Exercise effects on interstitial cystitis: two case reports, WB Karper

Tags: IC, exercise program, interstitial cystitis, muscle strengthening, day, exercise protocol, IBS symptoms, exercise session, IC symptoms, Journal of Personality Assessment, Case Reports William B. Karper, painful bladder wall, painful bladder, William B. Karper, Behavioral Health and Fitness Laboratory, IC exercise study, National Institute of Diabetes Digestive, Exercise and Sport Science, University of North Carolina at Greensboro
Content: Exercise Effects on Interstitial Cystitis: Two Case Reports William B. Karper
R ecently, Ratner and Perilli (2003) presented a review of interstitial cystitis (IC). They described a chronic, inflammatory, disabling, painful bladder wall syndrome, for which management is often challenging and controversial. The cause of IC is unknown, and despite research efforts there is no cure or optimal therapy available. Propert, Payne, Kusek, and Nyberg (2002) suggest that the disease may afflict as many as 37 to 67 per 100,000 persons in the United States. As a result of a local urologist's clinical observations and support, a small, multiple exercise Case Study project was undertaken to determine if exercise might benefit patients with IC. This decision was informed by the professional literature, which suggests that exercise may aid in alleviating chronic pain (Abrams, 1990; Janal, 1996; O'Connor & Cook, 1999; Weinberg & Gould, 2003). Also, the author's professional experiences drove speculation that strengthening the pelvic area and associated muscle groups might support or promote dynamic posture, which could affect bladder carriage and function. William B. Karper, EdD, is an Associate Professor, Behavioral health and Fitness Laboratory, Department of Exercise and Sport Science, School of Health and Human Performance, University of North Carolina at Greensboro, Greensboro, NC.
Interstitial cystitis (IC) is a painful bladder condition. Because of a reported link between exercise and pain reduction, a case study analysis was conducted to explore exercise effects on IC. Exercise was provided 3 days per week for 6 months.Two subjects appeared to have benefitted from the program. Implications for future research are discussed.
Six women with IC diagnosed using the National Institute of Diabetes Digestive and Kidney Diseases criteria, and findings from cystoscopic distention, were entered into a 6month, 3 days per week, IC exercise study. The outcomes of two women who completed the program are reported in this article. Description of Subjects Subject 1 was a 68-year-old widow with grown children. She was 5 feet, 10 inches tall, weighed 174 pounds, and had IC for approximately 48 years. Other health problems included knee osteoarthritis and spinal osteoporosis. Her medication regimen consisted of Ditropan® (10 mg once per day), Elmiron® (100 mg once per week), Lipitor® (100 mg once per day), Fosamax® (70 mg once per week), acetaminophen (500 mg once per day), calcium (600 mg once per day), Finest Nature Fish Oil® (100 mg once per day), coenzyme Q10 (one capsule once per day), glucosamine (500 mg once per day), chondroitin (400 mg once per day), and one Tylenol PM® each night. She engaged in an olderadult exercise program 3 days per week, while also participating in the IC exercise program.
The other program, which took place the same days as the IC program, consisted of calisthenictype muscle strengthening and range of motion activity. This subject attended the IC exercise program 82% of the time. Subject 2 was 44 years old and married with young children. She was five feet, four inches tall, weighed 119 pounds, and had IC for approximately 6 years. She also had significant problems with irritable bowel syndrome (IBS). Her medication regimen consisted of Elmiron (100 mg 3 times per day), hydroxyzine (25 mg once per day), dicyclomine (10 mg 3 times per day), Ditropan (10 mg once per day), Ortho Evra (one patch per week), Canasa® (500 mg once every other day), calcium (600 mg 2 times per day), Theragram M® multivitamin (one tablet per day), butalbital (as needed), Citrucel® (two tablets once per day), and Prelief® (as needed). She did not engage in organized exercise outside of the IC exercise program and attended the IC program 68% of the time. Clinical Interaction (Program and Testing) The subjects began each exercise session by walking at a
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Table 1. Pretest and Posttest scores/Ratings
Tests Tests Quarter Mile Walk 1 Chair Stand 2 Wall Pushup 3 Grip Strength 4 Seated Good Morning 5 Sit and Reach 6 Global IC Symptoms 7 Perceived Stress 8 Perceived Depression 9 Perceived QOL 10 IC Symptoms and Problems 11 Satisfaction with Life 12 Total Bowel Pain 13
Pretest
Subject 1 3:25
Subject 2 3:55
11
12
13
13
26
23
7
6
14
13
4
4
6
4
7
3
6
4
First Half of Program
Average
Average
15
17
31
16
7
4
Posttest
Subject 1 4:30
Subject 2 3:55
10
14 *
15 *
15 *
25
24 *
18 *
15 *
15 *
17 *
6*
5*
2
3
3
5*
6
5*
Second Half of Program
Average
Average
11 *
11 *
26
16
7
4
1. Minutes and seconds (lower time good) 2. Number of repetitions in 30 seconds (higher score good) 3. Number of pushups in 30 seconds (higher score good) 4. Best of three maximal attempts in Kgm (higher score good) 5. Number of repetitions in 30 seconds (higher score good) 6. Number of inches reached on the sit and reach box (higher score good) 7. 1 very, very bad; 7 = very, very good 8. 1 = very, very bad; 7 = very, very good 9. 1 = very, very bad; 7 = very, very good 10. 1 = very, very bad; 7 = very, very good 11. Average score on questionnaire (lower score good) 12. Average score on scale (higher score good) 13. Average rating: 1 = very, very bad; 7 = very, very good
* Improvement from pretest to posttest or between first half of program average and second half of program average.
moderate pace for approximately 10 to 15 minutes. This was followed by 35 to 40 minutes of light dumbbell (3-4 lbs) strength training, range of motion exercises, balance exercises, static bridging core strengthening exercises (on mats), and calisthenic exercises. Most strengthening and calisthenic exercises were done in 2 to 4 sets (8-10 repetitions per set), and most static/bridging and balance work was held for approximately 10 to 15 seconds, sometimes performing two sets. The precise daily protocol was dependant upon subjects' IC dis-
comfort at each session. Subjects were evaluated on Physical Fitness, IC symptoms/problems, stress, depression, quality of life (QOL), and bowel pain. Fitness, IC symptoms, stress, depression, and QOL were evaluated at the beginning, midpoint, and end of the program. Pretest and posttest scores/ratings are reported (see Table 1). Also, other types of IC symptoms/problems and QOL measures were taken every 2 weeks and bowel pain was rated each month. The averages of scores/ratings taken during the first half of the program were
compared to the averages of scores/ratings taken during the second half of the program for these three factors. Walk capacity was measured with a 440-yard test, a modified form of an 880-yard test (Osness et al., 1990). Lower body strength was measured with the chair stand test (Rikli & Jones, 1999). Upper-body strength was measured using a homemade, standardized wall pushup test. Grip strength was measured with a grip dynamometer test (Stoeltig, Chicago, IL). Lower-back strength was measured with a seated good
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morning test and lower back range of motion was measured using a sit and reach box test (Country Technology, Inc, Gay Mills, WI). Global IC symptoms, perceived stress, perceived depression, perceived QOL, and total bowel pain were measured with an analog scale from 1 to 7 (1 = very, very bad; 7 = very, very good). IC information was also collected using an adapted form of the IC Symptom and Problem Questionnaire (O'Leary, Sant, Fowler, Whitmore, & SpolaricrKroll, 1997). QOL information was collected using the Satisfaction With Life Scale (Diener, Emmons, & Larsen, 1985). Results Data in Table 1 show that Subject 1 improved on the wall pushup test, seated good morning test, sit and reach test, global IC symptoms rating, and the IC Symptom and Problem Questionnaire. Subject 2 improved on the chair stand test, wall pushup test, global IC symptoms rating, perceived QOL rating, perceived depression rating, and the IC symptom and problem questionnaire. Additionally, Subject 1 revealed that she was certain the IC exercise protocol, added to her other exercise, greatly contributed to less chronic bladder pressure and urination urgency than was previously the case. Also, negative exercise effects were not observed or reported by these subjects. Clinical Implications These case studies were conducted to find out if exercise would help these patients with IC. It was thought that positive outcomes would provide support for pursuing future study into the relationship and impact of exercise on IC. Given the considerable morbidity associated with IC, it was reasoned that any positive change on the outcome measures would be potentially important to the subjects and to the author's decision concerning continuation with this line of inquiry. Results appeared posi-
tive enough to continue this work. Presently, another multiple case study (N=4) is being conducted to refine the exercise protocol for use in a randomized, controlled interventional trial. There are, of course, necessary considerations regarding research design relative to producing good results with this difficult population. Among them is the fact that there is no prior research to provide guidance about the type, frequency, intensity, or duration of exercise for those with IC. Also, the researcher is challenged to determine how to promote adherence to an exercise protocol, when many patients with IC suffer with symptoms to some degree all of the time. As one quickly learns, it is difficult to motivate these patients to exercise body parts that hurt, and this ultimately affects exercise session attendance. Given that much has been written about exercise effects on Psychosocial factors and their importance in pain management, it is also important to examine the relationship between psychosocial changes and changes relative to symptoms of IC as a result of an exercise program. Control or account for comorbid conditions is also crucial. Special attention should be given to IBS and widespread, muscular-skeletal pain, both of which are common among patients with IC. Since exercise can positively affect widespread pain in some people, this increased sense of well-being could affect perception of IC severity. Subject 2, for example, claimed that her IBS flare-ups caused more severe IC symptoms and that she often could not distinguish between the two conditions during flareups. Is it possible, then, that her overall positive fitness outcomes had a more direct affect on IBS symptoms yet had no affect on her IC symptoms? Conclusions Patients with interstitial cystitis need treatments that help them feel better. The results from these two subjects are positive
enough to continue research exploration into the link between exercise and IC. Urologic professionals are encouraged to investigate the efficacy of exercise as treatment for this condition. · References Abrams, S. (1990). Incidence ­ hypothe- sis ­ epidemiology. In M. StantonHicks (Ed.), Pain and the sympathetic nervous system (pp. 1-16). Boston: Kluwer Academic Publishers. Diener, E., Emmons, R.A., & Larsen, R.J. (1985). The satisfaction of life scale. Journal of Personality Assessment, 49, 71-75. Janal, M.N. (1996). Pain sensitivity, exercise and stoicism. Journal of the Royal Society of Medicine, 89, 376381. O'Connor, P.J., & Cook, D.B. (1999). Exercise and pain: The neurobiology, measurement, and laboratory study of pain in relation to exercise in humans. In J.O. Holloszy (Ed.), Exercise and sport sciences reviews (pp. 119-166). Philadelphia: Lippincott Williams & Wilkins. O'Leary, M.P., Sant, G.R., Fowler, F.J., Whitmore, K.E., & Spolaricr-Kroll, J. (1997). The interstitial cystitis symptom index and problem index (adapted version). Urology, 49(Suppl. 5A), 58-63. Osness, W.H., Adrian, M., Clark, B., Hoeger, W., Raab, D., & Wiswill, R. (1990). Functional fitness assessment for adults over 60 years (a field based assessment). Reston, VA: American Alliance for Health, physical education, Recreation and Dance. Propert, K.J., Payne, C., Kusek, J.W., & Nyberg, L.M. (2002). Pitfalls in the design of clinical trails for interstitial cystitis. Urology, 60, 742-748. Ratner, V., & Perilli, L. (2003). Interstitial cystitis: An updated overview. Urologic Nursing, 23(2), 107-110. Rikli, R.E., & Jones, C.J. (1999). Development and validation of a functional fitness test for communityresiding older adults. Journal of Aging and physical activity, 7, 129161. Weinberg, R.S., & Gould, D. (2003). Foundations of sport and exercise psychology (3rd ed.). Champaign, IL: Human Kinetics.
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