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Bowel Dysfunction and Management

Multifaceted Bowel Management Programs

Discussion

A combination of interventions, as components of a comprehensive bowel routine, is recommended for the management of neurogenic bowel following SCI. These include dietary manipulation, anorectal stimulation and 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 different protocols on bowel function following SCI. From the results of three pre-post studies and one RCT, it is apparent that response to the protocols is highly individualized. However, the Badiali et al. (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. (2006) 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%). These authors also reported a significant decrease in the mean duration of bowel management episodes with introduction of this protocol (Coggrave et al. 2006). 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. Using the same management program in their 2006 pre-post study (Coggrave et al. 2006), Coggrave and Norton (2010) more recently conducted a 6-week RCT in which the management program was compared to the control group’s usual bowel care consisting of each subject’s usual type, number and order of interventions to achieve evacuation. 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.Findings revealed that bowel care took longer in the experimental group, fecal incontinence was more frequent (p=0.04), and the need for oral laxatives and invasive interventions was not reduced (p=0.4). The findings in this RCT (Coggrave & Norton 2010) are in contrast with other published findings in which the use of a multifaceted program reduced the level of intervention needed for evacuation and duration of bowel management (Coggrave et al. 2006Badiali et al. 1997). The samples in the earlier studies, however, were younger and injured for a shorter period of time, and both factors are associated with less frequent use of medicated rectal stimulants, manual evacuation, and oral laxatives (Coggrave et al. 2009).

Conclusion

There is level 1b evidence (from one RCT; N=68)(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 also level 1b evidence (Coggrave & Norton 2010) that use of a multifaceted bowel management program may increase the duration of bowel management. This is in contrast with level 4 evidence (from three pre-post studies; aggregate N=65) (Coggrave et al. 2006Correa & Rotter 2000Badiali 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.

Author, Year; Country

Score

Research Design

Total Sample Size

Methods Outcome
Coggrave & Norton, 2010; UK

PEDro = 7

RCT N = 68

Population: Experimental group: 24M 11F; Median age = 49.5yrs; 17 AIS-A, 5 AIS-B, 4 AIS-C, 9 AIS-D. Control group: 21M 12F; Median age = 47 yrs; 19 AIS-A, 3 AIS-B, 2 AIS-C, 9 AIS-D. Treatment: 6-week, 8-stepwise protocol designed by Badiali et al. (2007) 1) simulation of gastro-colic reflex 20 min before starting bowel care followed by: 2) abdominal massage; 3) perianal digitation; 4) anorectal digitation; 5) glycerin suppositories; 6) rectal stimulants; 7) manual evacuation; 8) stimulant oral laxative. The control group maintained their usual bowel routine to achieve evacuation. Outcome Measures: duration of bowel movement and level of the 8-stepwise protocol reached to attain consistent evacuation.
  1. Bowel care was consistently longer in the experimental group throughout the study, and significantly longer at week 6.
  2. Less invasive interventions (i.e. steps 1-5) did not reduce the need for more invasive interventions (i.e. steps 6-8).
  3. Time to first stool was consistently but not significantly longer in the experimental group.
  4. Findings supported the need for manual evacuation of stool in neurogenic bowel management
Hwang et al., 2017; USA

Longitudinal Cohort N=131

Population: N=131 (84M, 47F) with pediatric-onset (before 19) SCI 58.8% tetraplegia 76.3% complete SCI 90% traumatic SCI Mean (SD) age 33.4 (6.1) years Mean (SD) time since injury 19.5 (7.0) years Treatment: None Outcome Measures: Structured questionnaire (type & time of bowel program, bowel & abdominal symptoms) and other psychosocial measures (CHART, SWLS, PHQ-9, SF-12)
  1. Yearly changes in odds (%) of using:
    • Manual evacuation +7.7
    • Oral laxatives +5.2
    • Colostomy +7.1
    • Rectal suppositories/enema -6.7
  1. Changes differ depending on injury level / completeness
  2. Individuals with paraplegia over time, compared to tetraplegia, are:
    • 5x more likely to use manual evacuation
    • 90% less likely to continue with rectal suppositories / enemas
    • 65% less likely to continue with oral laxatives.
  1. Participants using manual evacuation & digital stimulation are less likely to increase bowel program duration over time, whereas using rectal suppositories / enemas doubles this likelihood each year
  2. No change in odds of fecal incontinence over time using any method, but odds significantly increased if no bowel program used
  3. Laxative users had a 3.9-time increase in odds of abdominal pain every year
Ozisler et al., 2015; Turkey

Prospective cohort N=55

Population: N=55 (42M/13F) patients with Mean (SD) age 33.01 (12.25) Mean (SD) time since SCI 162.0 (110.1) days 37 complete SCI, 18 incomplete SCI Treatment: 2 bowel programs administered depending on upper (UMN) or lower (LMN) motor neuron bowel dysfunction classification Unique to UMN program: oral medication, glycerin suppository Common between programs: enema, digital stimulation, sit on toilet or lie on side in bed, diet & fluid regulation Outcome Measures: GI problems, method of bowel management, NBD Score
  1. Significantly decreased % of motor complete SCI patients after treatment with constipation (-16%), abdominal distension (-25%), and abdominal pain (-16%)
  2. No significant change in % of patients with gastrointestinal problems in motor incomplete SCI patients
  3. Significantly decreased use of oral medication, enema, and manual evacuation after treatment
  4. Significant decreases in NBD scores in both motor complete (17.45±6.37 to 11.4±3.58) and incomplete patients (8.44±9.39 to 5.22±6.38) after treatment.
  5. Mean NBD score significantly higher in motor complete patients than in motor incomplete patients both before and after treatment.
Coggrave et al., 2006; UK

Pre-post

N=17

Population: 14M 3F; Age: mean 41.2 yrs, range 19-59yrs; 8 cervical, 8 thoracic, 1 conus medullaris; all participants had motor compete SCI. Treatment: Baseline bowel management routine (2 weeks observation) was compared with bowel management following introduction of the modified progressive protocol (4 weeks of observation) designed by Badiali et al. (1997) with the addition of manual evacuation. Outcome Measures: Comparison of the number of bowel management episodes requiring laxative use at baseline and under the progressive protocol; duration of bowel management episodes.
  1. For 12 participants, use of the progressive protocol resulted in an increase in the number of successful bowel management episodes without the use of laxatives.
  2. Total number of successful bowel management episodes requiring laxative decreased significantly from 62.8% (baseline observation) to 23.1% (in protocol phase).
  3. In 3 participants, there were fewer successful bowel management episodes with use of the protocol
  4. Mean duration of bowel management episodes was less with use of the protocol than during baseline (51.8 vs. 73.5 minutes).
  5. There was a significant decrease in proportion of the bowel management episodes requiring manual evacuation in the protocol phase than in the baseline phase (87.6% versus 27%).
Correa & Rotter, 2000; Chile

Pre-post

N=38

Population: Age: range 19-71 yrs; 21 participants with complete injuries (2 with tetraplegia and 19 with paraplegia), 10 with incomplete injuries, 7 with conus medullaris and cauda equina; Duration of injury: range 5 months -16 yrs. Treatment: Intestinal program administration with 6-month follow-up. The program involved monthly evaluations of the patient’s intestinal function, symptoms and complications. Patients were educated on inadequate practices of evacuation and medications were changed when appropriate. Outcome Measures: Difficult Intestinal Evacuation (DIE) scale; colonic transit time; anorectal manometry; recto-colonoscopy; GI symptoms.
  1. Participants felt their DIE scores after their SCI worsened (from 2.6% to 26.3%) compared to before their SCI (based on subjective recall).
  2. The most frequent GI symptom was abdominal distention. The incidence of abdominal distention was reduced from 50% to 23.5% after the program.
  3. With the intestinal program, the incidence of DIE was reduced from 26.3% to 8.8% and episodes of manual extraction were reduced from 53% to 37%.
Badiali et al., 1997; Italy ,

Pre-post

N=10

Population: 5M 5F; Age: mean 33yrs, range 20-60yrs; Level of injury: C3 to L4 Treatment: Multifaceted intervention including diet, water intake, and evacuation schedule (15g/day fibre, 1500ml/24hr water) Outcome Measures: Bowel movement frequency, bowel habit (regular intestinal schedule, total and segmental large-bowel transit time.
  1. Bowel frequency was reported to have increased at the end of training.
  2. By the end of the study period the total GI transit time was significantly reduced (146+/-45 before vs 93+/-49 h).
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