationship between fluid intake and constipation, the main difference of our study from other studies is that we associated the severity of constipation with fluid intake. As a result, we found that the severity of constipation increased as fluid intake decreased in our study.
In our third and final model, pain was added to the analysis, and this variable contributed significantly to the severity of constipation. Among all factors, pain emerged as one of the strongest predictors. Although studies specifically examining the relationship between pain and constipation in children with CP are limited, it is known that chronic pain, especially abdominal or musculoskeletal pain, may affect gastrointestinal motility by increasing sympathetic activity and decreasing motility [24, 25]. In this context, pain can exacerbate constipation symptoms both directly through physiological mechanisms and indirectly by limiting physical activity. Importantly, physical activity, sleep problems, and fluid intake remained significant predictors of constipation severity even after pain was added to the model. This suggests that the multifactorial nature of constipation in children with CP is preserved even when pain is taken into account [24]. In addition, GMFM, which was significant in the first model, lost its significance in the third model. This finding suggests that the effect of motor function on constipation is mediated by other factors such as pain, activity level, and sleep [25].

Limitations

The children with CP included in our study were predominantly from families residing in urban areas. Future studies may aim for a more balanced distribution in terms of residential settings. Another important limitation is that, although our CP sample included individuals from different subtypes, we did not perform a subgroup analysis. Additionally, the sample size could have been slightly larger. These limitations may negatively affect the generalizability of our findings.

Conclusion

We found that GMFM, PAQ, PSQ, BEVQ, and pain level explained 46% of the variance in constipation severity in children with CP. In addition, we found that posture disorder and mean spasticity level had no effect on constipation severity. Future studies should consider these results when planning studies on children with CP with constipation. In addition, clinicians should inform families about modifiable factors such as sleep status, beverage consumption, and physical activity level.

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