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Physical Therapy for a Child With Encopresis: A Case Report

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DOI: 10.1097/PEP.0000000000000631

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 C A S E R E P O R T

Physical Therapy for a Child With Encopresis: A Case Report

Brittany Anderson, PT, DPT
Physical Therapy Program, University of Jamestown, Fargo, North Dakota.

Purpose: To describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a
child with encopresis.
Downloaded from http://journals.lww.com/pedpt by vRFGZDWGdpizut5rmjeBNZP/tI7J95NMhXLkUe1vEx08mAENDOofHHMKnr71gb7oHVKOvxc95BVqsPy5JQ8m1/F+FpBZqzzHIy00fW5pTodCL5xnQUyFMA== on 06/29/2019

Summary of Key Points: The child demonstrated chronic constipation, poor pelvic floor muscle awareness, weakness, and
incoordination during voiding. He participated in 8 sessions of physical therapy intervention including pelvic floor muscle
awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and
interactive visualization activities.
Conclusions: The child improved pelvic floor muscle strength and coordination and became fully continent of bowel in
home and community settings.
What This Case Adds to Evidence-Based Practice: This case report demonstrates that pediatric age-appropriate educational
and motivational tools (media, art, and interactive visualization activities) are readily available, economical, and effective
when used in conjunction with current practice to decrease impairments and improve active participation and compliance
during treatment of retentive encopresis in the pediatric population. (Pediatr Phys Ther 2019;31:E1–E7)
Key words: encopresis, incontinence, pelvic floor, sEMG

INTRODUCTION incontinence without constipation) and retentive encopresis

Encopresis (fecal incontinence) is a pediatric gastroin-
testinal condition with physical, psychological, and social
effect.1 Encopresis affects approximately 4% of all children 5
to 12 years old in western societies.1 The Diagnostic and Sta-
tistical Manual of Mental Disorders (Fifth Edition) lists 4 fea-
tures that must be present to support a diagnosis of encopresis:
(1) child’s age must be at least 4 years, (2) a repeated passage
of feces into inappropriate places (eg, clothing or floor, which
can be either intentional or involuntary), (3) at least 1 such
event must occur every month for at least 3 months, and (4)
the behavior is not attributable to the effects of a substance
(eg, laxative, or another medical condition, with the exception
of a mechanism involving constipation). There are 2 subtypes
of encopresis, which include nonretentive encopresis (fecal
0898-5669/110/3103-000E1
Pediatric Physical Therapy
Copyright © 2019 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Brittany Anderson, PT, DPT, Physical Therapy Pro-
gram, University of Jamestown, 4190 26th Ave South, Fargo, ND 58104
(brittany.anderson@uj.edu).
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions
of this article on the journal’s Web site (www.pedpt.com).
There was no financial support other than the salaries of the investigator.
The author declares no conflicts of interest.
DOI: 10.1097/PEP.0000000000000631
(fecal incontinence with constipation).2 Retentive encopresis is
largely correlated with chronic constipation with a recent survey
reporting 80% of children with encopresis also have chronic
constipation.3 Christophersen and Mortweet4 describe consti-
pation as the passage of large or hard stools, often accompanied
by complaints of abdominal pain, infrequent bowel movements
(<3 per week), the presence of abdominal masses upon phys-
ical examination, and emotional upset before, during, and after
defecation.
PSYCHOLOGICAL EFFECT
Encopresis is associated with negative psychosocial out-
comes in children.5 Joinson et al1 found that children who expe-
rience encopresis have a significantly higher rate of emotional
and behavioral problems than children without encopresis.1
Furthermore, children with encopresis are significantly more
likely to report being victims of bullying behaviors.1 This can
be attributed to the fact that the child is often unaware of the
leakage until it is noticed by a peer due to smell or a visible
stain on the child’s clothing. As a result of the stigma and shame
associated with encopresis, children often experience decreased
self-esteem, decreased self-confidence, and limited participation
with peers.1
ECONOMIC EFFECT
In the United States, approximately 25% of visits to a pedi-
atric gastroenterology clinic are constipation related.6 Consti-
pation is usually chronic resulting in significantly higher overall

Pediatric Physical Therapy Physical Therapy for a Child With Encopresis E1

Copyright © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
medical costs to the family. Children with constipation use more
health services ($3430/year) than children without constipation
($1099/year).7 Per year, this health service spending is equiva-
lent to an additional $3.9 billion spent on services/products for
treating constipation in children.7-10
CYCLE OF ENCOPRESIS
Chronic constipation in children is caused by multiple fac-
tors including poor fiber in the diet, insufficient water intake,
medications, past painful bowel movements, fear of defecating,
and defecation avoidance. Often, a child will develop a fear of
defecating due to a painful or large bowel movement in the past.
This aversion or fear of defecation can result in the child per-
forming purposeful holding to make the urge to defecate sub-
side. When the child chronically performs these holding maneu-
vers, stool is abnormally retained in the rectum. Typically, when
stool enters the rectum, the smooth muscle fibers and internal
anal sphincter relax sending signals to the brain for the need
to defecate. When a child relaxes the external anal sphincter,
the stool will evacuate normally. If the child performs a holding
maneuver and contracts the external anal sphincter, the stool
remains in the rectum and the urge to defecate subsides. Sup-
pressing the urge to defecate leads to prolongation of colonic
transit times, contributing to increased stool accumulation in
the colon. As the rectum/colon stretches to accommodate the
chronic retention of stool, it becomes desensitized and thereby
decreases colonic motor activity.11,12 The stool that remains in
the rectum continues to harden, as water is reabsorbed, which
can lead to fecal impaction. Overflow incontinence or soiling
can occur when semiliquid stool seeps past the impaction and
leaks out through the anal sphincter and is often unnoticed by
the child. This soiling is involuntary; however, it is commonly
interpreted as a purposeful behavior by the child, leading to the
negative responses of shame and punishment. These negative
responses can affect the child’s self-esteem and social interac-
tions, increase the child’s anxiety and apprehension, and cause
the child to continue to avoid defecation.
CURRENT TREATMENTS
The North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition committee published clinical prac-
tice guidelines to highlight evidence-based treatments for func-
tional constipation. The traditional approach to treatment for
functional constipation includes fecal disimpaction, laxative
therapy, dietary interventions, behavior modification, and child
and family education.13-15
Fecal Disimpaction and Laxative Intervention
Fecal disimpaction can be achieved by oral or rectal medica-
tion. Commonly, polyethylene glycol (PEG) is prescribed by the
child’s pediatrician or pediatric gastroenterologist for a “clean
out” procedure. The use of PEG is shown to be effective in
treating fecal impactions as well as preventing future accumula-
tion of stool.12 Evidence suggests that children using PEG typi-
cally have fewer episodes of fecal incontinence, decreased recur-
rence of fecal impactions, and incur lower health care costs.16-18
E2 Anderson
Copyright © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
Despite the benefits of PEG, further research is needed to deter-
mine the optimal dosing and long-term effects for treating
chronic constipation with PEG in children.19
Dietary Intervention
Common dietary interventions for children with chronic
constipation are addressing overall eating habits, water intake,
and fiber intake.20 The American Academy of Pediatrics rec-
ommends a daily fiber intake formula for all children, which
is the age in years plus 5 as the required number of grams of
fiber/day.21 Fiber intake of less than the recommended daily
amount is a risk factor for constipation; however, there is little
evidence that increasing fiber intake above the recommended
amount results in a decrease in constipation for children.12
Additional general dietary recommendations for children with
chronic constipation are to increase the consumption of specific
fruits and vegetables, decrease the consumption of foods that are
high in fat and sugar, and decrease the consumption of foods
that are constipating (ie, bananas, excessive dairy, applesauce,
and white bread). Daily fluid recommendations are 5 glasses per
day for 5- to 8-year-olds, 7 glasses per day for 9- to 12-year-olds,
and 8 to 10 glasses per day for 13-year-olds and older.22
Behavior Intervention
A combination of behavioral interventions with laxative
therapy is better than behavioral interventions or laxative inter-
ventions alone for children with encopresis.23,24 Due to the
noninvasive nature, behavioral interventions can facilitate active
participation from the child, lower the child’s anxiety, and give
the child positive reinforcement for achievements.
A primary behavioral modification is the implementation
and maintenance of a bowel and bladder-voiding schedule. A
bowel and bladder-voiding schedule involves having the child
sit on the toilet for up to 10 minutes (depending on age) after
meals when the child is most likely to have a bowel movement.25
A bowel and bladder-voiding schedule after eating can be effec-
tive due to the gastrocolic reflex, which triggers colon peristalsis
in response to stretching of the stomach from eating. It is typ-
ically recommended for families to keep a bowel and bladder
log to monitor for constipation (see Appendix 1, Supplemental
Digital Content 1, available at: http://links.lww.com/PPT/A256).
Monitoring for constipation is keeping track of how often the
child defecates, what time of the day or night the child defecates,
and the classification of the child’s stool as a guide for intestinal
transit time. The Bristol Stool Chart is a 7-category scale that
classifies stool based on its appearance and ease of passage.
Types 1 to 2 may indicate constipation, types 3 to 4 are ideal
stools, and type 5 to 7 may indicate diarrhea or urgency.26,27
Another important primary behavioral modification is the
child’s posture on the toilet as children often slouch or sit too
erect causing the pelvic floor muscles to be contracted instead of
relaxed. The puborectalis muscle is especially important in defe-
cation, as it creates a sling around the rectum, which sits con-
tracted and assists in maintaining fecal continence. In normal
defecation, the puborectalis relaxes and opens up the rectum
to allow for easier flow of stool. Children with chronic consti-
pation and anismus (dyssynergic defecation) have a shortened
Pediatric Physical Therapy
puborectalis during Valsalva (straining) than same-age
controls.28 When children slouch (posterior pelvic tilt) with
hip flexion less than 90°, the puborectalis muscle remains
shortened and can inhibit passage of stool. If the child places a
small step stool under the feet, this facilitates a greater than 90°
angle of hip flexion and allows the puborectalis to lengthen and
opens the rectal canal.
Child and Family Education
Educational interventions include child-friendly and age-
appropriate explanations to the child and family about the pro-
cess of normal defecation and the pathology of functional con-
stipation and encopresis. It is important to emphasize that enco-
presis is involuntary and not purposeful behavior from the child.
Providing appropriate educational interventions to the child and
parents can help alleviate anxiety, clarify misconceptions, and
help support the family/child/therapist relationship. There are
many age-appropriate educational resources for children and
families in print, online, and in application form (see Appendix
2, Supplemental Digital Content 2, available at: http://links.
lww.com/PPT/A257). Providing age-appropriate education to
the child and the family about chronic constipation, normal and
atypical defecation, and the physiology of the digestive/urinary
systems can lower anxiety and stress levels, and facilitate pos-
itive dialogue between the child and the parent. Many children
with fecal incontinence are negatively reinforced by shaming,
scolding, or embarrassment. Since fecal soiling is predomi-
nantly involuntary, it is important that parents understand that
the child is not soiling on purpose and should not receive neg-
ative reinforcement. Encouraging parents to positively reinforce
their child for active improvements in their bowel and bladder
continence will improve the child’s self-esteem and self-efficacy.
Through appropriate educational interventions and emotional
support, the child can become independent in internal control
and self-regulation of bowel and bladder functions.29-32
PURPOSE
The purpose of this case report is to describe the implemen-
tation and effectiveness of a multimodal therapeutic approach
used to successfully treat a child with encopresis.
CASE DESCRIPTION
Child is a 9-year-old boy who was home-schooled. He was
referred to outpatient physical therapy by his pediatrician to
address his medical diagnosis of encopresis. Significant med-
ical history includes attention-deficit hyperactivity disorder and
a history of constipation since birth. Medications include Ritalin
and probiotics. Mother reports that her son has been continent
of bladder since 3-years-old; however, he has never been fully
continent of bowel. This was the child’s first episode of phys-
ical therapy intervention; however, he had trialed various strate-
gies in the past including chiropractic, probiotics, diet changes,
and Miralax with little to no improvement in symptoms. At the
time of the evaluation, child and mother reported 1 void (bowel
movement) every 7 to 10 days of hard consistency (1-2 on the
Bristol Stool Chart). Fecal incontinence occurred 5 to 6 times
per week during daytime hours. When using the toilet, mother
Pediatric Physical Therapy
Copyright © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
reported that child is “very quick in and out of the bathroom”
and when asked whether he prefers to sit or stand while voiding
urine, mother states he prefers to stand. Mother reported that
her son ignores the urge to have a bowel movement and strains
when he tries. When asked, the child states, “I can’t feel it until
it’s too late.” Child is aware of his encopresis and is starting to
demonstrate some embarrassment with avoidance of peer activ-
ities. Mother was concerned that this will affect his confidence
and social skills. The mother gave a subjective rating on the per-
ceived severity of the problem as a 10 on a 0- to 10-point visual
analogue scale, with 10 indicating the highest level of severity.
Institutional Review Board and Consent
This case report was approved by the Institutional Review
Board of the University of Jamestown. Child’s mother provided
informed consent and the child assented.
Clinical Findings
Physical therapy systems review revealed no concerns in
cognition/communication, cardiopulmonary, integumentary, or
neuromuscular systems. The child had no complaints of pain,
although he stated that he does have painful bowel move-
ments. Posture screen was normal for sitting and standing.
Spinal Galant primitive reflex was integrated bilaterally. Range
of motion screen for lower extremities was normal, with min-
imal restriction in right lower extremity hip external rotation.
Manual muscle testing was normal bilaterally. Light touch was
intact for lower extremity dermatomes. Child and mother con-
sented to an external pelvic floor examination by the physical
therapist. From the external pelvic floor examination, the per-
ineum appeared healthy with no redness or irritation; how-
ever, the rest position of the anus appeared abnormally con-
tracted. Initial pelvic floor contraction demonstrated poor pelvic
floor muscle awareness with 100% accessory muscle substi-
tution of gluteals, abdominals, and quadriceps. Relaxation of
pelvic floor musculature after contraction was minimal. There
was minimal eccentric lengthening of the pelvic floor with a
mild Valsalva maneuver and the anal wink was present bilat-
erally. Surface electromyography (sEMG) electrodes for biofeed-
back were placed around the anus, and a grounding electrode
was placed on the child’s right ischial tuberosity. Using Telesis,
resting muscle activity was recorded for 60 seconds with an
average of 2.2 μV. During baseline recording of resting pelvic
floor muscle tone, the child had difficulty maintaining a resting
position and demonstrated frequent pelvic floor contractions.
Contract/relax exercises of pelvic floor muscles were recorded
with the prompt for 5-second contract and 10-second relax.
The child performed a pelvic floor muscle contraction for 1-
second duration while using large accessory muscles each repe-
tition. Contraction average was 43.4 μV and resting average was
4.9 μV.
Therapeutic Interventions
The child was seen for physical therapy treatment for 8 ses-
sions in a 4-month period. Sessions were prescribed at once per
week and then decreased in frequency as the child improved.
Physical Therapy for a Child With Encopresis E3

Interventions, Patient Outcomes, and Home Exercise Program by Visit
Visit Interventions
1 Clinical evaluation
sEMG biofeedback in supine position for
baseline measurements of PF resting tone
and contract/relax
2—45 min Read children’s book I Can’t, I Won’t, No
Way!33
On toilet: voiding education on single void.
Education on double voiding.
Diaphragmatic breathing × 5.
Supine contract/relax PF exercises of
2/10 × 10 reps × 2 sets with Q-tip
facilitation of anal reflex
3—40 min Supine contract/relax PF exercises of
2/10 × 10 reps × 2 sets with Q-tip
facilitation of anal reflex
Performed and demonstrated light
abdominal massage to child and mother
Watched GI-Kids educational video “The Poo
in You” on the digestive system and
constipation34
Discussed proper sitting posture on the toilet
Discussed water and fiber intake
4—45 min Supine contract/relax PF exercises of 3/10 ×
15 reps × 2 sets with Q-tip facilitation of
anal reflex
Read children’s book Look Inside Your Body.37
Supine and sitting diaphragmatic breathing
× 10
5—45 min Supine contract/relax PF exercises of 3/10 ×
15 reps × 2 sets with Q-tip facilitation of
anal reflex
Reviewed relaxation exercises on toilet
(breathing, trunk flexion/extension)
6—30 min Progress note visit
Reviewed therapy and patient goals and
progress with mother and child
Sitting contract/relax PF exercises of 3/10 ×
15 reps × 2 sets
Diaphragmatic breathing with trunk
flexion/extension in sitting × 5 reps
Discussed discharge plan with mother and
child
7—45 min Supine contract/relax PF exercises of 4-5/10
× 8 reps
sEMG biofeedback in sitting with
contract/relax exercises of 3/10 × 10
Discussed upcoming discharge with mother
and child
8—30 min Reviewed progress with child and mother
Gross motor activities while cuing for PF
contraction during moments of impact
(jumping) or increased intra-abdominal
pressure
9—60 min Reviewed goals for discharge with child and
mother
sEMG biofeedback in supine with PF resting
tone and contract/relax recorded
Graduation from therapy activity
Abbreviations: BM, bowel movement; N/A, not available; HEP, home exercise program; PF, pelvic floor; sEMG, surface electromyography.
E4 Anderson
Copyright © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
TABLE 1
Patient Outcomes
N/A
Returned intake/output log
100% with HEP
Decreased accessory muscle use noted
during contract/relax
1 d without a stool leak
BM on the toilet 2 times
Independently informed mother that he
“had to go” 1 time
Decreased accessory muscle use noted
during contract/relax
BM on the toilet 4 times
Only slight smearing in underwear
No longer resisting cues to use the
bathroom
7 d without stool leak
No accessory muscle use noted
7 d without stool leak or smear
Independently informed mother that he
“had to go poop” 1 time
Verbally able to describe how he knew he
needed to void a BM
Decreased frequency of visits to every
2 wk
8/11 goals met
2 wk without stool leak or smear
Independently uses the bathroom for
urine and BMs
Able to maintain supine PF
contraction × 4-5 s
Able to maintain sitting PF
contraction × 3 s
2 wk without stool leak or smear
Able to participate in all home-school and
community activities without a leak
Decreased frequency to 1 more follow-up
visit in a month to assess generalization
of skill prior to discharge
11 out of 11 goals met
1 mo without stool leaks or smear
Independent in home program
Independent in continence and toileting
Decreased PF resting tone
Improved PF isolation and strength during
contractions
Home Exercise Program
Intake/output log (see Appendix 1,
Supplemental Digital Content 1, available
at: http://links.lww.com/PPT/A256)
Diaphragmatic breathing
Cat/cow exercise
Diaphragmatic breathing on toilet × 5
Cat/cow exercise × 10/d
Using the toilet every 2-3 h
Sitting on the toilet after supper for
3-5 min/d
Supine PF contract/relax exercises × 10/d
Increase water intake
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Coloring sheets of digestive and urinary
systems35,36
Supine PF contract/relax exercises × 10/d
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Coming up with words to describe “having
to go”
Supine PF contract/relax exercises × 15/d
Diaphragmatic breathing on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 2-3 h
Supine PF contract/relax exercises × 15/d
Diaphragmatic breathing with trunk
flexion/extension on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
Sitting PF contract/relax exercises × 10/d
Diaphragmatic breathing with trunk
flexion/extension on toilet × 5
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
Sitting PF contract/relax exercises during
every car ride
Sitting on the toilet after supper for 3-5 min
Using the toilet every 3-4 h
Continue with PF exercises as able
Continue to monitor fiber and water intake
Continue to monitor for constipation
Pediatric Physical Therapy
The first 2 visits focused on body awareness, purpose, and isola-
tion of the pelvic floor muscles, and initiating a voiding schedule
every 2 to 3 hours. By the third visit, the child had been con-
tinent for 1 day and had used the toilet for a bowel movement
twice during the week. He preemptively told his mother that he
had to have a bowel movement before using the bathroom, indi-
cating the child was more aware of his body signals. By visit 4,
he had 4 bowel movements on the toilet and had not had any
full stool leaks, only smearing. Visits 5 and 6 focused on making
a sustainable routine of all his home programming activities, as
he had been fully continent since visit 4. Frequency of visits
decreased by visit 7, as the child continued to be fully continent
and discharge planning was discussed with child and mother.
Visits 8 and 9 were focused on generalization of skills, discharge
planning, and celebration of progress. Therapeutic interventions
are in Table 1.
OUTCOMES
Upon discharge, the child met 11 of 11 therapy goals
(Table 2). As there are no valid and reliable outcome measures
for encopresis, clinical outcomes were used to measure
progress. sEMG biofeedback using Telesis revealed a resting
muscle activity average of 1.8 μV. The child was able to perform
a pelvic floor muscle contraction for 5 seconds in duration with
no accessory muscle use. Contraction average on discharge
was 4.1 μV and resting average was 1.5 μV. The child is now
aware of his pelvic floor muscles and their purpose and can
answer simple questions about how the gastrointestinal/urinary
systems work together for continence. He feels when he
needs to have a bowel movement and describes how that
feels to his physical therapist and parents. The child is now
able to attend home-school and church events without fecal
incontinence. The child participated fully during all physical
therapy sessions and was highly motivated to improve. The
child and family were 100% compliant in home programming.
Mother states that he is fully continent of bowel in all settings
and independently uses the bathroom to void when he feels
his body’s signals. Mother states that the child’s self-esteem
and confidence have also improved since becoming fully
continent.
DISCUSSION
In 8 treatment sessions, the child went from experiencing
fecal incontinence 5 to 6 times per week to becoming fully con-
tinent of bowel in home and community settings. In addition to
current practices, this child responded positively to use of media
(device applications and videos), games, coloring anatomical
diagrams, and visualization activities throughout his treatment
(see Appendix 2, Supplemental Digital Content 2, available at:
http://links.lww.com/PPT/A257). The available literature rec-
ommends behavioral interventions such as a toileting schedule
and posture education; and with help from current technology,
there are now many age-appropriate activities to encourage and
motivate children to improve their continence. Since encopresis
is a complex and multisystem condition, pediatric physical ther-
apists are well equipped to provide comprehensive and age-
appropriate care to these children. Our additional knowledge of
behavioral interventions and child-friendly treatments can help
make the difference for overcoming this embarrassing and diffi-
cult disorder.
This case report provides a description of physical therapy
treatments for a child with encopresis by highlighting a mul-
timodal delivery of care to motivate and involve the child and
parents in treatment. A limitation of this case report is that cur-
rently there are no gold standard outcome measures to use for
children with encopresis. Despite the limitation, this case report

TABLE 2
Patient Goals by Visit

Achieved by
Patient Goals Visit Count

Patient and parents will complete weekly home programming activities and return the activities or data by the next session, 90% of 2
opportunities
Patient will complete assessment of pelvic floor contraction/relaxation using sEMG biofeedback while voiding on the toilet during a 2
physical therapy session
Patient will improve pelvic floor muscle endurance in supine position to 3-s contract, 5-s relax, for 5 consecutive sessions to improve 4
muscle strength and endurance for continence
To increase pelvic floor muscle isolation, patient will decrease compensatory strategies of using accessory muscles 100% of trials, to a 5
level of little to no observed accessory muscle activation while completing contract/relax exercises in supine position
Patient will decrease bowel leakage from a level of 5-6 times per week to a level of no more than 2-3 times per week 5
Patient will improve awareness of leakage as evidenced by indicating to an adult that he had a leak without verbal cues from sibling or 5
parent, 50% of opportunities
Patient will improve sensation and awareness of urinary/bowel urge as evidenced by being able to describe the sensation so an adult 6
can understand
Patient will attend community events with no more than one bowel or bladder leakage, across all activities 6
Patient will demonstrate understanding of urinary and digestive systems as evidenced by completing simply drawing or coloring of 8
systems
Patient will improve pelvic floor muscle endurance in sitting to 3-s contract, 5-s relax, for 5 consecutive sessions to improve muscle 8
strength and endurance for continence
To increase pelvic floor muscle isolation, patient will decrease compensatory strategies of using accessory muscles 100% of trials, to a 8
level of little to no observed accessory muscle activation while completing contract/relax exercises in sitting.

Abbreviation: sEMG, surface electromyography.

Pediatric Physical Therapy Physical Therapy for a Child With Encopresis E5

Copyright © 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
suggests the importance of age-appropriate motivating activities
to improve outcomes in children with fecal incontinence.
CONCLUSIONS
Treating a child with encopresis is challenging due to the
complex nature of the condition. Children experiencing enco-
presis can experience decreased self-esteem, decreased confi-
dence, and negatively affected social relationships due to embar-
rassment and shaming. Retentive encopresis is largely caused
by chronic constipation and the duration of treatment is often
months to years. It is important that children and families are
provided age-appropriate educational interventions and are pos-
itively supported throughout the duration of the treatment. This
case report highlights a child who benefitted from multimodal
physical therapy treatment of his retentive encopresis through
pelvic floor muscle awareness, strengthening and coordination
exercises, behavioral adaptations, diet modification, and use
of media, art, and interactive visualization activities. This case
report adds to evidence-based practice by demonstrating that
pediatric age-appropriate educational and motivational tools are
readily available and should be used in conjunction with current
practice to improve active participation and compliance during
treatment of retentive encopresis in the pediatric population.
ACKNOWLEDGMENTS
Thank you to everyone for their contributions—Dr Gregory
Gass, Dr Mitch Wolden, Dr Sara Voorhees, and Marilyn Hed-
berg, Beyond Boundaries Therapy Services.
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