Bowel Management Table 3: Multifaceted Bowel Management Programs

Author Year; Country


Research Design

Total Sample Size



Coggrave & Norton 2010;


PEDro = 7


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.

Coggrave et al. 2006; UK



Population: 14M 3F; Age: mean 41.2 yrs, range 19-59yrs; 8 cervical, 8 thoracic, 1 conus medullaris; all subjects 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 subjects, 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 subjects, 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




Population:Age: range 19-71 yrs; 21 subjects 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. Subjects 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 was reduced from 53% to 37%.

Badiali et al. 1997;




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/die 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).