|Year : 2021 | Volume
| Issue : 1 | Page : 39-43
Behavioral intervention for bladder control and its impact on quality of life in persons with traumatic paraplegia: A one-arm interventional study
Aradhana Nayak1, Ram Kumar Sahu2
1 Department of Occupational Therapy, SuVitas Holistic Healthcare, Hyderabad, Telangana, India
2 Department of Occupational Therapy, SVNIRTAR, Cuttack, Odisha, India
|Date of Submission||10-Mar-2021|
|Date of Acceptance||01-Jun-2021|
|Date of Web Publication||22-Jun-2021|
Flat No. 301, Pooja Residency, Shilpa Valley, Serilingampalle (M), Hyderabad - 500 084, Telangana
Source of Support: None, Conflict of Interest: None
Background: Injury to spinal cord results in many neurological problems, and bladder dysfunction is one of the major factors affecting quality of life (QOL). Improvement in bladder control leads to improvement of psychosocial well-being related to urinary incontinence, thereby enhancing QOL. The effect of behavioral intervention (BI) on bladder control is well documented in patients with urinary incontinence. However, very few evidences are available on its effect in patients with traumatic paraplegia in Indian context. Objectives: The study objective was to determine the effect of BI on bladder control and QOL in patients with traumatic paraplegia and to find the relationship between status of bladder control and QOL. Study Design: This was a one-arm interventional study design. Methods: Initial screening was done by using the American Spinal Injury Association (ASIA) Impairment Scale, and thirty six traumatic paraplegics were recruited for the study. BI along with traditional bladder management was provided to them for 8 weeks, and after this period, home exercise program was prescribed. Pre- and postintervention data were recorded using Urogenital Distress Inventory short form (UDI-6) and Incontinence QOL (IQOL). Follow-up data were recorded 6 months after completion of intervention to measure the retention effect. Results: Friedman test showed a significant difference (P = 0.000 and 95% confidence interval [95% CI]: 0.000–0.080) across preintervention, postintervention, and follow-up data for both outcome measures. Post hoc Wilcoxon signed-rank test showed a significant difference (P = 0.000 and 95% CI: 0.000–0.080) between preintervention and postintervention scores as well as preintervention and follow-up scores for both the outcome measures. No significant difference was noted on analysis of postintervention and follow-up scores (P=0.472 and 95% CI: 0.026-0.052) for UDI-6 and (P=0.743 and 95% CI:0.000-0.0130) for IQOL. When preintervention scores of UDI-6 and IQOL were correlated using Kendall's tau correlation coefficient, it gave a high negative correlation (−0.725), which implied that the poorer status of bladder control is related to poorer QOL. Conclusion: BI was an effective technique in improving bladder control, aid to faster improvement when used along with other traditional bladder management techniques in patients with traumatic paraplegia leading better QOL seen over a period of 6 months.
Keywords: Behavioral Intervention, Bladder Control, Bladder Management, Quality of Life, Traumatic Paraplegia
|How to cite this article:|
Nayak A, Sahu RK. Behavioral intervention for bladder control and its impact on quality of life in persons with traumatic paraplegia: A one-arm interventional study. Indian J Occup Ther 2021;53:39-43
|How to cite this URL:|
Nayak A, Sahu RK. Behavioral intervention for bladder control and its impact on quality of life in persons with traumatic paraplegia: A one-arm interventional study. Indian J Occup Ther [serial online] 2021 [cited 2021 Jul 28];53:39-43. Available from: http://www.ijotonweb.org/text.asp?2021/53/1/39/318982
| Introduction|| |
Paraplegia refers to impairment or loss of motor and/or sensory function below cervical segments secondary to damage of neural elements of the spinal cord. Conditions that may result in interference of neural conduction in spinal cord include physical injuries, hemorrhage, tumor, and diseases. The most common cause of paraplegia is physical injuries termed as traumatic paraplegia. Injury to spinal cord results in many neurological problems such as loss of sensory and motor function, autonomic dysreflexia, and sexual and bowel dysfunction etc. Disturbances of bladder functions remain one of the most debilitating factors with a life-threatening impact as renal diseases are responsible for majority of deaths among patients with spinal lesions.
The effect of spinal cord injury (SCI) on bladder function depends on the level of injury: (1) automatic (hyperreflexic) bladder: when injury occurs at thoracic level 12 (T12) of spinal cord or above and (2) flaccid (areflexic) bladder: injury below T12 spinal level.
The World Health Organization defines quality of life (QOL) as a “broad concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment.”
Bladder dysfunction such as urinary incontinence, voiding difficulties, and urine retention can be a distressing and embarrassing condition leading to social withdrawal, lowered self-esteem, increased marital problems, and sexual dysfunction ultimately affecting the QOL of patients with traumatic paraplegia.
Traditional bladder management techniques in SCI include intermittent catheterization, indwelling catheterization, indwelling suprapubic catheterization, Valsalva and Crede voiding, and reflex voiding.
Behavioral interventions (BIs) include urinary incontinence education, pelvic floor muscle exercises (PFMEs) and bladder training which improve bladder function by changing the incontinent patient's behavior, especially his/her voiding habits and teaching skills for preventing urine loss.,
A varied number of studies were found on the effect of BI for bladder control in patients with urinary incontinence. Lack of evidence makes BI difficult to practice clinically for developing bladder control in patients with traumatic paraplegia., The present study objective was to determine the effect of BI on bladder control and QOL in patients with traumatic paraplegia.
| Methods|| |
Study Design and Participants
In a one-arm interventional study design, medically stable male and female patients in an age range of 18–55 years with traumatic (with injury due to road traffic accident, fall, and direct assault to back) paraplegia (from thoracic level 1 and below) were screened as motor incomplete with voluntary anal contraction according to the American Spinal Injury Association (ASIA) Impairment Scale (revised, 2011) and recruited in the research study. Exclusion criteria encompassed any pathological condition of bladder or kidney, any orthopedic condition of pelvis, surgically managed cases of bladder dysfunction, comorbidities such as diabetes mellitus, heart conditions, any history of prolapse of intervertebral disc, Pott's spine, and any head trauma, or history of psychiatric condition.
Thirty-six patients with traumatic paraplegia were included for study according to inclusion and exclusion criteria through convenient sampling in the Department of Occupational Therapy, Swami Vivekanand National Institute of Rehabilitation Training and Research (SVNIRTAR). The study was conducted in adherence to the principles of the Declaration of Helsinki (version 2013). The purpose of the study was explained to each patient, and written informed consent was obtained. Their bladder history and daily fluid intake were recorded. BI was given to all the participants for 8 weeks, along with the conventional bladder management, mainly clean intermittent catheterization and Valsalva and Crede voiding methods. [Table 1] of illustration shows the descriptive characteristics of the patients. Thirty-one male and 5 female patients were recruited for the study with a ratio of 6.2:1.
Outcome measures such as Urogenital Distress Inventory short form (UDI-6) for assessing bladder control and Incontinence QOL (IQOL) for measuring changes in QOL were used.
UDI-6 is a brief 6-item self-rated questionnaire that was developed as a measure to detect bladder-related problems in males and females. It has a very high reliability with Cronbach's alpha value at 0.88 and had also been validated to measure the bladder problems in SCI.,
IQOL is a self-report questionnaire with 22 items and measures the effect of urinary incontinence on QOL. It has a very strong reliability with Cronbach's alpha ranging from 0.79 to 0.93 and good construct validity, indicating that IQOL is a reliable measure of QOL in neurogenic urinary incontinence of patients with SCI.
The triad of intervention techniques constituting BI is first urinary incontinence education which includes general bladder anatomy, symptoms of bladder incontinence, and required hygiene; second, bladder training which includes maintaining bladder diary, scheduling voiding interval according to diary and relaxation; and finally, PFME which includes locating pelvic floor muscles correctly, giving equal duration for contraction as well as relaxation while practicing and increasing the duration with time.
Prior to the program along with general history, bowel and bladder histories of the patients were noted and physical examination was done. Patients were asked to keep a bladder diary for at least 3 days continuously and were given urinary incontinence education. Bladder diary consisted of hourly record of fluid intake and urine output from 6 am to 10 pm under the headings of time, drinks (what/how much), trips to bathroom (how many times/how much urine), accidental leaks (if any, how much), any strong urge to go (yes/no), and any cause for urination (coughing, sneezing, and exercising).
In 8 weeks of training program (4-week intensive training and 4-week self-training), during the 1st week, the PFME was demonstrated and patients were encouraged to practice the exercise repeatedly during the session being taken every alternate day for a period of 1 h. For bladder training, intervals between voluntary voiding were scheduled based on daily voiding pattern according to the diary of each participant. They were taught to utilize distraction and relaxation techniques to control the urge of urination if it appears before scheduled time. Patients were asked to continue reporting the diary regularly.
On the 2nd, 3rd, and 4th week of intervention, PFME was demonstrated again and practiced repeatedly during session being taken every 2 days for a period of 1 h. In addition, the interval between voiding for bladder training was re-adjusted based on the voiding diary of the previous week.
After the 4th week, feedback and reinforcement for self-training was provided to each participant for PFME and was asked to reschedule their voiding program themselves and maintain the diary regularly. On the last day of every week, their performance was re-evaluated till the 8th week of intervention was over.
After completion of entire intervention program, each participant was educated about its effect. They were instructed about the home program to continue practicing the PFME, maintain regular bladder diary, and reschedule their voiding plan according to it until 6 months.
Pre- and postintervention data were collected before commencement of study and immediately after completion of 8 weeks of study program, respectively. Follow-up data were recorded 6 months after completion of the 8th week of intervention to measure the retention effect.
Statistical analysis was performed using Statistical Product and Service Solutions (SPSS) version 20.0 package by International Business Machine (IBM) All the statistical tests were carried out with the level of significance set at α < 0.05. Friedman test along with post hoc Wilcoxon signed-rank test was used to analyze the preintervention, postintervention, and follow-up data of both UDI-6 and IQOL. To know the correlation between the scores of UDI-6 and IQOL, Kendall's tau correlation coefficient was used for the preintervention data.
| Results|| |
The descriptive statistics of scores on the outcome measures is shown in [Table 2] and [Table 3] of illustration. A remarkable difference was found in mean scores and confidence interval (CI) of pre- and postintervention data, but there was a very minimal difference in postintervention and follow-up data.
|Table 2: Descriptive Statistics and Statistical Analysis of UDI-6 Scores|
Click here to view
Friedman test showed a significant difference (P = 0.000 and 95% CI: 0.000–0.080) across preintervention, postintervention, and follow-up data for both outcome measures. Post hoc Wilcoxon signed-rank test showed a significant difference (P = 0.000 and 95% CI: 0.000–0.080) between preintervention and postintervention scores as well as preintervention and follow-up scores for both the outcome measures. No significant difference was noted on analysis of postintervention and follow-up scores (P=0.472 and 95% CI: 0.026-0.052) for UDI-6 and (P=0.743 and 95% CI:0.000-0.0130) for IQOL [Table 2] and [Table 3].
To know the correlation between the scores of UDI-6 and IQOL, Kendall's tau correlation coefficient was used. On analyzing preintervention data of both the scales, a high negative correlation (−0.725) was found, which implies that higher scores on one scale are related to lower score on the other scale. The result of Kendall's tau correlation coefficient for UDI-6 and IQOL preintervention is depicted in [Table 4] of illustration.
| Discussion|| |
The present study indicated that BI is effective in improving bladder control in patients with traumatic paraplegia. These changes could be, because of modification in voiding behavior through appropriate education about bladder and related problems as well as complications, individually adjusted programs by direct monitoring and habit formation along with strengthening of muscles which control bladder and sphincter activity.
The fact has been substantiated through statistical analysis of pre- and postintervention data where a significant improvement was found. Retention effect was seen when the data were analyzed with follow-up data which were collected after 6 months of completion of study program [Table 2] and [Table 3].
The result of the present study is consistent with previous studies of rehabilitation. A systematic review done on the effect of BI and other conservative management techniques for managing neurogenic bladder (NB), concluded that the conservative treatment is and will remain the primary choice in majority of the patients with NB.
A study done on newer management options available for neurogenic detrusor overactivity in patients with multiple sclerosis, Parkinson's disease, cerebral palsy, and myelomeningocele, stated that BI is one of the first-line therapies but may be limited by the patient's underlying neurologic condition as well as social factors. Hence, it can be used along with other first-line therapies such as drug therapy and catheterizations.
A systematic review done on different studies about various bladder management methods to bring out catheter-free status in SCI patients, found out that bladder training along with clean intermittent catheterization and pharmacotherapy had a low incidence of urinary tract damage and showed better improvement for bladder control.
A review article on different management techniques available in NB problem happening due to lack of bladder control from a brain, spinal cord, or nerve dysfunction, stated that individualized patient education regarding management of their bladder is important for achieving successful NB management. A comprehensive bladder-retraining program that incorporates appropriate education, training, medication, and surgical interventions can mitigate the adverse consequences of NB dysfunction, thereby reducing mortality rate and improving QOL.
The result of previous studies cited above is supporting the findings of the current study that the intervention techniques used in BI positively impact bladder function in patients with traumatic paraplegia at different levels, i.e., bladder anatomy, hygiene, and most importantly, voiding pattern.
Along with previous studies, the present study found that bladder control is related to QOL. The statistical calculation showed a strong negative correlation which implied that poor status of bladder control is related to poorer QOL [Table 4].
NB following traumatic SCI is unavoidable, and the management of bladder dysfunction is a crucial component of a rehabilitation program. It is difficult to predict bladder and sphincter behavior on the basis of clinical somatic neurological deficits. Urinary incontinence resulting from bladder and sphincter disorder is frequently associated with a negative impact on QOL of the patient.
Previous studies had also supported the idea that bladder problems remain the most important issue in QOL of patients with chronic SCI apart from physical problems.,, A study done about QOL after SCI reflected that bowel and bladder problems negatively influence QOL due to fear of embarrassment about incontinence. A study done on 2008 Sichuan earthquake survivors with SCI stated that urinary dysfunction among all other complications after SCI most negatively affects QOL, social role, and community re-integration.
This study showed BI used along with other prevailing conventional bladder management techniques like intermittent catheterization and pharmacotherapy, improves bladder control which is a major factor that influences QOL in patients with traumatic paraplegia seen over a period of six months.
It is a one-arm intervention design taking a small sample size, and follow-up has been done for a short period of 6 months.
Future study can focus on a randomized controlled trial to generate higher level of evidence. A comparison of QOL related to bladder incontinence between males and females with SCI can be done. Further study can be done on patients with traumatic quadriplegia and other conditions affecting spinal cord at specific levels as well as on different types of bladder problems after SCI.
| Conclusion|| |
Patients with traumatic paraplegia face many challenges in day-to-day activity due to complications after SCI, and problems related to bladder incontinence play a remarkable role in diminishing QOL. In the present study, BI showed to have significant effect in improving bladder control and positively influence QOL. It also provides statistical proof for occupational therapists to confidently select BI for managing bladder-related problems.
I would like to thank the Director of SVNIRTAR for kind permission for conducting this research and our patients and their caregivers for informed written consent to participate in this study.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Kirshblum SC, Burns SB, Sorensen FB. International standards for neurological classification of spinal cord injury. J Spinal Cord Med 2011;34:535-546.
Keane M, O'Toole MT. Miller- Keane Encyclopedia and Dictionary of Medicine Nursing and Allied Health – Revised Reprint. 7th
ed. United States of America: Saunders; 2005. p. 325-49.
Brombley I, Plested J, Upton J. Tetraplegia and Paraplegia: A Guide for Physiotherapists. 5th
ed. China: Churchill Livingstone, Elsevier; 2006. p. 19-25.
Jamison J, Maguire S, McCann J. Catheter policies for management of long-term voiding problems in adults with neurogenic bladder disorders (Review). Cochrane Database Sys Rev 2004;12;1-11.
Kelleher CJ, Radley S. Textbook of Female Urology and Urogynecology. 2nd
ed. United States of America: CRC Press; 2006. p. 64-73.
Linsenmeyer TA, Bodner DR, Creasey GH, Green BG, Groah SL, Joseph A, et al.
Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. J Spinal Cord Med 2006;29:527-573.
Burgio KL. Behavioral treatment options for urinary incontinence. Gastroenterology 2004;126:S82-89.
Ghodsbin F, Karge M, Jahanbin I, Sagheb MM. The efficiency of a behavioral intervention program for urinary incontinence in elderly female. J Nurs Care 2012;1:122.
Tran K, Levin RM, Mousa SA. Behavioral intervention versus pharmacotherapy or their combinations in the management of overactive bladder dysfunction. Adv Urol 2009;2009:1-10.
Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131-139.
Chen CY, Liao CH, Kuo HC. Therapeutic effects of detrusor botulinum toxin A injection on neurogenic detrusor overactivity in patients with different levels of spinal cord injury and types of detrusor sphincter dyssynergia. Spinal Cord 2011;49:659-664.
Schurch B, Denys P, Kozma CM, Reese PR, Slaton T, Barron R. Reliability and validity of the Incontinence Quality of Life questionnaire in patients with neurogenic urinary incontinence. Arch Phys Med Rehabil 2007;88:646-652.
Dorsher PT, McIntosh PM. Neurogenic bladder: Review article. Adv Urol 2011;1-16. doi: 10.1155/2012/816274.
Wyndaele JJ. Conservative treatment of patients with neurogenic bladder. Eur Urol Suppl 2008;7:557-565.
Ellsworth P, Cone EB. Neurogenic detrusor overactivity: An update on management options. R I Med J (2013) 2013;96:38-40.
Jamil F. Towards a catheter free status in neurogenic bladder dysfunction: A review of bladder management options in spinal cord injury (SCI). Spinal Cord 2001;39:355-361.
Singh NJ, Keshkar S, Singh NA, Kumar R. Urodynamic study of bladder behaviour in traumatic spinal cord injury patients in response to rehabilitation. Indian J Phy Med Rehab 2013;24:87-91.
Charalambous S, Trantafylidis A. Impact of urinary incontinence on quality of life: Review article. Pelviperineology 2009;28:51-53.
Sánchez Raya J, Romero Culleres G, González Viejo MA, Ramírez Garcerán L; García Fernández L, Conejero Sugrañes J. Quality of life evaluation in spinal cord injured patients comparing different bladder management techniques. Actas Urol Esp 2010;34:537-542.
Ku JH. The management of neurogenic bladder and quality of life in spinal cord injury. BJU Int 2006;98:739-745.
Jain NB, Sullivan M, Kazis LE, Tun CG, Garshick E. Factors associated with health-related quality of life in chronic spinal cord injury. Am J Phys Med Rehabil 2007;86:387-396.
Noonan VK, Kopec JA, Zhang H, Dvorak MF. Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome. Arch Phys Med Rehabil 2008;89:1074-1082.
Hu X, Zhang X, Gosney JE, Reinhardt JD, Chen S, Jin H, et al.
Analysis of functional status, quality of life and community integration in earthquake survivors with spinal cord injury at hospital discharge and one-year follow-up in the community. J Rehabil Med 2012;44:200-205.
[Table 1], [Table 2], [Table 3], [Table 4]