Multifaceted Bowel Management Programs

Multifaceted programs include several different interventions combined in a bowel routine to promote effective and timely fecal evacuation.

Discussion

A combination of interventions, or a multi-faceted program, as components of a comprehensive bowel routine, is often recommended for the management of neurogenic bowel following SCI. These include dietary modification, anorectal stimulation, manual evacuation, timing the performance of the bowel routine to follow food intake (thus taking advantage of gastro-colic and recto-colonic reflexes), and a variety of pharmacological agents, oral and rectal. Unfortunately, only a limited number of studies evaluated the effects of ‘multi-faceted programs’ on bowel function in people with SCI that were comparable. From the results of three pre-post studies and one RCT, it is apparent that response to the protocols is highly individualized. Badiali et al.’s (1997) multifaceted bowel management program effectively reduced gastrointestinal transit time while Correa and Rotter’s (2000) program reduced the incidence of difficult evacuation. Coggrave et al. (2006a) modified the bowel management program originally proposed by Badiali et al. (1997) by including an additional step of manual evacuation and found a significant decrease in the number of bowel movement episodes requiring laxatives (from 62.8% to 23.1%) and a significant decrease in mean duration of bowel management episodes. As these three studies incorporated several factors into the bowel management programs including diet, fluid consumption, and routine bowel practice, it is not possible to determine the key factor.

Coggrave and Norton (2010) conducted a 6-week RCT in which the management program was systematically applied from less invasive to most invasive and was compared to the control group’s usual bowel care. The authors wanted to examine whether systematic use of less invasive interventions (i.e., the first few steps in the management program: simulation of gastro-colic reflex, 20 min before starting bowel care, abdominal massage, perianal digitation, anorectal digitation, and glycerin suppositories), could reduce the need for oral laxatives or more invasive interventions such as rectal stimulants and manual evacuation. However, there was no difference between the groups in the level of intervention at which bowel evacuation was completed (p=0.4-0.1). There were also no significant differences in time to first stool, percentage of BM episodes where stool was passed, stool consistency, or diet and fluid intake. The need for oral laxatives and invasive interventions was not reduced (p=0.4). The only significant group difference was that bowel care was significantly longer in the experimental group than the control group at week six (p=0.05). Differences between this RCT and previous studies mentioned could be due to the samples; in the earlier studies, the participants were younger and injured for less time – both factors that are commonly associated with less frequent use of medicated rectal stimulants, manual evacuation, and oral laxatives (Coggrave et al. 2009).

Zhang et al. (2018b) investigated a quantitative assessment-based nursing approach which included adjusted nurse-patient ratios, dietary modification, abdominal massage, abdominal muscle exercise (breathing and defecation), digital rectal stimulation, and manual evacuation for people with severe constipation in comparison to regular nursing (dietary education, disease health education, psychological care, and catharsis by drugs or artificial means). Findings showed that abdominal distention, constipation, drug-dependency, defecation time, and fecal incontinence were significantly lower compared to controls (p<0.05). In addition, physical functioning, bodily pain, general health, vitality, social functioning, and mental health significantly increased over time (p<0.01).

Hwang et al. (2017) interviewed 131 people with pediatric onset SCI to see what multi-faceted programs people were using re: bowel management. Initially, rectal suppositories/enemas, digital stimulation, oral laxatives (or a combination of these methods) were most common. Interestingly, changes in the type of bowel program over time depended on level and completeness of injury. Paraplegia was associated with a 5x higher likelihood of using manual evacuation (p=0.002), decreased odds of using rectal suppositories or enemas (90% less likely; p<0.001) and oral laxatives (65% less likely; p=0.012) compared to tetraplegia. People with complete SCI were 3x more likely to use oral laxatives over time compared to people with incomplete SCI (p=0.012).

Johns et al. (2021) explain the importance of bowel management education for people to gain independence and improve their quality of life. One case consultation (Cabigon et al. 2019; N=27) investigated the implementation of a peer mentor program for people with SCI finding bowel management difficult. Peer mentors, or people who had been living with injury for at least two years, had a strong ability to manage their care, and increase engagement with their community. The people who received the peer mentorship rated the program highly. The majority felt that this program helped them understand the importance of bowel management, recognize their own future independence through the peer mentor, and would recommend the program to others. A cohort study by Borsh et al. (2019) implemented an education program for bowel after SCI; they found that patient knowledge increased significantly from pre-education to post-education including understanding what a SCI is (p = 0.02), level of injury (p = 0.016), use of suppositories (p = 0.008), and digital stimulation (p = 0.001).

Conclusion

There is level 1 evidence (from one RCT; Zhang et al. 2018b) that people who received quantitative assessment-based nursing improved quality of life and scores for bloating, constipation, prolonged defecation, defecation drug dependence, and fecal incontinence compared to those who received regular nursing, as well as higher satisfaction and quality of life.

There is level 1 evidence (from one RCT; Coggrave & Norton 2010) that systematic use of less invasive interventions does not reduce the need for oral laxatives or more invasive interventions such as rectal stimulants and manual evacuation.

There is level 1 evidence (Coggrave & Norton 2010) that use of a multifaceted bowel management program may increase the duration of bowel management.

There is level 2 evidence (Borsh et al. 2019) that patient knowledge increased significantly from pre-education to post-education including understanding of what a SCI is and with bowel management techniques.

There is level 2 evidence (Ozisler et al. 2015) that bowel programs administered depending on upper (UMN) or lower (LMN) motor neuron bowel dysfunction classification significantly decreased NBD scores in people with both motor complete and motor incomplete SCI, though there were no significant change in % of motor incomplete SCI patients with gastrointestinal problems.

There is level 4 evidence (from three pre-post studies – Coggrave et al. 2006a; Correa and Rotter 2000; Badiali et al. 1997) that multifaceted bowel management programs may reduce GI transit time, incidences of difficult evacuations, and duration of time required for bowel management.

There is level 5 evidence from one study (Hwang et al. 2017) that bowel management changes over time with increased use of manual evacuation, colostomy, and oral laxatives, and decreased use of rectal suppositories/enemas particularly in individuals with paraplegia.

There is level 5 evidence (Cabigon et al. 2019) that peer mentorship may be a feasible education method for neurogenic bowel management.

There is level 5 evidence (Adriaansen et al. 2015) that the most used defecation methods were digital evacuation (35%) and mini enemas (31%).

There is level 5 evidence (Khadour et al. 2023) that most of the respondents performed their bowel movement daily (52.0%), defecation time was 31–60 min among 23.8% of them, 50.7% used medication (drops or liquid) to treat constipation, and 57.5% used digital stimulation more than once per week to boost the bowel evacuation.

There is level 5 evidence (Tate et al. 2016) that less bowel dysfunction was associated with participants using laxatives/oral medications as a main method of bowel management (P<.05), having a higher fiber intake (p<.05), and lower scores on the FISI (p<.0005).