Hypothesis / aims of study
Nocturnal enuresis (NE) is defined as “an unconscious leakage of urine during sleep, at least 3 times in a week, in children aged 5 years and above in the absence of congenital or acquired defects of the CNS. The prevalence of Nocturnal Enuresis (NE) is 7.61 % - 16.35% in India.[1] Children with NE experience chronic stress having a negative impact on their self-concept & self-esteem leading to psychological problems, affecting their academic performance. [2, 3, 4] Thus, this study intends to evaluate the effect of school based yoga program on NE in 6-10 year old children.
Study design, materials and methods
This was a randomized controlled trial conducted in 2 phases from July 2018- February 2019 targeting children of the age group 6-10 years having nocturnal enuresis. In the 1st phase, screening for nocturnal enuresis was done. In the 2nd stage, an intervention program was given for children with nocturnal enuresis. Ethical clearance was obtained from the Institutional Ethical Committee.
A pamphlet containing details of free nocturnal enuresis camp was distributed to 10,500 children from the 20 schools chosen based on convenience and every child was requested to show it to their parents. Interested parents whose children had symptoms of NE were requested to attend the camp in the Bedwetting clinic of Pediatric Urology Department of a tertiary care hospital. About 70 enuretic children along with their parents reported to the camp. They were educated about NE, examined by the urologist and were prescribed medications and referred to the physical therapy department. The Principal investigator (Physical Therapist) then explained the details of the study to the parents. All the children of willing parents in the age group 6-10 years having NE were included in the study. Children with diagnosed cases of Cerebral palsy, metabolic disorders, genetic disorders; Urinary system problems like UTI, Diurnal enuresis, urge incontinence were excluded.
47 enuretic children were recruited based on inclusion criteria were randomly assigned to Yoga group and Control group by envelope method. Both the groups were prescribed mainstream medication (MINIRIN® Melt 120mcg); behavioural modification therapy (Fluid restriction, Timed voiding, Reward system); Bladder training using distraction techniques and Start-stop exercises. Structured school based Yoga program of 45 mins was given twice a week for 6 weeks to the Yoga group, in addition to medication and Behavioural therapy. Yoga program for NE was designed in consultation with a certified yoga instructor and focused on a set of 11 postures like Chakrasana, Uttanasana, Paschimottanasana, Baddha Konasana, Dhanurasana, Ardha Matysendrasana, Suryanamaskar, Padmasana, Anulom-Vilom Pranayama, Yoga mudra and Shavasana as well as a pamphlet containing written description and pictures of the yogic postures taught in the class was given. Parents were requested to make their children practice these postures at home and regular feedback was taken from them through telephone calls. Demographic details, Child Behaviour Checklist (CBCL) to assess their behaviour, Pediatric Incontinence Questionnaire (PIN-Q) scores to assess their quality of life and voiding frequency with the help of a voiding diary were recorded during pre-post intervention.
Sample size: 46 Participants (23 in each group)
n = 2SD2/d2 (Zα+Zβ) 2; where S1 = 1.6, S2 = 2.3, d = 2.0, 𝑍α = 1.96
with 𝑍β = 1.642 at 95% power and 5% α error
Interpretation of results
School based Yoga intervention showed superior results than conventional treatment on nocturnal enuresis in 6-10 year old children. The average number of bedwetting frequency reduced significantly at the end of 6weeks of intervention and continued effect was obtained 1 month later also in the yoga group whereas there were relapses post 6 weeks of intervention in the some participants in Control group.
According to NICE guidelines, Combination therapy have given better results in enuretic children, thus , in our study , combination therapy was adopted as it has not been practiced collectively.[5] Drugs combined with Behavioural therapy have provided better results as compared to either alone to achieve better and long term results which was also observed in our study. In the present study, Behavioral therapy aided in improvising the participants voiding habits by correcting their extrinsic body mechanisms, improving their awareness of pelvic organs and their physiologic functions and encouraging active participation from them. Pelvic floor muscle training has an important influence on reducing the child’s voiding frequency by increasing the strength of pelvic muscle control and bladder capacity which was given in the form of Start-stop exercise (Kegal’s) and Yoga therapy in our study.[5, 6,]
QoL also improved post intervention that can be attributed to reduction in night-time bedwetting, reduced sleep disturbances, improved behavioural and emotional states of the child as well as reduced parental stress which indirectly affects the child’s mental and emotional states was observed in all participants.
Yoga therapy helps in activating the CNS, regulating the ANS, strengthening the pelvic floor muscles and thereby decreasing the lower urinary tract symptoms, thereby, showing significant percentage change of voiding frequency reported in the Yoga group as opposed to the control group.[7, 8] Yoga and meditation assists in achieving the balance of increased melatonin release from the pineal gland by influencing the endocrine system as variations in the melatonin circadian rhythmicity is linked to various psychosomatic disorders, anxiety & sleep problems. [9] This could be the reason for improved scores on all the behaviour and emotional domains of CBCL in the present study.
This study also shows that the reduction in voiding frequency was observed from 3rd week onwards of the intervention period which suggests that a minimum of 3 weeks of intervention program is required for its successful implementation in children with NE.