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. 2006; Badiali 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. 2006; Correa & 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.
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. |
|
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) |
|
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 |
|
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. |
|
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. |
|
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. |
|