The Effect of Pelvic Floor Rehabilitation on Lower Anterior Resection Syndrome After Colorectal Cancer Treatment

doi:10.21203/rs.3.rs-1747128/v1

Download PDF

Research Article

The Effect of Pelvic Floor Rehabilitation on Lower Anterior Resection Syndrome After Colorectal Cancer Treatment

https://doi.org/10.21203/rs.3.rs-1747128/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Purpose

Lower anterior resection (LAR) is the preferred surgical treatment of rectosigmoid or rectal cancers but is often associated with bowel dysfunction, termed Lower Anterior Resection Syndrome (LARS). Daily bowel dysfunction symptoms have a detrimental effect on quality of life (QOL). Pelvic floor rehabilitation (PFR) can improve pelvic floor function and QOL among patients with LARS. This quality improvement (QI) project seeks to assess prevalence of LARS within our population and develop and incorporate PFR for treatment and prevention of LARS.

Methods

A convenience sample of 20 patients met project inclusion and 13 participated. Individuals were categorized by diagnostic risk: “low risk”, “high risk”, and “established.” The intervention included 1-hour PFR sessions with the physical therapist (PT) and 5 minutes of daily self-led pelvic floor muscle exercises. Outcome questionnaires included the LARS Score and FiQOL Scale. Data were collected both pre and post CRC treatment.

Results

Overall prevalence of LARS was 76.9% and significantly higher than the retrospective cohort comparison rate of 21.8% (p < .001). Prevalence of major LARS was 89%, 83%, and 50% at initial, second, and third session, representing a 44% relative decrease. Embarrassment was significantly affected among individuals with major LARS, though ongoing PFR facilitated improvement.

Conclusion

PFR is a valuable adjunct therapy for LARS, with continued sessions decreasing overall prevalence among our cohort. Major LARS negatively impacts QOL measures early on in treatment but improves with continued PFR.

Pelvic floor rehabilitation

lower anterior resection syndrome

colorectal cancer

bowel dysfunction

quality of life

supportive oncology

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States (U.S.), with an average of 53,200 deaths in 2020 [1]. Treatment is multimodal, including chemotherapy, radiation therapy, and surgery. Lower anterior resection (LAR) is performed for surgical management of rectal cancer and involves total mesorectal excision and either colorectal or coloanal anastomosis, preserving the anorectal sphincter allowing bowel continuity.

Unfortunately, bowel dysfunction characterized by fecal incontinence, urgency, frequency, and fragmentation is common months to years after surgery [2]. This constellation of symptoms has been named lower anterior resection syndrome (LARS). Incidence of LARS in the U.S. ranges from 19–90% [1, 3–10]. Daily bowel dysfunction can impact quality of life, be burdensome, and carry a social stigma. Over 80% of patients with LARS feel the condition negatively impacts their QOL [11].

Adjuvant chemoradiation or radiation therapy, tumor height, mesorectal excision, female gender, anastomotic type, and duration of defunctioning stoma prior to reversal are associated with major LARS [2, 4–7, 12–14]. Combined chemoradiation therapy compared to chemotherapy alone causes poorer functional outcomes and is associated with major LARS [2, 14]. Though radiation treatment alone has unfavorable effects to pelvic floor muscle structure and function, a synergistic effect with chemoradiation negatively affects bowel function to a greater degree than either therapy alone [12].

Treatment is largely symptom focused, including dietary modifications, antidiarrheal medications, supplemental bulking agents, and bowel training; however, efficacy varies. Growing evidence supports pelvic floor rehabilitation (PFR) as an effective and valuable therapy [15]. PFR, a safe, effective, and noninvasive therapy for fecal incontinence, is gaining momentum in rehabilitation medicine as an adjunct therapy for LARS. PFR combines diagnostic and therapeutic strategies to isolate and strengthen pelvic floor muscles by repeated contraction, generating awareness of sensation, control, and engagement [10].

Bowel dysfunction following LAR can develop immediately or later; there is no absolute association between time from treatment and development of LARS. [2, 3]. There are ample studies evaluating LARS 1 year or more after treatment, but few evaluating it within the first year. At project inception, only three studies assessed PFR for LARS and QOL measures within the first year from surgery [3, 9, 14]. Evaluation of LARS, its effect on QOL, and potential treatment strategies within the first 12 months from surgery should be emphasized to improve functional outcomes and QOL and lessen patient anxiety related to bowel changes. This builds on previous studies reporting gainful benefit in bowel function and QOL when therapy is introduced within 12 months of surgery [3, 9, 14].

Daily pelvic floor exercises can significantly improve bowel function and QOL among patients with LARS within the first year [3, 9, 10]. Systematic reviews show no association with prolonged symptom duration and efficacy of PFR; symptoms and QOL measures can improve significantly with symptom duration greater than 24 months [16, 17]. Regardless of timing, PFR may have a positive impact. There is no literature evaluating PFR as a preventative strategy for LARS by integrating PFR into patient care prior to treatment. In fact, there is no primary report or discussion on using PFR to prevent LARS.

Gastrointestinal (GI) surgical oncologists at our center performed 55 LAR surgeries in 2020; a retrospective review revealed a 21% prevalence of LARS among these patients within 1 year after surgery [(removed for blinded review)]. Diagnosis was defined by identifying the following within the patient’s medical record: a diagnosis of “bowel dysfunction” (ICD10 code K59.9); prescription antidiarrheal or antispasmodic medications or bulking agents following LAR; or electronic medical record documentation of bowel dysfunction post LAR. Retrospective review showed LARS was primarily treated with dietary modification and pharmacologic support.

Objectives

The purpose of the QI project was to assess prevalence of LARS among our patient population and the effect of PFR in treating and preventing LARS. The specific aims were;

Aim 1: To develop and implement a protocol utilizing PFR as an adjunct treatment for LARS.

Aim 2: To lower prevalence of major LARS by 25% among patients at least 2 weeks postoperative from surgery throughout intervention timeline.

Aim 3: To incorporate PFR as a preventative treatment for at least 50% of patients undergoing LAR prior to definitive cancer treatment.

Implementation Context and Setting

This QI project took place from June 2021 - October 2021 in the department of GI Surgical Oncology and Oncology Rehabilitation at a single large tertiary cancer care institution in Southeast U.S., including surgical oncologists, medical oncologists, radiation oncologists, nurse practitioners, physical therapists (PTs), nurses, nursing assistants, and dieticians. The department of GI Surgical Oncology has three practicing surgical oncologists and one full-time nurse practitioner (NP). An average of 50-55 new patients are seen annually for CRC treatment and LAR surgery. During project development, over 30established CRC patients with LARS continued their cancer surveillance with the practice. The facility Institutional Review Board (IRB) approved this project and deemed it a QI initiative. A Model for Change to Evidence-Based Practice by Rosswurm and Larrabee was used to guide development and implementation [19].

Interventions

A convenience sample was used for this QI project. The target population was adult patients with either rectosigmoid or rectal cancer and a surgical treatment plan for LAR, or any patient 0 - 24 months postoperative from LAR or post-LAR ostomy closure with existing LARS. LARS severity and QOL can be improved early in symptom course but may take up to 24 months; thus, this criterion was used as reference point for this QI project.

Patients were categorized into three groups; “low risk”, “high risk”, and “established”. For newly diagnosed CRC patients, the surgeons discussed the QI project at initial consultation; capturing the “low risk” and “high risk” patients. A fact sheet detailing a brief overview of LARS, PFR intervention, project aims, and contact information was provided at consultation. The project lead then contacted individual patients to gauge interest. “Established” patients were captured by both the NP and surgeons during regularly scheduled surveillance visits, or when LARS was diagnosed. All patients received the same fact sheet reviewing project details and LARS. The high- and low-risk groups had initial PFR intervention pre-CRC treatment, exploring PFR as a preventative measure for LARS. The “established” group had PFR intervention following CRC treatment and LAR surgery, exploring the use of PFR to treat LARS.

The intervention included 1-hour PFR physical therapy sessions with the pelvic physical therapist and 5 minutes of daily self-led pelvic floor muscle exercises. The PERFECT assessment (Power, Endurance, Repetitions, Fast contractions, and Every Contraction Timed), a digital assessment of pelvic floor muscle engagement, was performed by the PT at each session to guide patients on exercise technique and inform future goals. The PERECT assessment has high inter-examiner reliability (p < .001), test-retest reliability (p < .001), and validity (p = .001) [20]. Patient-reported outcome questionnaires included the LARS Score and FiQOL Scale, completed before most PFR sessions and at the 3-month follow-up appointment with the clinician.

Collection of outcome measurements varied (Table 1). The “low risk” and “high risk” groups did not receive FIQOL Scale pre-PFR, it was not expected these patients have impaired QOL related to fecal incontinence prior to treatment. Differences in treatment for locally advanced and low-risk rectal cancer, rectosigmoid, and sigmoid colon cancer informed the number of sessions for each group. The justification for this approach is the aim to utilize PFR as a preventative measure prior to CRC treatment in both high- and low-risk groups.

The clinical staff vital in project promotion and progresswere SJ (nurse practitioner, project lead) and ET (pelvic physical therapist). Three key clinical nursing staff (SO, BG, and KZ) issued the fact sheet to patients and informed project lead of potential patients after initial consult or follow-up visit. The project lead assumed primary role for data import into the data warehouse. The three surgeons helped capture appropriate patients in initial consult and define treatment algorithms.

Table 1 Treatment Intervention Timeline. Patients were categorized into three groups: “low risk” (rectosigmoid colon cancer or T1/T2 N0 rectal cancer), “high risk” (locally advanced T3/T4 or N-positive rectal cancer with surgical plan for LAR, or any T any N-positive rectal cancer patient treated with neoadjuvant radiation with surgical plan for LAR), and “established” (patient post-LAR surgery or ostomy closure after previous LAR surgery with existing LARS).

Group Description		Session 1	Session 2	Session 3	Session 4	Session 5
Group 1: “Low Risk”	Treatment timeline	2 weeks pre-op	2 weeks post-op	6 weeks post-op	3 months post-op	---
	Intervention^a	X	X	X	---	---
	Outcome measures^b	X^c	X	X	X	---
Group 2: “High Risk”	Treatment timeline	2 weeks pre-radiation	2 weeks pre-op (LAR)	2 weeks post-op^d	6 weeks post-op^d	3 months post-op^d
	Intervention^a	X	X	X	X	---
	Outcome measures^b	X^c	X	X	X	X
Group 3: “Established”	Treatment timeline	Initial evaluation^e	2 weeks after initial evaluation	6 weeks after initial evaluation	3 months after initial evaluation	---
	Intervention^a	X	X	X	---	---
	Outcome measures^b	X	X	X	X	---

Note: “X”: intervention or outcome measure collection; “---”: no intervention or data collection per project protocol

^a1-hour session of PFR with physical therapist; ^b LARS Score and FiQOL Scale; ^cLARS Score only; ^dPost-LAR ostomy closure or post-op LAR if no ostomy; ^eWhen diagnosed with LARS

Study of the Interventions

Patients often use a multi-therapy approach for LARS treatment. Strong evidence supports PFR as a treatment for LARS compared to other therapies, irrespective of timing from bowel continuity or symptom duration [16]. There is no literature showing PFR as a preventative strategy for LARS prior to definitive CRC treatment. Establishing a protocol, identifying the prevalence of LARS, and incorporating PFR as a preventative measure and treatment offers strong potential to enhance patient care and improve outcomes.

Measures

A number of instruments are used to assess bowel dysfunction; however, many focus on a single component of the condition and do not evaluate QOL [8, 10]. The LARS Score is a 5-question patient-reported outcome instrument that categorizes LARS based on severity on a binomial scale of either minor or major LARS; it is validated in English and has strong convergent validity in QOL (p < .01) and discriminative validity (p < .02), and high test-retest reliability (intraclass correlation coefficient 0.83) [6, 14]. The LARS Score assesses five different bowel dysfunction symptoms, including fecal incontinence, frequency, urgency, clustering, and indiscrimination of gas versus stool.

The Fecal Incontinence Quality of Life (FiQOL) Scale is commonly used to evaluate QOL due to fecal incontinence, a hallmark symptom of LARS. It includes 29 questions measuring QOL in four domains, including lifestyle, coping/behavior, depression/self-perception, and embarrassment. Scores range from 1 to 5, higher scores indicating better quality of life. Psychometric evaluation shows both tools produce reliable and valid measurements [3, 6, 14].

Analysis

Power analysis revealed a sample size of 30 would provide adequate effect. Data analyses were conducted via IBM SPSS Statistics 27 software. Descriptive statistics were used to summarize demographic and diagnostic data, evaluate patient acceptance, and summarize reasons for opting out. Chi squared and Fisher’s exact tests were used to evaluate categorical data among groups. Fisher’s exact test of retrospective data was used to compare the prevalence of LARS among groups. Kruskal Wallis tests were used to examine change in QOL median scores among LARS severity at various timepoints. A p value of < .05 was considered statistically significant. This manuscript was written per SQUIRE 2.0 Guidelines [21, 22].

Ethical Considerations

This project was performed in accordance with the Declaration of Helsinki. Approval was granted by facility IRB and determined to be quality improvement. No direct or indirect ethical considerations of project development or implementation were identified.

Demographic and Clinical Characteristics

Male and female representation was similar (45% female, 55% male). Half were less than 55 years of age (50%) with the remaining half between 56 to 64 years of age and 65 years of age and greater spitting the remainder (25% each group). Rectal and rectosigmoid cancer were the most common diagnoses (40% and 35%, respectively). Previously tried therapies varied highly among groups. The majority of individuals received no neoadjuvant therapy (60%) (Table 2).

Of 20 patients who met the criteria, 15 accepted. Of those 15, 13 completed at least one PFR session. Two individuals opted out prior to the first PFR session. Five eligible patients declined inclusion, for reasons including no desire for PFR (33%), did not want added visits (22%), transportation issues (22%), and satisfied with bowel function (22%) (Fig. 1). There were no associations between gender and therapies tried, nor diagnosis and therapies tried (all p > .05) (Table 3).

Table 2 Patient characteristics

Variable	n	%
Gender
Female	9	45
Male	11	55

Age
40-55	10	50
56-64	5	25
65+	5	25

Race
Black	3	15
Middle eastern or North African	2	10
White/Caucasian	14	75
Not specified	1	5

Diagnosis
Rectosigmoid Cancer	7	35
Sigmoid Cancer	3	15
Rectal Cancer	8	40
Ovarian cancer (metastatic to colon or rectum)	2	10

Previous Therapies Tried
None	5	16
Dietary modifications	8	26
Toilet training	4	13
Bulking agents	5	16
Antidiarrheal agents (Imodium, Lomotil)	4	13
Antispasmodics (Bentyl)	4	13
Other	1	3

Type/Sequence of Neoadjuvant Therapy
Standard: Conventional Radiation with 5-FU Analog^a	1	5
Standard: Conventional Radiation with Xeloda	1	5
Standard: Other	3	15
TNT^b Agent/Chemotherapy: Single Agent	1	5
TNT Agent/ Chemotherapy: Multiagent	1	5
TNT Agent/Radiation: Conventional Radiation	1	5
None	12	60

^a5-fluorouracil; ^bTotal Neoadjuvant Therapy (TNT) consisting of the combination of chemoradiation followed by chemotherapy followed by surgery, or chemotherapy followed by chemoradiation followed by surgery.

Table 3 Associations between gender and diagnosis with previous therapies tried

Previous Therapy Tried	Gender (N= 15)			Diagnosis (N = 15)
Previous Therapy Tried	Males (n = 6)	Females (n = 9)	p^a	Rectosigmoid Cancer (n =6)	Sigmoid Cancer (n =2)	Rectal Cancer (n = 6)	Ovarian cancer: metastatic to colon or rectum (n = 1)	p
None	2 (33)	3(33)	.999	1 (17)	1 (50)	3 (50)	0 (0)	.522
Dietary modifications	2 (33)	6 (67)	.315	4 (67)	1 (50)	3 (50)	0 (0)	.658
Toilet training	2 (33)	2(22)	.999	3 (50)	0 (0)	0 (0)	1(100)	.062
Bulking agents	3 (50)	2 (22)	.329	3 (50)	0(0)	2(33)	0 (0)	.522
Antidiarrheal agents (Imodium, Lomotil)	1 (17)	3 (33)	.604	2 (33)	0 (0)	2(33)	0 (0)	.714
Antispasmodics (Bentyl)	1 (17)	3 (33)	.604	1 (17)	0 (0	3(50)	0 (0)	.381
Binding Agents	0 (0)	0 (0)	--	0 (0)	0 (0)	0 (0)	0 (0)	---
Other: PFR	1 (17)	0 (0)	.400	1 (17)	0 (0)	0 (0)	0 (0)	.658

Note: “---” not computed due to no data

^aFisher’s exact test p-value reported due to no 2x2 comparison

LARS Prevalence

Retrospective data analysis revealed LARS among 12 out of 55 patients who had LAR surgery in 2020 (21.8%). This QI project found the overall prevalence of LARS at the time of last PFR session to be 76.9% (10 out of 13, p < .001). Evaluating prevalence of major LARS among groups at each session revealed 89% of individuals reporting major LARS at initial intervention session, 83% at second session, and 50% at third session, resulting in a 44% relative decrease from initial session (Fig. 2). For participants with minor or major LARS who completed at least 2 weeks of PFR (n = 6), two saw reduced LARS severity by the end of their last session (33.3%) and four remained unchanged (66.7%). Six participants had only one session, thus a matched reduction could not be appraised. Two participants reported no LARS at initiation; of these, one had not yet had surgery and the other was 1 month postoperative from ileostomy reversal. Only one participant had 3 months of PFR, and this individual continued to report significant LARS throughout therapy.

Quality of Life

Due to small sample sizes and deviations from normality for domain scores, non-parametric Kruskal Wallis tests were used to examine changes in FiQOL median scores among LARS severity levels after sessions 1, 2, and 3, with higher scores indicating better QOL. At the initial intervention session (session 1), there were no statistically significant differences between LARS severity on any quality of life domains (Lifestyle p = .114; Coping p = .118; Depression p = .120; Embarrassment p = .115). After 2 weeks of PFR therapy (session 2), there was a significant difference in embarrassment (p = .047) but not lifestyle (p = .051), coping (p = .053), or depression (p = .051). After 6 weeks of PFR (session 3), there were no differences among any of the domains (Lifestyle p = .165; Coping p = .165; Depression p = .223; Embarrassment p = .135) (Fig. 3).

After 6 weeks of PFR, all subscale scores among individuals with major LARS improved, except the depression subscale which declined from 3.3 to 3.0 (Lifestyle, from 2.3 to 2.5; Embarrassment, from 2.7 to 3.3; Coping, from 2.1 to 2.4). There were no reports of minor LARS at session 1 or 2, therefore comparisons were unattainable. Individuals reporting no LARS throughout had the highest QOL scores among all subscales.

Summary and Interpretation

We implemented a QI project to assess incidence of LARS and effect of PFR as both a preventative and treatment strategy. We also appraised the effect of LARS on QOL. Our sample size was smaller than calculated effect size, largely due to abbreviated data collection timeframe. Thus, analysis was adjusted to account for small sample size and generated inferential results. Our cohort had a considerable proportion of younger individuals, with 50% being less than 55 years of age, including 70% who were under 50 years of age. This supports data demonstrating young-onset CRC (< 50 years of age) is becoming more prevalent due to earlier detection and epidemiological, genetic, and environmental influences [23, 24]

Risk factors of LARS include chemoradiation therapy, radiation therapy, duration of defunctioning stoma, tumor height, and female gender. Combination chemoradiation therapy compared to monotherapy increases risk of LARS [4, 13]. A systematic review of the effects of radiation therapy on pelvic floor muscle structure and function assessed four high-quality studies involving rectal cancer patients showing significantly decreased muscle tone at rest (p = .003), maximum squeeze pressure (p = .013), contractile response (p = .007), and spontaneous activity (p = .001) [12]. Long-term evaluations of bowel function outcomes post-CRC treatment identify combined radiation therapy and surgery causing a 2-fold increased risk of bowel dysfunction compared to surgery alone [13]. Our program found similar results - of patients reporting LARS at last PFR session, 60% received either chemoradiation or radiation therapy and 40% did not.Female gender was not found to be more prevalent among our cohort.

The retrospective cohort were an average of 16 months from surgery and our cohort was an average of 8 months postoperative from either LAR surgery or ileostomy closure. Previous studies observed optimal bowel physiology recovery around 6-24 months, with extended time for maximum restoration if tissues were irradiated [9, 10, 12, 25]. Evaluating bowel function early in physiologic restoration may lead to false-negative assessments of expected restorative potential; however, this may explain the increased prevalence found in our project. Ongoing PFR provided meaningful benefit for participants and lowered major LARS prevalence, with a 44% relative decrease by the 6-week follow-up session compared to initial session.

At project conception, this project was the first in the literature that evaluated PFR as a preventative measure for LARS among CRC patients. The American Society of Colon and Rectal Surgeons advises against “preventative” PFR prior to abdominopelvic surgery, given lack of substantive evidence in the literature, but recommends its use in the treatment of bowel dysfunction [26]. Conversely, preventative PFR is widely used in obstetric medicine to obviate postnatal pelvic floor dysfunction. A systematic review of preventative PFR showed lasting reduction of urinary incontinence after delivery among women who incorporated antenatal PFR in late pregnancy and postpartum [27]. The National Institute of Health and Care Excellence recommends all women over 12 years of age incorporate PFR to prevent pelvic floor dysfunction [28]. Preventative PFR has been used extensively outside of colorectal medicine. Since project conclusion, a current literature review now reveals one randomized clinical trial pilot study looking at PFR as a preventative therapy for LARS [29].

We met our aim by incorporating PFR prior to CRC treatment in 80% of individuals. In the pre-treatment preventative PFR group (Group 1), there were no reports of LARS by last session; however, this included only one individual. This individual’s results were clinically impactful as pre-PFR LARS Score was 22 (mild LARS) and 9 (no LARS) by the last session of PFR. Pre-treatment group findings were limited due to small sample size; therefore we could not meaningfully assess the effect of PFR as prevention for LARS.

Quality of Life

We found statistically significant lower scores on embarrassment with major LARS (p = .47) at the 2-week follow up but improved scores with ongoing PFR. Hung et al. found significant embarrassment scores among patients early in post-treatment phase, lasting up until 2 months following surgery; but this domain improved with ongoing PFR [3]. These researchers found QOL scores significantly improved throughout all subscales, though their study utilized 9 months of PFR and improvements were not derived until 6 months [3]. As such, these researchers recommend instituting PFR at least up to 6 months postoperatively to maximize benefit of QOL. Our findings of increased embarrassment earlier in PFR therapy are likely due to more awareness of dysfunctional bowel condition and associated struggles dealing with a new health condition. PFR training increased QOL scores among all subscales except depression scores.

Unsurprisingly, QOL scores were highest among individuals who reported no LARS. After 6 weeks of PFR, depression was the only unimproved subscale, implying ongoing despair due to bowel dysfunction symptoms despite improvement in other areas of life such as embarrassment, lifestyle, and coping. Early embarrassment scores were significantly lower among those with major LARS, which this is expected considering the necessary time for optimal bowel restoration and timing from index treatment. Gainful benefit in bowel function may take upwards of 24 months. Hence, appraisal of bowel dysfunction earlier in bowel restoration may not reflect potential natural improvement.

Limitations

This project’s primary limitation was small sample size, restricting generalizability and overall implicit power. Due to standard CRC treatment timeline and data collection combined with patient population at time of implementation, some groups’ accrual was less than anticipated, further contributing to small sample size. Only one pelvic PT was available for project involvement. Personal life circumstances and necessary time away from work resulted in rescheduling of patients and some attrition.

Per quality improvement philosophy, confounders were not accounted for; patients did not cease existing therapies. This increases difficulty in fully discerning benefit derived solely from ongoing PFR. This project was conducted in a single department of a large tertiary hospital. Many patients travel hours to receive care and are unlikely to travel long distances for therapy sessions - two individuals opted out for this reason. Further, the institution’s department of colorectal surgery patient population was not included in this program, primarily because most of LAR surgeries performed by this department are done for benign conditions. This was a limitation, as more patients may have met criteria and derived benefit. Due to nuances in recommended treatment duration and timeline, Group 2 was inadequately captured throughout intervention and data collection. Broadening the data collection window would easily rectify this issue.

LARS is widely prevalent among CRC survivors. Evaluation should include LARS Score and QOL measurement tools with good psychometric scores evaluating symptoms. Evidence shows that LARS occurs immediately following surgery, though bowel dysfunction can be present at time of diagnosis. Though risk factors of LARS vary, multimodal therapy is a leading cause [2, 4]. PFR is a viable option for LARS treatment, maximally beneficial within 6 months post treatment, though perceivable benefits have been gained as early as 6 weeks post treatment and years beyond index CRC treatment.

PFR is a viable pre-treatment option for CRC patients to optimize pelvic floor muscle engagement, control, awareness, and overall outcomes. We found an important relative decrease in major LARS among individuals with ongoing daily PFR. By incorporating this QI project, we identified both the prevalence of LARs among our patients and improved outcomes. This QI project shed light on PFR usefulness and efficacy, allowing this therapy to be adopted within clinical practice and potentially among other departments with similar patients.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Availability of Data and Material

The authors confirm that the data supporting the findings of this project are available from the corresponding author, S.J., on special request.

Code Availability

Not applicable

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Shelby Jones, Dr. Emily Troop, and Dr. Julie Thompson. The first draft of the manuscript was written by Shelby Jones and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics Approval

This quality improvement project was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of Atrium Health and determined to meet criteria of quality improvement (March 30, 2021/No. 1510).

Consent to Participate and Publish

Informed consent was obtained from all individuals prior to project initiation. All data are deidentified within this quality improvement project.

Conflicts of Interests

The authors declare no conflicts of interest. Quality improvement work presented in this paper was supported by Atrium Health. Atrium Health retains primary control of the data presented in this manuscript. Data may be available for external review if explicit permission is obtained directly from Atrium Health.

Acknowledgments:

Atrium Health Levine Cancer Institute, Charlotte, North Carolina, USA is acknowledged as clinical site for project Elena Turner, Editorial Advisor, Duke University, Durham, North Carolina, USA is acknowledged for editorial advisement services in manuscript drafting

Siegel RL, Miller KD, Sauer AG, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70:145–164. https://doi.org/10.3322/caac.21601
Qin Q, Huang B, Cao W, et al. Bowel Dysfunction After Low Anterior Resection With Neoadjuvant Chemoradiotherapy or Chemotherapy Alone for Rectal Cancer: A Cross-Sectional Study from China. Dis Colon Rectum. 2017;60:697–705. https://doi.org/10.1097/DCR.0000000000000801
Hung S-L, Lin Y-H, Yang H-Y, et al. Pelvic floor muscle exercise for fecal incontinence quality of life after coloanal anastomosis. J Clin Nurs. 2016;25:2658–2668. https://doi.org/10.1111/jocn.13314
Croese AD, Lonie JM, Trollope AF, et al. A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg. 2018;56:234–241. https://doi.org/10.1016/j.ijsu.2018.06.031
Trenti L, Galvez A, Biondo S, et al. Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study. Eur J Surg Oncol. 2018;44:1031–1039. https://doi.org/10.1016/j.ejso.2018.03.025
Juul T, Battersby NJ, Christensen P, et al. Validation of the English translation of the low anterior resection syndrome score. Colorectal Dis. 2015;17:908–916. https://doi.org/10.1111/codi.12952
Badic B, Joumond A, Thereaux J, et al. Long-term functional and oncological results after sphincter-saving resection for rectal cancer - Cohort study. Int J Surg. 2018;52:1–6. https://doi.org/10.1016/j.ijsu.2018.02.003
Keane C, Wells C, O’Grady G, Bissett IP. Defining low anterior resection syndrome: a systematic review of the literature. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2017;19:713–722. https://doi.org/10.1111/codi.13767
Lin Y-H, Yang H-Y, Hung S-L, et al. Effects of pelvic floor muscle exercise on faecal incontinence in rectal cancer patients after stoma closure. Eur J Cancer Care (Engl). 2016;25:449–457. https://doi.org/10.1111/ecc.12292
Nishigori H, Ishii M, Kokado Y, et al. Effectiveness of Pelvic Floor Rehabilitation for Bowel Dysfunction After Intersphincteric Resection for Lower Rectal Cancer. World J Surg. 2018;42:3415–3421. https://doi.org/10.1007/s00268-018-4596-8
Bohlok A, Mercier C, Bouazza F, et al. The burden of low anterior resection syndrome on quality of life in patients with mid or low rectal cancer. Support Care Cancer. 2020;28:1199–1206. https://doi.org/10.1007/s00520-019-04901-2
Bernard S, Ouellet M-P, Moffet H, et al. Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review. J Cancer Surviv Res Pract. 2016;10:351–362. https://doi.org/10.1007/s11764-015-0481-8
Bregendahl S, Emmertsen KJ, Lous J, Laurberg S. Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2013;15:1130–1139. https://doi.org/10.1111/codi.12244
Tan S-H, Liao Y-M, Lee K-C, et al. Exploring bowel dysfunction of patients following colorectal surgery: A cohort study. J Clin Nurs. 2019;28:1577–1584. https://doi.org/10.1111/jocn.14757
Sakr A, Sauri F, Alessa M, et al. Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl). 2020;133:1824–1833. https://doi.org/10.1097/CM9.0000000000000852
Chan KYC, Suen M, Coulson S, Vardy JL. Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: a systematic review. Support Care Cancer. 2021;29:1795–1809. https://doi.org/10.1007/s00520-020-05832-z
Dulskas A, Smolskas E, Kildusiene I, Samalavicius NE. Treatment possibilities for low anterior resection syndrome: a review of the literature. Int J Colorectal Dis. 2018;33:251–260. https://doi.org/10.1007/s00384-017-2954-x
Atrium Health. Colorectal surgical report (Colorectal Lower Anterior Resection Surgery Patient Census Audit January 1, 2020 - December 31, 2020). Atrium Health; 2020.
Rosswurm MA, Larrabee JH. A Model for Change to Evidence-Based Practice. Image J Nurs Sch. 1999;31:317–322. https://doi.org/10.1111/j.1547-5069.1999.tb00510.x
Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 2001;87:631–642. https://doi.org/10.1016/S0031-9406(05)61108-X
Ogrinc G, Davies L, Goodman D, et al. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process. BMJ Qual Saf. 2016;25(12):982–992. doi: 10.1136/bmjqs-2015-004411
Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). 2015. Accessed online: https://www.coursehero.com/file/67912922/SQUIRE-Guidelinespdf/
Jackson CS, Oman M, Patel AM, Vega KJ. Health disparities in colorectal cancer among racial and ethnic minorities in the United States. J Gastrointest Oncol. 2016;7:S32–S43. https://doi.org/10.3978/j.issn.2078-6891.2015.039
Done JZ, Fang SH. Young-onset colorectal cancer: A review. World J Gastrointest Oncol. 2021;13:856–866. https://doi.org/10.4251/wjgo.v13.i8.856
Bulfone G, Del Negro F, Del Medico E, et al. Rehabilitation strategies for low anterior resection syndrome. A systematic review. Ann Ist Super Sanità. 2020;56:38–47. https://doi.org/10.4415/ANN_20_01_07
Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015;58:623–636. https://doi.org/10.1097/DCR.0000000000000397
Romeikienė KE, Bartkevičienė D. Pelvic-Floor Dysfunction Prevention in Prepartum and Postpartum Periods. Medicina (Mex) 2021;57:387. https://doi.org/10.3390/medicina57040387
Recommendations | Pelvic floor dysfunction: prevention and non-surgical management | Guidance | NICE. https://www.nice.org.uk/guidance/ng210/chapter/Recommendations. Accessed 16 Jan 2022
Sacomori C, Lorca LA, Martinez-Mardones M, et al. A randomized clinical trial to assess the effectiveness of pre- and post-surgical pelvic floor physiotherapy for bowel symptoms, pelvic floor function, and quality of life of patients with rectal cancer: CARRET protocol. Trials. 2021;22:448. https://doi.org/10.1186/s13063-021-05396-1

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

The Effect of Pelvic Floor Rehabilitation on Lower Anterior Resection Syndrome After Colorectal Cancer Treatment

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Objectives

Methods

Results

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1