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Rehabilitation in Patients with Inflammatory Bowel Disease and Familial Adenomatous Polyposis 475
phase, including the best strategies to counteract the
main postoperative problems, thus developing a
greater awareness of their condition. However,
depending on the urgency of the patient’s condition,
this rehabilitative intervention may not always be
possible, particularly if patient is affected by Crohn’s
disease. During the preoperative phase, a preventive
functional evaluation is established. Patients are
trained in breathing induction and relaxation tech-
niques. Moreover, they learn the different types of
cough, to be mainly performed using their intercostal
muscles, and breathing techniques. They are also
trained to adopt the correct posture when forced to
bed for certain periods.
Acute Post-operative Phase
The rehabilitation process includes pain treatment,
breathing re-education, as well as functional, motor
and sphincterial re-education.
The main objectives of breathing rehabilitation
are to:
– achieve optimal blood oxygen levels.
– Promote the dissolving of and then elimination of
bronchial secretions.
– Train the patient how to best face and overcome
physical efforts.
Motor re-education aims at:
– Promoting autonomy in moving to and from the
bed, allowing the patient to slowly reach a correct
standing and walking position.
– Helping the patient adopt the correct posture
when lying, sitting or standing.
– Promoting progressive tolerance of physical
efforts.
Exercises in this phase are designed to:
– Re-establish good general muscular tone.
– Counteract the effects of long periods of immobil-
isation on the metabolism of bones, muscles and
articulations so as to prevent muscle contrac-
tures, osteoporosis and thromboembolic compli-
cations.
Attention is also paid to the patient’s posture in order
to avoid the development of skin breakdown. It must
be stressed how beneficial training is from a psycho-
logical point of view: in fact, it helps reduce and man-
age anxiety and stress, contributes to higher morale
and promotes greater self-esteem.
Sphincterial re-education consists of early
removal of bladder catheters (usually within 1–2
days). Functional re-education aims at attaining
autonomy in carrying out daily activities and achiev-
ing early oral nutrition. Patients also learn the cor-
rect use of stomas.
Long-Term Rehabilitation
Exercises learnt during the hospital stay must also be
practised once the patient has returned home. Para-
meters such as frequency, intensity, duration, mode
and time progression of physical training may vary
after hospitalisation. As to long-term rehabilitation,
at the moment, there are no definite guidelines or
parameters suggesting exercises and follow-up
schedules.
Specific Health Training
Health education refers to the patients’ knowledge of
their medical condition and the critical factors that
may affect it. Patients are therefore instructed to
are made aware of the importance of following con-
stantly the therapeutic physical and pharmacological
programme designed for them. In particular,
patients are checked for and informed about:
– pain management.
– Colonic carcinoma.
– Metabolism and nutritional balance.
– Specific training techniques to use stomas correctly.
Psychosocial Evaluation
A psychological evaluation is performed to deter-
mine:
– The kind of social/family environment the patient
comes from and the kind of support he/she can
receive from it.
– The patient’s engagement in free-time/recreation-
al activities.
– The patient’s job and physical and emotional work
involvement.
Evaluation and Treatment of Possible Surgical or
Internal Complications
Faecal Incontinence
Faecal incontinence is defined as either involuntary
passage or inability to control the discharge of faecal
matter through the anus. Three subtypes of faecal
incontinence have been identified [5]:
1. Passive incontinence: involuntary discharge of
stool or gas without the patient’s awareness.
2. Urge incontinence: discharge of faecal matter
despite the patient’s active attempts to retain
bowel contents.
476 F. Lipanje, G. Colucci, G.G. Delaini
3. Faecal seepage: leakage of stool that follows other-
wise normal evacuation.
The severity of incontinence can range from unin-
tentional elimination of flatus to seepage of liquid fae-
cal matter or, sometimes, to the complete evacuation
of bowel contents. These events can be a cause of con-
siderable embarrassment for patients, affecting in the
long run their self-esteem and causing in turn social
isolation and a poorer quality of life [6]. To maintain
normal faecal continence, it is important to preserve
the neuromuscular integrity of the rectum, anus and
adjoining pelvic floor musculature. It follows that
incontinence occurs when there is disruption of one
or more mechanisms that maintain continence; the
disruption is to such an extent that other mechanisms
are unable to compensate. Incontinence in patients
affected by IBD and by FAP is caused by[5]:
– Decrease in rectal compliance and accommoda-
tion.
– Disruption of the external anal sphincter complex
due to (a) anorectal surgery for fistulas, hemor-
rhoids or fissure; (b) anal dilation of lateral
sphincterotomy.
The aim of the treatment is to restore continence
and improve quality of life.
Conservative Therapy
Habit training involves a regular schedule for defae-
cation, usually after breakfast, and often including
the use of extra fibre. Hygienic measures are also
taken, such as changing undergarments and cleaning
the perianal skin immediately after a soiling episode.
Other supportive measures can include modifica-
tions in diet, such as reducing caffeine or fibre con-
sumption.
Specific Treatment
1. Pharmacologic therapy: antidiarrhoeal agents,
such as Loperamide, suppositories or enemas are
usually prescribed [5].
2. Biofeedback: this is a “non-surgical, non-invasive,
and relatively inexpensive method of treating fae-
cal incontinence on an outpatient basis” [7].
Biofeedback has proven effective in the strength-
ening of “the external sphincter and anorectal sen-
sation” [8], providing “immediate and long-term
improvement of faecal incontinence” and “restor-
ing a normal quality of life” [9]. The patient is
trained to recognise small volumes of rectal dis-
tension and contract the external anal sphincter
while simultaneously keeping intraabdominal
pressure low. This is accomplished by measuring
anal canal pressure, showing this on a visual dis-
play to the patient, and providing verbal feedback.
Usually, better results are observed with motivat-
ed, mentally capable patients. Patients should also
have some degree of rectal sensation and be able
to contract the external anal sphincter [10].
Among other approaches, the augmented biofeed-
back program is also to be mentioned. This pro-
gramme includes electrical stimulation of the anal
sphincter with electromyogram (EMG) feedback.
To achieve a sustained improvement of bowel
function, however, these neuromuscular condi-
tioning techniques must be used together with
pelvic muscle strengthening or other supportive
measures.
3. Plugs, sphincter bulkers and electrical stimula-
tion: At present, these devices should be consid-
ered as experimental and deserve further con-
trolled clinical trials [5, 11].
Surgery
Surgery should only be considered for patients who
fail conservative measures or biofeedback therapy [5].
Extraintestinal Symptoms Located in the
Articulations
It has been observed that patients affected by IBD
frequently experience complications of joints com-
plaints, with prevalence that varies between 30% and
36%. IBD-related arthropathy may be expressed as
peripheral or axial arthritis, frequently indistinguish-
able from the classical ankylosing spondylitis [12].
Ankylosing Spondylitis
This chronic inflammatory disease is characterised
by a progressive ligament calcification with harden-
ing of the spine that reduces the function of the spine
and therefore causes disability[13]. Although at pres-
ent there are few clinical trials to confirm the benefits
of therapeutic exercise in treating ankylosing
spondylitis[14], it is firmly believed that a rehabilita-
tive program for patients with IBD should include:
1. Pain control treatment.
2. Achieving and maintaining correct posture.
3. Maintaining correct breathing function.
4. Maintaining quality of life.
Rehabilitation in Patients with Inflammatory Bowel Disease and Familial Adenomatous Polyposis 477
Osteoporosis
Osteoporosis is common in patients with IBD [15,
16], which is confirmed using dual-energy X-ray
absorptiometry that measures bone mineral density
(BMD). Further studies and debates need to be
undertaken to determine the absolute fracture risk,
the contribution of steroids and the role of prophy-
laxis in treating osteoporosis. Population-based data
on fracture incidence suggest only a small increased
risk of fracture amongst patients with IBD compared
with the general population [16]. A comparative
study has evaluated, through the use of bone biopsy,
microarchitecture and bone reshaping both in
menopause patients and subjects being treated with
corticosteroids (7.5 mg per day of prednisone for at
least 6 months). This study revealed that patients
treated with corticosteroids presented bones with
smaller volume (bone volume/tissue volume) and
reduced thickness of both trabecular and cortical
bone as well as a smaller number of osteoids [17].
If therapy using corticosteroids is undertaken, it is
recommended that the minimum effective dose be
taken and that therapy be periodically interrupted.
Use of calcium and vitamin D may be helpful to con-
trast the effects of corticosteroids, which can cause
secondary hyperparathyroidism, a reduction in
osteoblastic activity and have a negative effect on
kidney and bowel calcium transport [18].
“For patients with IBD and low BMD, it is possible
that calcium and Vitamin D supplementation alone
may be sufficient unless the patient is also receiving
corticosteroids or has a history of fragility fractures.
. . . Combination antiresorptive therapy (typically a
bisphosphonate combined with oestrogen or ralox-
ifene) may produce greater gains in bone mass than
either agent alone, but the use of two antiresorptive
agents is not recommended because the benefit on
fracture risk has not been demonstrated and there is
increased cost and side effects” [16]. Bernstein and
Leslie suggested that “to date, there remains no ther-
apy proven to be efficacious in inflammatory bowel
disease-related osteoporosis: however, calcium and
vitamin D supplementation and bisphosphonates
have their roles” [16].
References
1. Italian Society of Physical Medicine and Rehabilitation
(2005) Guidelines for rehabilitation services in Italy.
Eur Med Phys 41:95–109
2. Kehlet H (1997) Multimodal approach to control post-
operative pathophysiology and rehabilitation. Br J
Anaesth 78:506–517
3. Basse L, Raskow H, Jakobsen DH et al (2002) Acceler-
ated postoperative recovery program after colonic
resection improves physical performance, pulmonary
function and body composition. Br J Surg 8:1–10
4. Andersen J, Kehlet H (2005) Fast track open ileo-colic
resections for Crohn’s disease. Colorectal Dis
7:394–397
5. Rao SSC (2004) Practice guidelines. Diagnosis and
management of fecal incontinence. Am J Gastroen-
terol 99:1586–1604
6. Sailer M, Bussen D, Debus ES et al (1998) Quality of life
in patients with benign anorectal disorders. Br J Surg
85:1716–1719
7. Wald A (1981) Biofeedback therapy for fecal inconti-
nence. Ann Intern Med 95:146–149
8. Whitehead WE, Burgio KL, Engel BT (1985) Biofeed-
back treatment of fecal incontinence in geriatric
patients. J Am Geriatr Soc 33:320–324
9. Enck P, Daublin G, Lubke HJ, Strohmeyer G (1994)
Long-term efficacy of biofeedback training for fecal
incontinence. Dis Colon Rectum 37:997–1001
10. Latimer PR, Campbell D, Kasperski J (1984) A compo-
nents analysis of biofeedback in the treatment of fecal
incontinence. Biofeedback Self Regul 9:311–324
11. Norton C, Hosker G, Brazzelli M (
2004) Biofeedback
and/or sphincter exercises for the treatment of faecal
incontinence in adults (Cochrane Review). In: The
Cochrane Library, Issue 2. John Wiley, Chichester
12. Podswiadek M, Punzi L, Stramare R et al (2004) The
prevalence of radiographic sacroiliitis in patients
affected by inflammatory bowel disease with inflam-
matory low back pain. Reumatismo 56(2):110–113
13. Brophy S, Mackay K, Al-Saidi A et al (2002) The natu-
ral history of ankylosing spondylitis as defined by
radiological progression. J Rheumatol 29:1236–1243
14. Dagfinder H, Hagen K, Kvien TK (2005) Physiothera-
py interventions for ankylosing spondylitis (2005)
(Cochrane Review). In: The Cochrane Library, Issue 2,
John Wiley, Chichester
15. Scott EM, Gaywood I, Scott BB (2000) Guidelines for
osteoporosis in coeliac disease and inflammatory
bowel disease. Gut 46(Suppl 1):1–8
16. Bernstein CN, Leslie WD (2004) Review article: osteo-
porosis and inflammatory bowel disease. Aliment
Pharmacol Ther 19:941–952
17. Carbonare LD, Arlot ME (2001) Comparison of trabec-
ular bone microarchitecture and remodelling in glu-
corticoid and postmenopausal osteoporosis. J Bone
Mineral Res 16(1):97–103
18. Adachi JD, Bensen WG, Bianchi F et al (1996) Vitamin
D and calcium in the prevention of corticosteroid
induced osteoporosis : a 3 year follow-up. J Rheumat
23:995–1000
A
5-aminosalicylate 136, 212, 296, 297
abdominal abscess 160, 173, 191, 200, 388
absorption 51, 63, 64, 112, 113, 142, 143, 163, 183, 184,
192, 194, 197, 234, 310, 416
active
- immunity 62
- suppression 5, 24, 123, 136, 174, 231, 232, 314, 366,
429, 444
adhesion 157, 158, 162, 164 205, 235, 286, 382
aetiology 66, 296, 297, 317, 361, 381, 418, 419
anal sphincter function 257, 258, 301
ANCA 62, 68, 301
ankylosing spondylitis 61, 63, 64, 66, 245, 302, 476
antibiotics 93, 137, 146, 157, 159, 161, 164, 173, 177,
193, 198, 213, 218, 219, 223, 241, 243, 258, 288, 296,
303, 304, 306, 312, 415, 424, 457, 458, 465
antineutrophil cytoplasmic antibodies 62, 306, 436
appendicectomy 22
arthritis 61-63, 110, 159-161, 163, 245, 294, 302, 476
anti-tumor necrosis factor therapy 167
autoantibodies 62, 68, 176
autoantigens 62
APC mutations 43, 325, 347, 401
azathioprine 65-67, 70, 136, 143, 144, 159, 160, 163, 173,
174, 177, 192, 198, 213, 231, 244, 293, 298, 304, 309,
314, 319, 457
B
barrier function 111, 122
bias 19, 40, 95, 111, 138, 268
biological therapy 157, 158, 161, 164
bowel resection 92, 112, 144, 147, 279, 297, 450, 459
C
cancer risk in IBD 45, 46, 48, 95, 222, 265-270, 288, 294,
323, 341, 391, 441, 442
capsule endoscopy 89, 91, 93, 94, 326, 378-380, 436
carcinogenesis 164, 324, 346, 376, 432
CARD15 21, 426
CD4 235
chemoprevention 48, 324, 325, 346, 347, 369, 429
ciprofloxacin 85, 123, 137, 159, 174, 193, 197, 198, 298,
303-306
colectomy, prophylactic 376, 382, 387, 391, 408-410,
415, 418, 423, 425, 430, 431, 435-439, 441, 448, 455-
460
colonoscopy 25, 37, 39, 40, 47, 56, 70, 89, 90, 94-96,
101-105, 135, 146, 191, 199, 200, 247, 253, 265, 268,
294, 318, 319, 326, 379, 382, 383, 424, 430, 459
colonoscopic surveillance 40, 47, 246, 267, 269,
colorectal cancer
- risk in Crohn’s disease 319, 391, 424
- risk in ulcerative colitis 297
computer tomography 3, 74, 91, 135, 182, 252,
382, 383, 458
cytokine 54, 55, 62, 64, 68, 110-115, 117, 122,
157, 158, 162-164, 174, 193, 229, 235, 312, 419,
420, 425
D
DALM 37, 38, 42, 46, 103, 246, 247, 266-268, 294, 425
desmoid tumours 326, 329, 330, 335, 336, 357, 359-369,
383, 384, 387, 388, 392, 406, 429-431
dysplasia 35-42, 46, 47, 69, 70, 95, 101-105, 128, 198,
246, 247, 266-270, 287, 288, 293, 294, 298, 317-319,
325, 331, 334, 335, 346, 347, 377, 407, 424-426,
429, 447
E
endoscopic surveillance 95, 96, 103, 267, 311, 331, 332,
334, 346, 375, 378, 391
enteroclysis 4, 6, 7, 91, 94, 182
epidemiology 15, 18, 223, 307
etiology of IBD 54, 419
extraintestinal manifestations
- FAP 383, 405
- IBD 61, 62, 134, 245, 293, 297
F
fertility 129, 133, 137-139, 254, 424, 443
G
Gardner syndromes 350, 351, 384
gastroduodenal (Crohn’s disease) 93, 186, 335
gene
- mutations 329, 350
- therapy 162
genetic 17, 23, 24, 35, 38, 42, 45, 61, 62, 68, 110, 113,
121, 134, 157, 158, 186, 187, 268, 296, 317, 323, 324,
326, 329-335, 341, 345, 361, 366, 381, 401, 405, 407,
410, 419, 420, 429, 430
granulomatous vasculitis 18
gut flora 163
Subject Index
480 Subject index
I
ileal pouch-anal anastomosis 56, 105, 123, 148, 254,
259, 279, 281, 283, 285, 301, 325, 330, 348, 360, 426,
436, 437, 448, 451, 455, 461
ileitis 25, 54, 55, 63, 90, 101, 144, 181, 183, 186, 212, 258,
296, 424, 459
ileo anal pouch 39, 40, 331, 391
imaging 3-5, 7, 8, 68, 74-77, 83, 84, 87, 89, 91, 93, 94,
145, 146, 159, 182, 217, 219, 252, 295, 323, 326, 334,
348, 351, 357, 383, 436
immune system 232, 61, 135, 163, 181, 416, 419, 420
immunosuppressive therapy 176, 239, 254, 259, 286,
293, 296, 458
indeterminate colitis 28, 91, 101, 102, 127, 129, 191,
424, 435, 439, 449
induction of remission
- ulcerative colitis 229, 236
infliximab 3, 63, 65-67, 85, 93, 108, 114, 115, 136, 147,
157-164, 175, 177, 193, 198, 223, 241, 244, 253, 305,
424, 437, 458
intestinal
- perforation 181, 182, 195, 197, 348, 360, 457
- transplantation 309, 311, 312, 314
intraoperative frozen section 183
L
laparoscopic surgery 286, 335, 336, 460
liver transplantation 68, 70, 71, 306, 310, 313, 317-319
M
6-mercaptopurine 65, 66, 136, 174, 175, 192, 198, 212,
223, 245, 294
magnetic resonance 3, 10, 68, 74, 89, 159, 182, 252, 295,
319, 326
major histocompatibility complex 62, 157
malnutrition 64, 107, 108, 112, 114, 115, 127, 133, 182,
194, 293, 310,
manometry 52, 222
medical management 195, 218, 220, 226, 230, 241, 244,
252, 423, 424, 431, 459
methylprednisolone 172, 192, 234, 253, 313
methotrexate 63, 69, 122, 136, 159, 174, 177, 192, 233,
368
metronidazole 123, 137, 159, 161, 173, 174, 176, 193,
197, 198, 213, 221, 258, 296, 303-306, 451, 465
microflora 65, 110, 115, 121, 124
mucosal
- biopsy 29, 175
- immune system 23, 149
N
neoplastic lesions 41, 104, 268, 431
nicotine 52, 54
nitric oxide 48, 54, 55, 68, 122, 235, 366
non-steroidal anti-inflammatory drugs 31, 67, 137
P
parenteral nutrition 107-109, 177, 182, 194, 253, 309-
311, 369
pathogenesis
- FAP 367
- IBD 17, 24, 46, 48, 142, 160, 164, 181, 303, 305, 415, 418
perianal
- problems 456
perinuclear antineutrophil cytoplasmic 62, 296, 436
peritonitis 183, 200, 206, 253, 348, 415, 457, 459, 460
postoperative
- management 311, 388
- pain 259, 335, 341
pouchitis 18, 48, 56, 121-124, 129, 164, 258, 270, 282,
288, 294-298, 301-306, 424, 436, 438, 439, 442-444,
448, 449, 451
pregnancy 94, 133-139, 161, 174, 182, 195, 233, 254, 348,
359, 361, 424, 426
primary sclerosing cholangitis 18, 35, 45, 48, 61, 69, 91,
102, 258, 266, 294, 305, 306, 317, 419
probiotic 121, 122, 124, 296, 305, 306
proctectomy 147,150, 171, 220, 222, 240, 253, 256, 257,
259, 270, 330, 331, 335, 339, 341, 393, 394, 409, 432,
448, 452, 463, 466, 469, 470
proctitis 45, 53, 112, 149, 220, 223, 256, 269, 423
proctocolectomy 18, 39, 40, 68, 69, 101, 105, 128, 129,
137, 149, 150, 172, 195, 196, 198-200, 239, 244, 245,
253, 257-260, 267-270, 273, 276, 285, 287, 293, 301,
303, 325, 330, 332, 335, 339, 347, 349, 351, 362, 376,
379, 382, 391, 398, 408-410, 415, 416, 424, 431, 435,
441, 444, 447-452, 464, 465
proximal disease 73, 217, 218, 220
pseudopolyps 89, 90, 102, 103
Q
quality of life 23, 69, 107, 108, 115, 123, 127-130, 133,
134, 137, 139, 149, 151, 159, 162, 181, 192, 195, 198,
223, 230, 244, 245, 277-289, 293, 294, 297, 301, 302,
305, 332, 392, 397, 399, 410, 415-418, 423, 424, 431,
441-444, 447, 448, 450-452, 473, 476
R
rectourethral fistula 144
rectovaginal fistula 74, 79, 85, 146, 225, 226, 456, 457
regional enteritis 95
rehabilitation 108, 309, 310, 449, 473-475
reproduction 26
rheumatoid arthritis 110, 159-161
S
screening 39-41, 86, 95, 102, 103, 160, 267, 304, 323,
325, 326, 330, 332, 346, 350, 377, 378, 407, 430, 436
severe colitis 251-254, 301, 319, 459
skip lesion 30
small bowel follow-through 91, 94, 182
smoking 16-18, 24, 111-113, 129, 159, 193, 194, 198,
212, 214, 296, 301, 424, 436
somatostatin 420
stapled anastomosis 259, 285, 303, 391
steroids 64-69, 199, 212, 220, 236, 241, 309, 423, 437
stoma 127-130, 141, 150, 171, 182, 194, -196, 198, 205,
206, 208, 221, 222, 225, 256, 258, 260, 269, 282, 283,
311, 348, 387, 391
strictureplasty 122, 184, 196, 197, 212, 275, 425, 459,
460
481
T
tacrolimus 66, 69, 70, 158, 163, 175, 177, 234, 243, 244,
253, 311, 313, 314, 325
tamoxifen 348, 363-365, 367, 368, 383
toxic megacolon 26, 51, 54, 89, 101, 137, 195, 199, 200,
239, 241-243, 251-253, 259, 293, 415, 421, 455-460
Turcot sindrome 350, 384, 405, 406
U
ultrasonography 67, 73, 74, 79, 139, 182, 217, 222, 378,
379, 457
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