Assistive Devices and Exercise

In addition to standard bowel protocols and pharmacological modalities, numerous devices and activity-based therapies were evaluated as means to improve bowel evacuation in individuals with SCI. These include standing and ambulation protocols, biofeedback, a wooden toothbrush, and a modified toilet seat.

Discussion

Johns et al. (2021) recommend regular physical activity for people with SCI, as it may have positive effects on bowel function with other health benefits. One cross-sectional study found that majority of people with SCI who exercised less than 30 minutes each week report more time spent on bowel management in comparison to people who exercise at least one hour a week (Forchheimer et al. 2016). Standing programs, aerobic arm ergometers, and assisted walking (with bodyweight support or exoskeletons) may be used to facilitate exercise (Johns et al. 2021). Most studies report the effects of activity-based therapies on bowel-related outcomes for people with SCI as a secondary measure.

Kwok et al. (2015) tried to replicate these results with 20 participants with SCI in a crossover trial with regular use of a standing frame (30 min, 5 times per week for 6 weeks) and found no difference in time to first stool or time to complete bowel care between the treatment and control phase.

Gorman et al. (2021) investigated exoskeletal-assisted walking (using ReWalk and Ekso powered exoskeleton devices) and bowel management/function as a secondary outcome measure. For people in the intervention group, there was some reduction in bowel evacuation time and normalization in stool consistency reported after 36 sessions of exoskeleton-assisted walking. Chun et al. (2020) reported similar findings with exoskeleton-assisted walking 3-4 sessions per week within 12-14 weeks. Brinkemper et al. (2021) also reported improvements in bowel incontinence and constipation after locomotion therapy/exoskeleton training with a HAL Robot Suit.

In two small studies, Hubscher et al. (2018 and 2021) found that most variables of bowel dysfunction were not different between arm crank erg, BWSTT, or standing groups. Medication usage, bowel emptying method, frequency of fecal incontinence, frequency of defecation, oral laxative usage, and NBD score changes were not statistically significant. The only significant difference between groups was time required for defecation; participants in locomotor training on a BWSTT for 80 daily one-hour sessions had significantly decreased (p=0.022) time required for defecation vs. those in weight-bearing standing for one hour every day. Similarly, Huang et al. (2015) found reductions for those doing RAT vs. those doing BWSTT on defecation time ((93.0±14.7 to 64.5±11.6 min) and reduction in enema dose (68.1±10.7 to 38.8±12.4 mL; p<0.01). Unfortunately, the study was also small, the study took place within 6 months of injury, and there were no data on level or completeness of injury for participants, we cannot attribute differences clearly to any one factor at this time.

Other assistive devices that may help improve bowel management and function include wooden toothbrush and toilet seat modifications. Esfandiari et al. (2017) investigated the effect of wooden toothbrush usage (5 minutes after breakfast and dinner over 6 weeks), on constipation for people with SCI. (They hypothesized that stimulation of the trigeminal sensory nerve would stimulate the vagus motor nerve responsible for gut activity through the medial longitudinal fasiculus (MLF) and therefore lead to GI reflexes). Esfandiari et al. 2017 reported a significant decrease in many constipation symptoms and increase in NBD scores. However, NBD scores only improved for individuals with thoracic or thoracolumbar injuries, and not cervical or lumbar. Additionally, this improvement was only observed for those between 30-40 years old. There were no differences in results between men and women. Results suggest the wooden toothbrush at least 5 minutes twice daily can be considered to assist in management constipation in SCI, but further research with control group is needed.

One prospective controlled study investigating anorectal biofeedback therapy found changes in anorectal parameters after the intervention along with larger improvements in constipation compared to the control group (40% vs. 27%; p=0.04; Mazor et al. 2016).

Uchikawa et al. (2007) developed a new procedure to induce bowel movements using a toilet seat equipped with an electronic bidet that provides water flow to the anorectal area. A CCD camera and light are included to facilitate location of the anorectal area. The authors report that a reduction in the time needed for bowel management, with an additional 8 (40%) participants who can complete defecation in less than 30 minutes. Mazor et al. (2016) trialed biofeedback once a week for 6 weeks in a matched controlled trial with 21 patients with motor incomplete SCI. There was improvement in constipation scores, first sensation threshold and maximum anal resting pressures. Ten of eleven SCI participants reported stable or improved bowel function at long term follow up.

Utilizing these programs and assistive devices to improve bowel management and function requires further research.

Conclusion

There is level 1 evidence from one RCT (Gorman et al. 2021) that some improvements in average bowel evacuation time and stool consistency occur with an exoskeletal-assisted walking intervention in comparison to usual activity for people with SCI.

There is level 1 evidence (Kwok et al. 2015) that a regular standing program did not change neurogenic bowel function.

There is level 2 evidence (Huang et al. 2015) that ambulation training programs may improve some aspects of neurogenic bowel function (enema dose and defecation time).

There is level 2 evidence (Hubscher et al. 2021) that after stand and arm crank training there were no significant differences in bowel dysfunction.

There is level 2 evidence (Hubscher et al. 2018) that people in the weight-supported treadmill training, locomotor training, or weight-bearing standing groups required less time for defecation.

There is level 2 evidence (Mazor et al. 2016) that anorectal biofeedback therapy improves anorectal function and neurogenic bowel constipation symptoms in motor incomplete participants.

There is level 4 evidence (Esfandiari et al. 2017) that a wooden toothbrush for 5 minutes twice daily has therapeutic effects and improves neurogenic bowel dysfunction symptoms.

There is level 4 evidence (Chun et al. 2020) that exoskeleton-assisted walking improves bowel evacuations, reduced time of bowel movements, decreased bowel accidents and frequency of laxative use.

There is level 4 evidence (Juszczak et al. 2018) that exo-skeleton walking is beneficial for bowel management although no increase in quality of life was reported.

Assistive Devices and Exercise- Case Series/Cross-sectional studies

There is level 5 evidence (Forchheimer et al. 2016) that people with SCI who exercise at least one hour per week will spend less time on bowel management.

There is level 5 evidence (Uchikawa et al. 2007) that a washing toilet seat with a CCD camera monitor for visual feedback reduces time spent on bowel care.

There is level 5 evidence (Brinkemper et al. 2021) that SCI bowel incontinence and constipation scores improve after locomotion therapy with a HAL Robot suit.