Chronic constipation is a common problem after SCI, with a prevalence of up to 80% of affected individuals (Krogh et al. 2002). The presence of constipation in patients with SCI with slow transit times has been well-documented (Geders et al. 1995).
Five studies exploring the use of cisapride for neurogenic bowel management have been removed from this review as the drug is no longer available.
Prokinetic agents are presumed to promote transit through the GI tract, thereby decreasing the length of time needed for stool to pass through the intestines and increasing the amount of stool available for evacuation. Since constipation in patients with both acute and chronic SCI is considered primarily a consequence of prolonged colonic transit time, stimulating intestinal motility would appear to be a reasonable therapeutic approach. Segal et al. (1987) investigated the use of metoclopramide (a potent dopamine receptor antagonist with prokinetic properties) for enhancing gastric emptying in individuals with SCI. They found that impaired gastric emptying in patients with SCI can be significantly improved using metoclopramide. Improvement in constipation and increased frequency of bowel movement were also seen with the use of prucalopride – a novel, highly selective serotonin receptor agonist with enterokinetic properties that facilitates cholinergic and excitatory non-adrenergic, non-cholinergic neurotransmission (Krogh et al. 2002). Korsten et al. (2005) found that neostigmine (a reversible cholinesterase inhibitor) or the combination of neostigmine and glycopyrrolate administered intravenously improved stool expulsion over normal saline. Rosman et al. (2008) reported similar findings for the use of neostigmine and glycopyrrolate in combination over placebo. Finally, a study by Cardenas et al. (2007) reported an increase in the number of days with bowel movements in approximately one-fifth of the subjects given sustained-release fampridine (selective potassium channel blocker).
Prucalopride: There is level 1b evidence (from one RCT: Krogh et al. 2002) that prucalopride increases stool frequency, improves stool consistency and decreases gastrointestinal GI transit time; higher doses (2mg/day) were associated with moderate/severe abdominal pain.
Metoclopramide: There is level 2 evidence (from one prospective controlled trial; N=20) (Segal et al. 1987) that intravenous administration of metoclopramide decreases time of gastric emptying.
Neostigmine: There is level 1b evidence (from one RCT: Korsten et al. 2005) that neostigmine, administered with or without glycopyrrolate, leads to a greater expulsion of stool. There is level 1 evidence that neostigmine with glycopyrrolate decreases total bowel evacuation times and improves bowel evacuation.
Fampridine: There is level 1b evidence (from one RCT: Cardenas et al. 2007) that fampridine can increase the number of days with bowel movements.
|Author Year; Country
Total Sample Size
|Rosman et al. 2008;
PEDro = 8
N = 7
|Population: 7 SCI participants with defecatory problems (mean (SD) age: 46.9 (3.4) yrs, range 30 – 56 yrs); 4 cervical, 3 thoracic.
Treatment: injections of neostigmine (2 mg) and glycopyrrolate (0.4 mg) for 1 week, wash-out period for 1 week, and placebo for 1 week, in random order
Outcome Measures: Total bowel evacuation time; time to first flatus; time to beginning of stool flow; time to end of stool flow.
|Krogh et al. 2002; Denmark
PEDro = 7
Double blind RCT
|Population: mean (SD) age: 34.7 (2.5) yrs (placebo), 36.5 (3.9) yrs (1mg group), 44.3 (3.1) yrs (2mg group). No information on level of injury was reported.
Treatment: Participants randomized with double blind design to treatment with prucalopride 1mg or placebo, taken once daily for 4 wks. A 2nd group of participants was randomized to prucalopride 2mg or placebo for 4wks
Outcome measures: constipation; urinary habit; constipation severity and symptoms; colonic transit times
|Korsten et al. 2005; USA
PEDro = 6
|Population: Level of injury: C4-T12 (5 tetraplegics, 8 paraplegics; 12/13 motor complete, 5/13 sensory incomplete); Age: mean (range) 46 (25-69)yrs; Duration of injury: mean (range) 14 (1-31)yrs
Treatment: On different days, participants received, in a randomized, double-blinded design, one of three intravenous infusions (normal saline, 2 mg neostigmine, or 2 mg neostigmine and 0.4 mg glycopyrrolate)
Outcome Measures: time to bowel evacuation using barium paste
|Cardenas et al. 2007; USA
PEDro = 6
|Population: 91 participants with motor-incomplete SCI randomized to three groups:
(I) Fampridine, sustained release, 25 mg bid: Level of injury: 23 cervical, 7 thoracic; AIS grade: 14 C, 16 D; 22M:8F; Age: mean (range) 44 (23-66)yrs; Duration of injury: mean (range) 8.3 (1-30)yrs
(II) 40 mg bid: Level of injury: 24 cervical, 6 thoracic; AIS grade: 12 C, 18 D 26M:,4F; Age: mean (range) 42 (21-67)yrs; Duration of injury: 10.8 years, range 1-35;
(III) Placebo: Level of injury: 26 cervical, 5 thoracic; AIS grade: 18 C, 13 D; 24M:7F; Age: mean (range) 38 (19-61)yrs; Duration of injury: mean (range) 8.3 (1-37)yrs
Treatment: Drug treatment (Fampridine orally 25mg bid or 40mg bid) or placebo for 8 weeks
Outcome Measures: Number of days with bowel movement, Subject Global Impression (SGI), Ashworth
|Segal et al. 1987;
Prospective Controlled Trial
|Population: 11 participants with tetraplegia, 9 participants with paraplegia (all complete SCI), 8 able-bodied controls; Age range: 20-55yrs
Treatment: participants ingested a liquid meal, then within 2 weeks, ingested 2nd liquid meal while metoclopramide (10mg) was administered intravenously; gastric emptying (GE) was evaluated after each liquid meal
Outcome Measures: half time of gastric emptying, gastric emptying patterns in the early and later phases
|Kim et al. 2016
|Population: N=25 (22M, 3F)
Mean (SD) age 50.9 (17.3) years
Mean (SD) time since SCI 5.3 (6.0) months
19 traumatic, 6 non-traumatic
Cervical AIS-A/B/C/D: 2/2/3/7
Thoracic AIS-A/B/C/D: 3/3/1/4
Treatment: Poncirus fructus extract 800mg before breakfast & lunch for 14 days
Outcome Measures: Bristol Stool Form Scale, constipation score, stool retention score, colon transit time, adverse events