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Bowel Dysfunction and Management

Assistive Devices

In addition to standard bowel protocols and pharmacological modalities, numerous devices were evaluated as means to improve bowel evacuation in individuals with SCI. These include a standing table and a modified toilet seat.

Discussion

Hoenig et al. (2001) reported the case of an individual with SCI who, through the use of a standing table, doubled the frequency of his bowel movements and reduced time spent on bowel care. 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%) subjects who can complete defecation in less than 30 minutes.

Conclusion

There is level 5 evidence (from one case report with one subject: Hoenig et al. 2001) that a standing table alleviates constipation in an individual with SCI.

There is level 4 evidence (from one cross-sectional study: Uchikawa et al. 2007) that a newly developed washing toilet seat with a CCD camera monitor for visual feedback reduces time spent on bowel care.

Author Year; Country

Score

Research Design

Total Sample Size

Methods Outcome
Kwok et al 2015

Australia

RCT with Crossover

PEDro = 8

N=20

Population: N=20 (15M, 5F) wheelchair dependent SCI community members

Median (IQR) age:

Treatment first group: 46 (39-55)

Control first group: 46 (42-51)

Median (IQR) time since SCI:

Treatment first group: 4 (3-11)

Control first group: 9 (6-20)

15 cervical, 5 thoracic

AIS-A/B: 13/7

Treatment:

Standing phase: participants stood on tilt table for 30min, 5 times/week

No-stand phase: participants did not stand

Crossover with:

6 weeks of standing/no-stand phase +

4 weeks of washout phase +

6 weeks of no-stand/standing phase

Outcome Measures: time to first stool, time to complete bowel care, Neurogenic Bowel Dysfunction Score, Cleveland Clinic Constipation Score, St. Mark’s Incontinence Score, SCI-SET

  1. No significant mean between-intervention difference for any outcome measure.
  2. Median (IQR) of perceived change in bowel function is 0/10 (0-3).
  3. Median (IQR) of inconvenience is 5/10 (0-7).
Huang et al. 2015

China

PEDro = 5

Randomized Trial

N=24

Population: N=24 incomplete SCI from T8 to L2, less than 6 months post-SCI

BWSTT group:

N=12 (7M, 5F)

Mean (SD) age 38.4 (2.25)

RAT group:

N=12 (9M, 3F)

Mean (SD) age 41.7 (2.25)

Treatment: 20min BWSTT or RAT (robot-assisted training) sessions 4 times per week for 1 month

Outcome measures: defecation time, glycerine enema dose

  1. Significant interactions in defecation time and enema dose in both groups.
  2. Significant within-group decrease in enema dose (68.1±10.7mL to 38.8±12.4mL) and defecation time (93.0±14.7min to 64.5±11.6min) in RAT group.
  3. No significant within-group change in enema dose and defecation time in BWSTT group.
Mazor et al. 2016

Australia

Prospective Case-control

N=21

Population: N=21 (4M, 17F) patients with motor incomplete SCI and N=42 (8M, 34F) matched controls with anorectal disorders,  all with a neurogenic bowel

Mean (range) time since SCI 3.5 (1-24) years

10 lumbosacral, 4 thoracic, 2 cervical, 3 cauda equina

AIS-C/D: 3/13

17 traumatic SCI

10 of SCI patients also had urinary symptoms

Treatment: Anorectal biofeedback 30-60 min/session, once a week for 6 weeks

Outcome Measures: Knowles Constipation Questionnaire, Fecal Incontinence

Severity Index, VAS for impact of bowel dysfunction on QoL, satisfaction with bowel

Movement and feeling of control over bowel function, and other anorectal function parameters

  1. Greater improvement in constipation score in treatment group (40%) compared to controls (27%).
  2. No between group differences in other bowel outcome measures.
  3. Within-group decrease in first sensation threshold (75±53 to 64±65mL) and max anal resting pressure (62±19 to 53±21mmHg) in SCI group, but not in controls.
  4. Within-group increase in sustained squeeze duration (23±9 to 31±14s) in controls, but not in SCI group.
  5. 10/11 SCI group reported stable or improved bowel symptoms at long-term follow-up.
Uchikawa et al. 2007; Japan

Cross-sectional

N=20

Population: 11 participants with cervical, 7 with thoracic, and 2 with lumbar SCI; AIS level: 8 A, 4 B, 4 C, and 4 D; all male; Age: mean (range) 46.3 (18-73) yrs; all were at least 5 months post injury

Treatment: Newly developed procedure to induce bowel movement involving a toilet seat equipped with an electronic bidet (provides water flow), a charge-coupled device (CCD) camera monitor and a light (facilitates location of anorectal area).

Outcome Measures: Time required for successful bowel movement, amount of residual stool in rectum

  1. Time needed for bowel management was shorter with the intervention than that with participants’ usual manner of bowel care.
  2. 35% (n=7) of participants originally spent less than 30 minutes for usual defecation compared to 75% (n=15) with modified device.
  3. Residual stools found in 8/15 participants who successfully defecated within 30 minutes with the device.
  4. Success of defecation not related significantly with injury level or AIS impairment scale.
Hoenig et al. 2001;

USA

Case Report

N=1

Population: 62-year-old male with T12/L1 AIS B paraplegia; time since injury = 36 years

Treatment: Standing table for the treatment of constipation 1 hr/day, 5 days/wk for 1 month.

Outcome Measures: Frequency of bowel movements and length of bowel care episodes.

  1. The frequency of bowel movements nearly doubled (from 10 to 18) with the use of the standing table.
  2. The time spent on bowel care was reduced from 21 to 13 minutes.
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