Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury

Bowel burdens: a systematic review and meta-analysis examining the relationships between bowel dysfunction and quality of life after spinal cord injury

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Many individuals with spinal cord injury (SCI) experience autonomic dysfunction, including profound impairments to bowel and cardiovascular function. Neurogenic bowel dysfunction (NBD) is emerging as a potential determinant of quality of life (QoL) after SCI. For individuals with high-level lesions ( > T6), bowel care-related autonomic dysreflexia (B-AD; profound episodic hypertension) further complicates bowel care. We aimed to evaluate the extent of bowel dysfunction after SCI, and the impact of bowel dysfunction on QoL after SCI.

METHODS

We searched five databases to identify research assessing the influence of NBD or B-AD on QoL after SCI. Metrics of bowel dysfunction (fecal incontinence [FI], constipation, time to complete, and B-AD) and QoL data were extracted and synthesised. Where possible, meta-analyses were performed.

RESULTS

Our search identified 2042 titles, of which 39 met our inclusion criteria. Individuals with SCI identified problems with NBD (74.7%), FI (56.9%), and constipation (54.6%), and 49.3% of individuals with SCI > T6 experienced B-AD. Additionally, 40.3% of individuals experienced prolonged defecation ( > 30 min). Moderate/severe deterioration in QoL due to NBD was reported by 55.5% of individuals with SCI, with negative impacts on physical, emotional, and social health-related QoL associated with inflexibility of bowel routines, fear of accidents, and loss of independence.

CONCLUSION

Bowel dysfunction and bowel care challenges are prevalent and disabling for individuals with SCI, with a profoundly negative impact on QoL. Improving bowel management is a key target to improve QoL for those living with SCI.

State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

BACKGROUND

Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

METHODS

To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

RESULTS

Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

CONCLUSION

Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Effective bowel management in spinal cord injury during inpatient rehabilitation: data from the Dutch spinal cord injury database

STUDY DESIGN

Retrospective Observational Study.

OBJECTIVES

To describe bowel management in individuals with a recently acquired spinal cord injury (SCI) both at admittance and discharge from first inpatient rehabilitation, and to determine factors that contribute to effective bowel management (EBM) at discharge.

SETTING

Specialized rehabilitation centers in the Netherlands.

METHODS

Data from the Dutch Spinal Cord Injury Database (DSCID) collected between 2015 and 2019 was used. EBM was defined by the variables of stool frequency and fecal incontinence. After univariate analysis, a multivariate regression analysis was conducted.

RESULTS

Of 1,210 participants, 818 (68%) did not have EBM at admittance. At discharge, 308 (38%) did still not have EBM (in total 33% of all participants). The odds of having EBM at discharge was 2.82 times higher for participants with ASIA Impairment Scale (AIS) D compared to those with AIS-A (95% CI: 1.38-5.78). Participants with non-traumatic SCI had higher odds of having EBM than those with traumatic SCI (OR: 0.59, 95% CI 0.38-0.91). Use of suppositories, small enema, medication influencing bowel function, and oral laxatives at admittance did not influence EBM significantly at discharge.

CONCLUSIONS

Bowel management improves during first inpatient rehabilitation. However, realizing EBM after a recently acquired SCI is a challenge. This endorses the importance of bowel management during inpatient rehabilitation, especially for people with AIS-A and non-traumatic etiology.

Intermittent colonic exoperistalsis for chronic constipation in spinal cord-injured individuals. A long-term structured patient feedback survey to evaluate home care use

STUDY DESIGN

Structured patient feedback survey evaluating real-world home care use.

OBJECTIVES

To assess the long-term effectiveness, tolerability, and satisfaction with the intermittent colonic exoperistalsis (ICE) treatment device MOWOOT in spinal cord-injured (SCI) individuals with chronic constipation.

SETTING

Four specialized German hospitals.

METHODS

SCI individuals with chronic constipation were invited to use MOWOOT 10-20 min daily and answer a questionnaire about their bowel situation before treatment (feedback 1, F1) and after ≥10 months of use (feedback 2, F2). Collected variables were device use, bowel function effectiveness, chronic constipation symptoms, concomitant use of laxatives and evacuation aids, and satisfaction with bowel function and management, which were compared between time points. At F2, participants reported efficacy, tolerability/side effects, and ease of use.

RESULTS

Eleven participants used the device for a mean (SD) of 13.27 (4.03) months. From F1 to F2, mean time per evacuation decreased by 24.5 min (p = 0.0076) and the number of failed attempts to evacuate/week, by 1.05 (p = 0.0354) with a tendency toward increased bowel movements and softer stool consistency, and decreased incomplete bowel movements. Participants experienced decreased difficulty/strain (p = 0.0055), abdominal pain (p = 0.0230), bloating (p = 0.0010), abdominal cramps (p = 0.0019), and spasms (p = 0.0198), without significant changes in the use of laxatives and evacuation aids. Satisfaction with bowel function and management improved (p = 0.0095) and more participants reported being very satisfied/satisfied (p = 0.0300). Most reported tolerability, efficacy, and ease of use as very good/good.

CONCLUSION

Long-term in-home ICE treatment improved bowel function and chronic constipation symptoms in SCI individuals, providing clinical benefits to this population.

SPONSORSHIP (MOWOOT DEVICES LENDING)

4 M Medical GmbH, Norderstedt, Germany.

Effects of non-invasive spinal cord stimulation on lower urinary tract, bowel, and sexual functions in individuals with chronic motor-complete spinal cord injury: Protocol for a pilot clinical trial

INTRODUCTION

Electrical spinal cord neuromodulation has emerged as a leading intervention for restoring autonomic functions, such as blood pressure, lower urinary tract (LUT), bowel, and sexual functions, following spinal cord injury (SCI). While a few preliminary studies have shown the potential effect of non-invasive transcutaneous spinal cord stimulation (tSCS) on autonomic recovery following SCI, the optimal stimulation parameters, as well as real-time and long-term functional benefits of tSCS are understudied. This trial entitled "Non-invasive Neuromodulation to Treat Bladder, Bowel, and Sexual Dysfunction following Spinal Cord Injury" is a pilot trial to examine the feasibility, dosage effect and safety of tSCS on pelvic organ function for future large-scale randomized controlled trials.

METHODS AND ANALYSIS

Forty eligible participants with chronic cervical or upper thoracic motor-complete SCI will undergo stimulation mapping and assessment batteries to determine the real-time effect of tSCS on autonomic functions. Thereafter, participants will be randomly assigned to either moderate or intensive tSCS groups to test the dosage effect of long-term stimulation on autonomic parameters. Participants in each group will receive 60 minutes of tSCS per session either twice (moderate) or five (intensive) times per week, over a period of six weeks. Outcome measures include: (a) changes in bladder capacity through urodynamic studies during real-time and after long-term tSCS, and (b) resting anorectal pressure determined via anorectal manometry during real-time tSCS. We also measure assessments of sexual function, neurological impairments, and health-related quality of life using validated questionnaires and semi-structured interviews.

ETHICS AND DISSEMINATION

Ethical approval has been obtained (CREB H20-01163). All primary and secondary outcome data will be submitted to peer-reviewed journals and disseminated among the broader scientific community and stakeholders.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Spinal Cord Injury Patient's Physical and Psychological Care Needs at Home from Patients’ and Caregivers’ Perspectives: A Qualitative Study

Background: Limited studies have attempted to identify the care needs of patients with spinal cord injury (SCI) and their professional caregivers at home and after discharge from the hospital. However, little information about these needs has led to increased physical and psychological complications and thus a reduced quality of life in SCI patients. Objectives: This study aimed to explain the experiences of patients and their caregivers regarding physical and psychological care needs at home. Method: This qualitative descriptive study was conducted on 24 SCI patients and their professional caregivers using the conventional content analysis. Data were collected through unstructured and semi-structured interviews. Purposeful sampling was continued until data saturation was reached. The conventional content analysis approach proposed by Graneheim and Lundman (continuous comparison) was used to analyze the data. Results: The age range of the participants was 29 - 48 years, with an average age of 37.8 years. Seven of the participants had paraplegia, and three of them had tetraplegia. The results of data analysis led to the extraction of two main categories, including physical and psychological care needs. Conclusions: By identifying the real needs of patients after discharge from the hospital, we emphasize the need to remove barriers to home health care services and provide more financial support to meet patients' needs. Therefore, policymakers are encouraged to use the results of this study to plan at-home patient care services.

Transanal Irrigation for People With Neurogenic Bowel Dysfunction: An Integrative Literature Review

Transanal irrigation has been introduced as a complement to standard bowel care for people with neurogenic bowel dysfunction. There is no contemporary integrative review of the effectiveness and feasibility of transanal irrigation from a holistic nursing perspective, only fragments of evidence to date. The aim was to investigate the effectiveness and feasibility of transanal irrigation for people with neurogenic bowel dysfunction. An integrative literature review was conducted. Nineteen studies were included. According to the results, transanal irrigation can reduce difficulties associated with defecation, episodes of incontinence, and the time needed for evacuation and bowel care. Transanal irrigation can increase general satisfaction with bowel habits and quality of life and decrease level of dependency. However, there are practical problems to overcome and adverse effects to manage. Discontinuation is relatively common. The results support the effectiveness of transanal irrigation, but feasibility is inconclusive. Users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported during transanal irrigation treatment, especially during introduction. The quality of the studies found was generally weak; therefore, high-quality quantitative and qualitative studies are needed on the topic.

The importance of dedicated colorectal team participation in the management of spina bifida and spinal cord injury patients

PURPOSE

In September 2020, the colorectal team of the International Center for Colorectal and Urogenital Care joined the spina bifida and spinal cord injury multidisciplinary clinic at Children's Hospital Colorado. Many important lessons were learned.

METHODS

A retrospective review of patients seen in the spina bifida and spinal cord injury multidisciplinary clinic from September 2020 to May 2021 was conducted. Data collected included demographics, diagnosis, pre or post-natal repair for those with myelomeningocele, whether the patient was previously seen by the colorectal team, wheelchair usage, voluntary bowel control vs. fecal incontinence, urinary control vs. clean intermittent catheterization, characteristics of contrast enema, and our proposed intervention.

RESULTS

Overall, 189 children were seen during the study period, ranging from 3 months to 20 years of age (average = 9.5 years). One hundred and two were males and 87 were females. Diagnosis included myelomeningocele (n = 153), spinal cord injury (n = 18), transverse myelitis (n = 7), sacral agenesis (n = 5), diastematomyelia (n = 2), spinal stenosis (n = 2), and tethered cord with lipoma (n = 2). Fifteen patients with myelomeningocele were repaired in-utero. One hundred and sixty patients were new to the colorectal team. Eighty-one patients were wheelchair users. One hundred and twenty-three patients suffered from fecal incontinence and needed enemas to be artificially clean for stool and thirty-eight patients had voluntary bowel movements and were clean with laxatives, suppository, or rectal stimulations. Twenty-eight patients were younger than three years of age and still in diapers. Despite a non-dilated colon on contrast enema, this population has a hypomotile colon. One hundred and twenty-eight patients required clean intermittent catheterization.

CONCLUSION

Joining the spina bifida and spinal cord injury multidisciplinary clinic allowed us to better serve this population and gave us enormous satisfaction to contribute to improve the quality of life of the patients and their parents.

LEVEL OF EVIDENCE

III.

The usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life

PURPOSE

To describe the usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life.

METHODS AND MATERIALS

Descriptive and interpretive thematic analysis of transcribed semi-structured interviews with 11 men living with spinal cord injury, aged 23-77 years, 8-45 years post injury.

RESULTS

Participants had different levels and types of injuries. While there were common aspects of the bowel care routines of study participants, none was exactly the same as any other. Each had developed a routine in accordance with the needs of their own body, preferences, and convenience in relation to availability of carers and work commitments. Personal factors in the person with SCI were important for successful integration of bowel care into their everyday life.

CONCLUSION

An appropriate and consistent bowel care routine was found to be significant in enabling people with spinal cord injury to experience wellness and quality in their everyday lives. Characteristics and actions of the person with SCI enabled the person to actively drive the process of integrating bowel care into their everyday life. How best to foster the development of these personal factors warrant further investigation.IMPLICATIONS FOR REHABILITATIONSupport for the ongoing development of self-management of bowel dysfunction expertise by people living with spinal cord injury needs to continue after discharge from hospital.Characteristics of the person with spinal cord injury, such as a state of mind indicating acceptance of their situation, motivation to avoid bowel accidents and constipation, and willingness to take responsibility, are important factors influencing the integration of bowel care into everyday life.Actions undertaken by the person with spinal cord injury, such as discipline to establish, refine and maintain a bowel care regime, and proactive self-management are important factors influencing the integration of bowel care into everyday life.This small study suggests the role of personal factors in the development of self-management expertise, for example the development of a self-management mindset and the acquisition of skills to drive that process, should be considered during rehabilitation.

Changes in gut microbiota in the acute phase after spinal cord injury correlate with severity of the lesion

After spinal cord injury (SCI), patients face many physical and psychological issues including intestinal dysfunction and comorbidities, strongly affecting quality of life. The gut microbiota has recently been suggested to influence the course of the disease in these patients. However, to date only two studies have profiled the gut microbiota in SCI patients, months after a traumatic injury. Here we characterized the gut microbiota in a large Italian SCI population, within a short time from a not only traumatic injury. Feces were collected within the first week at the rehabilitation center (no later than 60 days after SCI), and profiled by 16S rRNA gene-based next-generation sequencing. Microbial profiles were compared to those publicly available of healthy age- and gender-matched Italians, and correlated to patient metadata, including type of SCI, spinal unit location, nutrition and concomitant antibiotic therapies. The gut microbiota of SCI patients shows distinct dysbiotic signatures, i.e. increase in potentially pathogenic, pro-inflammatory and mucus-degrading bacteria, and depletion of short-chain fatty acid producers. While robust to most host variables, such dysbiosis varies by lesion level and completeness, with the most neurologically impaired patients showing an even more unbalanced microbial profile. The SCI-related gut microbiome dysbiosis is very likely secondary to injury and closely related to the degree of completeness and severity of the lesion, regardless of etiology and time interval. This microbial layout could variously contribute to increased gut permeability and inflammation, potentially predisposing patients to the onset of severe comorbidities.

Problems people with spinal cord injury experience accessing help with bowel care when hospitalised outside a specialist spinal injury service

AIMS AND OBJECTIVES

To examine the nature of problems experienced by people with spinal cord injury (SCI) when accessing help to maintain recommended bowel regimes while hospitalised outside a specialist spinal injury service.

BACKGROUND

Bowel dysfunction is one particularly undesirable aspect of life with a SCI, with constipation and incontinence common.

DESIGN

Descriptive qualitative.

METHODS

Accounts of problems encountered in hospitals in New South Wales Australia collected during interviews with 11 people living with SCI and 12 responses provided by spinal clinicians via an online survey were subjected to thematic analysis. The COREQ guidelines were followed for reporting.

RESULTS

There were similarities across data collected from both sources. Individuals with SCI described instances where their bowel care needs did not fit with the pace and processes in acute hospitals. The clinician data pointed to a failure of healthcare professionals to assist people with SCI to maintain bowel care regimes recommended by specialist spinal services. Both groups described times when bowel care received was unreliable and fragmented, along with reports of staff who were unwilling and/or unable to provide the assistance required. Many and varied physical and psychosocial repercussions for individuals were associated with these system failures. In some instances, rather than restoring health, being admitted to hospital represented a significant health risk.

CONCLUSION

A failure of hospital systems to meet the bowel care needs of people with SCI when hospitalised outside a specialist spinal unit was identified. System and individual factors contributed to these problems, hence addressing them requires both system and individual responses.

RELEVANCE TO CLINICAL PRACTICE

If this problem is left unaddressed, the health and quality of life of people with SCI will continue to be compromised. Nursing scope of practice needs to be clarified and communicated to nurses outside specialist spinal injury units in relation to their role in maintaining bowel care regimes recommended for their patients by spinal specialists, and nurses need to ensure they possess the skills required. To allocate the time needed to provide this care, individual nurses need the support of the whole nursing team, including managers who are prepared to arrange additional staff when needed.

Excretory dysfunction and quality of life after a spinal cord injury: A cross-sectional study

AIMS AND OBJECTIVES

To determine the aspects of excretory dysfunction most influential in determining the quality of life of survivors of spinal cord injury.

BACKGROUND

Excretory dysfunction is one of the most common and troublesome sequelae of spinal cord injury. Previous studies have shown that it can restrict social participation restriction, cause readmission and generally influence quality of life substantially.

DESIGN

A cross-sectional survey of hospital inpatients following STOBE guidelines.

METHODS

A convenience sample of 101 patients with traumatic or non-traumatic spinal cord injury were asked about their experiences of excretory dysfunction, and management and their self-perceived quality of life. Univariate analysis and multiple linear regression were performed to isolate the most important relationships.

RESULTS

Only 2 of the 101 subjects professed to be unaffected by excretion dysfunction. Bladder-related dysfunction was the most frequently mentioned type of problem. Quality of life impairment was found to be most often associated with bladder accidents, bowel accidents and having more than one bladder complications.

CONCLUSIONS

Excretory dysfunction substantially impacts quality of life after a spinal cord injury. Bladder accidents, bowel accidents and more than one bladder complication are factors independently influencing the quality of life of spinal cord injury survivors.

RELEVANCE TO CLINICAL PRACTICE

To improve excretion-related QOL, patients' bladder and bowel self-management training should be strengthened seeking to prevent complications and reduce the risk of bladder and bowel accidents.

Current State of Knowledge on Digital Rectal Stimulation in Individuals With Traumatic and Nontraumatic Spinal Cord Injury: A Scoping Review

OBJECTIVES

To map and characterize the nature of the evidence on the use of digital rectal stimulation for bowel management in individuals with spinal cord injury (SCI).

DATA SOURCES

Five electronic databases were searched (ie, MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and Cochrane Incontinence Group) from 1990 to November 2019.

STUDY SELECTION

Articles that provided information on the use of digital rectal stimulation either alone or in combination with treatments were included. Title and abstract screening was split between 2 reviewers after reaching consensus on the first 100 studies screened. Full-texts were reviewed independently by 2 reviewers. Discrepancies were resolved by a third reviewer.

DATA EXTRACTION

The data extraction form was developed by 2 reviewers and piloted. Data were extracted by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

A total of 4841 studies were screened, including 425 full text articles; 33 articles were identified. Thirty-two studies focused solely on individuals with SCI and 1 study explored the experiences of caregivers of individuals with SCI. The majority of participants were aged between 30 and 59 years old. Most studies used quantitative methods (n=30, 91%). Fourteen of the studies (42%) were cross-sectional. Within experimental or quasiexperimental designs, digital rectal stimulation was commonly studied as an adjunct to other methods such as suppositories or enemas. Incontinence and defecation time were the most commonly examined outcomes.

CONCLUSION

There were few studies found that focus on digital rectal stimulation. Further studies examining experience, effectiveness, complications, and long-term outcomes are warranted.

An open prospective study on the efficacy of Navina Smart, an electronic system for transanal irrigation, in neurogenic bowel dysfunction

Background

Transanal irrigation (TAI) has emerged as a key option when more conservative bowel management does not help spinal cord injured (SCI) individuals with neurogenic bowel dysfunction (NBD).

Aim

To investigate the short-term efficacy and safety of an electronic TAI system (Navina Smart) in subjects with NBD.

Design

We present an open, prospective efficacy study on Navina Smart, in individuals with NBD secondary to SCI, studied at three months.

Population

Eighty-nine consecutive consenting established SCI individuals (61 male; mean age 48, range 18–77) naïve to TAI treatment were recruited from ten centres in seven countries. Subjects had confirmed NBD of at least moderate severity (NBD score ≥10).

Methods

Subjects were taught how to use the device at baseline assisted by the Navina Smart app, and treatment was tailored during phone calls until optimal TAI regime was achieved. The NBD score was measured at baseline and at three months follow up (mean 98 days). Safety analysis was performed on the complete population while per protocol (PP) analysis was performed on 52 subjects.

Results

PP analysis showed a significant decrease in mean NBD score (17.8 to 10, p<0.00001). In subjects with severe symptoms (defined as NBD score ≥14), mean NBD scores decreased (19.4 to 10.9, p<0.0001). The number of subjects with severe symptoms decreased from 41 (79%) subjects at baseline to 16 (31%) at three months follow-up. Device failure accounted for the commonest cause for loss of data. Side effects possibly related to the device developed in 11 subjects (12%). Discontinuation due to failure of therapy to relieve symptoms was reported by 5 subjects (6%).

Conclusion

Navina Smart is effective for individuals with NBD, even those with severe symptoms; long-term data will follow. Whilst there were some device problems (addressed by the later stages of subject recruitment) the treatment was generally safe.

Clinical trial

(ClinicalTrials.gov number NCT02979808)

The Monitoring Efficacy of Neurogenic Bowel Dysfunction Treatment on Response (MENTOR) in a Non-Hospital Setting

BACKGROUND

Most patients with a spinal cord injury (SCI) suffer from neurogenic bowel dysfunction (NBD). In spite of well-established treatment algorithms, NBD is often insufficiently managed. The Monitoring Efficacy of Neurogenic bowel dysfunction Treatment On Response (MENTOR) has been validated in a hospital setting as a tool to support clinical decision making in individual patients. The objective of the present study was to describe clinical decisions recommended by the MENTOR (either "monitor", "discuss" or "act") and the use of the tool to monitor NBD in a non-hospital setting.

METHODS

A questionnaire describing background data, the MENTOR, ability to work and participation in various social activities was sent by mail to all members of The Danish Paraplegic Association.

RESULTS

Among 1316 members, 716 (54%) responded, 429 men (61%) and 278 women (39%), aged 18 to 92 (median 61) years. Based on MENTOR, the recommended clinical decision is to monitor treatment of NBD in 281 (44%), discuss change in treatment in 175 (27%) and act/change treatment in 181 (28%). A recommendation to discuss or change treatment was associated with increasing age of the respondent (p = 0.016) and with impaired ability to work or participate in social activities (p < 0.0001).

CONCLUSION

A surprisingly high proportion of persons with SCI have an unmet need for improved bowel care. The MENTOR holds promise as a tool for evaluation of treatment of NBD in a non-hospital setting.

Effects of Lower Thoracic Spinal Cord Stimulation on Bowel Management in Individuals With Spinal Cord Injury

OBJECTIVE

To systematically determine whether use of the spinal cord stimulation (SCS) system to restore cough may improve bowel management (BM) in individuals with spinal cord injury (SCI).

DESIGN

Experimental studies (clinical trial).

SETTING

Inpatient hospital setting for electrode insertion; outpatient setting for measurement of respiratory pressures; home setting for application of SCS.

PARTICIPANTS

Participants (N=5) with cervical SCI.

INTERVENTION

A fully implantable SCS cough system was surgically placed in each subject. SCS was applied at home, 2-3 times/d, on a chronic basis, every time bowel regimen was performed and as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation, which was used as an index of expiratory muscle strength. Participants also used SCS during their bowel routine.

MAIN OUTCOME MEASURES

Airway pressure generation achieved with SCS. Weekly completion of Bowel Routine Log including BM time, mechanical measures, and medications used.

RESULTS

Mean pressure during spontaneous efforts was 30±8 cmH₂O. After a period of reconditioning, SCS resulted in pressure of 146±21 cmH₂O. The time required for BM routines was reduced from 118±34 minutes to 18±2 minutes (P<.05) and was directly related to the magnitude of pressure development during SCS. Mechanical methods for BM were completely eliminated in 4 patients. No patients experienced fecal incontinence as result of SCS. Each participant also reported marked overall improvement associated with BM.

CONCLUSIONS

Our results of this pilot study suggest that SCS to restore cough may be a useful method to improve BM and life quality for both patients with SCI and their caregivers. Our results indicate that the improvement in BM is secondary to restoration of intra-abdominal pressure development.

Enteric Nervous System Remodeling in a Rat Model of Spinal Cord Injury: A Pilot Study

The physiopathology of digestive disorders in patients with spinal cord injury (SCI) remains largely unknown, particularly the involvement of the enteric nervous system (ENS). We aimed in a rat model of chronic thoracic SCI to characterize (1) changes in the neurochemical coding of enteric neurons and their putative consequences upon neuromuscular response, and (2) the inflammatory response of the colon. Ex vivo motility of proximal and distal colon segments of SCI and control (CT) rats were studied in an organ chamber in response to electrical field stimulation (EFS) and bethanechol. Immunohistochemical analysis of proximal and distal segments was performed using antibodies again Hu, neuronal nitric oxide synthase, (nNOS), and choline acetyltransferase. Colonic content of acetylcholine and acetylcholinesterase was measured; messenger RNA (mRNA) expression of inflammatory cytokines was measured using reverse transcription quantitative polymerase chain reaction (RT-qPCR) approaches. Compared with the CT rats, the contractile response to bethanechol was significantly decreased in the proximal colon of SCI rats but not in the distal colon. The proportion of nNOS immunoreactive (IR) neurons was significantly reduced in the proximal but not distal colon of SCI rats. No change in proportion of choline acetyltransferase (ChAT)-IR was reported; the tissue concentration of acetylcholine was significantly decreased in the proximal colon of SCI rats. The expression of tumor necrosis factor alpha (TNF-α) and intercellular adhesion molecule-1 (ICAM-1) was significantly reduced in the proximal and distal colon of SCI rats. This study demonstrates that functional motor and enteric neuroplastic changes affect preferentially the proximal colon compared with the distal colon. The underlying mechanisms and factors responsible for these changes remain to be discovered.

Needs, priorities, and attitudes of individuals with spinal cord injury toward nerve stimulation devices for bladder and bowel function: a survey

Study Design:

Survey.

Objectives:

To investigate the needs and priorities of people with spinal cord injury for managing neurogenic bladder and bowel function and to determine their willingness to adopt neuromodulation interventions for these functions.

Methods:

Anonymous online survey. It was advertised by word-of-mouth by community influencers and social media, and by advertisement in newsletters of advocacy groups.

Results:

Responses from 370 individuals (27% female, 73% male) were included. Bladder emptying without catheters was the top priority for restoring bladder function, and maintaining fecal continence was the top priority for restoring bowel function. The biggest concerns regarding external stimulation systems were wearing a device with wires connecting to electrodes on the skin and having to don and doff the system daily as needed. The biggest concerns for implanted systems were the chances of experiencing problems with the implant that required a revision surgery or surgical removal of the whole system. Respondents were willing to accept an external (61%) or implanted (41%) device to achieve improved bladder or bowel function.

Conclusions:

Bladder and bowel dysfunction remain important unmet challenges for individuals living with SCI who answered our survey. These individuals are willing to accept some potential risks of nerve stimulation approaches given potential benefits. Additional consumer input is critical for guiding both research and translation to clinical use and personalized medicine.

Diet in neurogenic bowel management: A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.

Development of a novel neurogenic bowel patient reported outcome measure: the Spinal Cord Injury Patient Reported Outcome Measure of Bowel Function & Evacuation (SCI-PROBE)

STUDY DESIGN

Outcome measure item generation and reduction.

OBJECTIVES

To develop a patient reported outcome measure (PROM) addressing the impact of neurogenic bowel dysfunction (NBD) on individuals living with traumatic or nontraumatic spinal cord injury (SCI).

SETTING

Tertiary rehabilitation center in Toronto, Canada.

METHODS

A PROM based on the International Classification of Functioning, Disability and Health (ICF) framework was developed using the following steps: (a) item generation, (b) item refinement through iterative review, (c) completion of items by individuals living with SCI and NBD followed by cognitive interviewing, and (d) further item refinement, item reduction, and construction of the preliminary PROM.

RESULTS

Following initial item generation and iterative review, the investigative team agreed on 55 initial items. Cognitive interviewing, additional revisions, and item reduction yielded an instrument comprised of 35 items; while ensuring at least two items were retained for each of the 16 previously identified challenges of living with NBD following the onset of a SCI. Scoring for the preliminary PROM ranges from 0 to 140.

CONCLUSIONS

A preliminary PROM informed by the ICF for assessing the impact of NBD post-SCI has been devised, which can be used to inform clinicians and decision-makers on optimal ways to treat this serious secondary health complication. Future work will assess the validity and clinimetric properties of the PROM.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Bowel function and care: Guidelines for the care of people with spina bifida

PURPOSE

Bowel dysfunction, such as constipation and fecal incontinence, has a significant impact on health, activities of daily living, and quality of life among people with spina bifida. Secondary complications may result from bowel dysfunction and include urologic dysfunction, loss of skin integrity, shunt (hydrocephalus) function, as well as loss of social opportunities and employability.

METHODS

Using a consensus building methodology, the guidelines for management of bowel dysfunction in spina bifida were written by experts in the field of spina bifida and bowel function and care.

RESULTS

The evidence-based guidelines are presented in table format and provide age-specific recommendations to achieve fecal continence without constipation. Recommended treatments are presented from least to most invasive options. Literature supporting the recommendations and the interval research published to date is also presented.

CONCLUSION

These guidelines present a standardized approach to management of bowel dysfunction in spina bifida. Bowel management in children and young adults with spina bifida is limited by variability in clinical practice and paucity of robust research in neurogenic bowel. Collaborative multi-institutional efforts are needed to overcome research barriers and provide innovative solutions.

Prioritization of rehabilitation Domains for establishing spinal cord injury high performance indicators using a modification of the Hanlon method: SCI-High Project

Objectives: To prioritize Domains of SCI Rehabilitation Care (SCI-Care) based on clinical importance and feasibility to inform the development of indicators of quality SCI-Care for adults with SCI/D in Canada. Methods: A 17-member external advisory committee, comprised of key stakeholders, ranked 15/37 Domains of rehabilitation previously flagged by the E-scan project team for gaps between knowledge generation and clinical implementation. Priority scores (D) were calculated using the Hanlon formula: D=[A+(2×B)]×C , where A is prevalence, B is seriousness, and C is the effectiveness of available interventions. A modified "EAARS" (Economic, Acceptability, Accessibility, Resources, and Simplicity) criterion was used to rank feasibility on a scale of 0-4 (4 is high). The product of these two scores determined the initial Domain ranking. Following the consensus process, further changes were made to the Domain rankings. Results: Despite a low feasibility score, Sexual Health was ranked as high priority; and, the Community Participation and Employment Domains were merged. The 11 final prioritized Domains in alphabetic order were: Cardiometabolic Health; Community Participation and Employment; Emotional Well-Being; Reaching, Grasping, and Manipulation; Self-Management; Sexual Health; Tissue Integrity; Urinary Tract Infection; Urohealth; Walking, and Wheeled Mobility. Conclusions: The modified Hanlon method was used to facilitate prioritization of 11 of 37 Domains to advance the quality of SCI-care by 2020. In future, the Spinal Cord Injury Rehabilitation Care High Performance Indicators (SCI-High) Project Team will develop structure, process and outcome indicators for each prioritized Domain.

Dietary management of neurogenic bowel in adults with spinal cord injury: an integrative review of literature

OBJECTIVE

To examine the literature for current evidence on the dietary management of neurogenic bowel in adults with spinal cord injuries (SCIs).

BACKGROUND

Neurogenic bowel dysfunction presenting as faecal incontinence or constipation is a common occurrence in individuals with SCI. It poses numerous challenges for the management of bowel function and has a significant impact on quality of life following SCI. Dietary management is a common, early treatment strategy as a conservative approach for neurogenic bowel; however, current recommendations rely on expert opinion only.

METHODS

An integrative review of the literature using a systematic search was conducted using Medline, Embase, CINAHL, Proquest, and Google Scholar. The selected articles were critically appraised using Critical Appraisal Skills Programme checklists by two independent reviewers. The risk of bias of studies and the quality of evidence for outcomes were assessed using the risk of bias tool and the grading of recommendations, assessment, development, and evaluation system in the Cochrane handbook for systematic review of interventions.

RESULTS

Thirteen studies that met the inclusion criteria were identified exploring a variety of diet-related factors: foods, dietary behaviours, and multiple interventions including a diet plan. However, the dietary management strategies used varied significantly between studies, posing challenges to ascertain its efficacy.

CONCLUSION

Given the low level of evidence and paucity of data on dietary management of neurogenic bowel, the efficacy of dietary strategies (alone or in combination with others) in managing neurogenic bowel cannot be substantiated from the studies identified. Therefore, more robust studies are warranted to bridge this gap.IMPLICATIONS FOR REHABILITATIONConsumption of ∼15 g dietary fibre is shown to be beneficial in managing neurogenic bowel in SCI.Further research is required to strengthen evidence for fibre recommendations and investigating the potential benefits of traditional and non-traditional dietary approaches.

Beyond the Diagnosis: Lived Experiences of Persons with Spinal Cord Injury in a Selected Town in Ghana

Background

Although several studies have been conducted on the lived experiences of persons with spinal cord injury (SCI) in high income countries, there is no published data on such experiences in Ghana. The purpose of this study was to explore the lived experiences of persons with SCI in the Tamale Metropolis of the Northern Region of Ghana.

Material and Methods

A qualitative descriptive design involving thirteen participants was conducted at the Tamale Metropolis-Ghana. A purposive sampling technique was used to recruit participants, using the Neurosurgical Unit of the Tamale Teaching Hospital as an outlet for recruitment of the sample. Data was gathered mainly through face-to-face in-depth interviews. The data was analyzed concurrently with data collection, using thematic content analysis. Ethical approval was obtained for the study from the Noguchi Memorial Institute for Medical Research and the research unit of the Tamale Teaching Hospital.

Results

The three main themes that emerged from the data during analysis were “physical effects,” “psychological effects,” and “social issues.” Conclusion. The findings from the study suggest that SCI is a life threatening condition and that persons with SCI grapple with a myriad of physical symptoms that range from chronic pain and paralysis of lower and/or upper limbs, to bladder and bowel incontinence. These physical symptoms have significant psychological and social effects on the functioning of the affected persons.

Bowel Control Strategies Used by Veterans With Long-Standing Spinal Cord Injuries

STUDY PURPOSE

The aim of the study was to describe strategies used by veterans with spinal cord injury to achieve control over bowel function and fit their bowel programs into their lifestyles in the years following the initial injury.

METHODS/DESIGN

Using a qualitative descriptive design, 18 outpatient veterans with spinal cord injuries were interviewed at a Veteran's Administration hospital. Recorded interviews were transcribed verbatim and analyzed to determine major themes.

FINDINGS/CONCLUSIONS

Fourteen of 18 participants had gained control over bowel function and led active lives. They emphasized the importance of positive attitudes, listening to their bodies, being physically active, taking charge, and using trial and error to find the best bowel control strategies. Findings also highlighted the value of peer support and the problem of military service connected back injury leading to spinal cord injury.

CLINICAL RELEVANCE

Participants provided practical advice for adapting strategies learned during rehabilitation for long-term bowel control after discharge home.

Reduced colonic smooth muscle cholinergic responsiveness is associated with impaired bowel motility after chronic experimental high-level spinal cord injury

The mechanisms underlying bowel dysfunction after high-level spinal cord injury (SCI) are poorly understood. However, impaired supraspinal sympathetic and parasympathetic control is likely a major contributing factor. Disruption of the descending autonomic pathways traversing the spinal cord was achieved by a T3 complete spinal cord transection, and colonic function was examined in vivo and ex vivo four weeks post-injury. Total gastrointestinal transit time (TGTT) was reduced and contractility of the proximal and distal colon was impaired due to reduced M₃ receptor sensitivity. These data describe a clinically relevant model of bowel dysfunction after SCI.

Bowel Dysfunction in Spinal Cord Injury

PURPOSE OF REVIEW

To evaluate and report current evidence regarding the management of bowel dysfunction in spinal cord injury. There is a paucity of high-quality large studies on which to base management advice.

RECENT FINDINGS

Recent research has focused on defining the nature of symptomatology of bowel dysfunction in SCI and describing the effects on quality of life and social interactions. Technical aspects of colonoscopy have received attention, and aspects of understanding the pathophysiology in relation to both neural and non-neural dysfunction have been studied. There has been refinement and expansion of the pharmacological and non-pharmacological treatment options for bowel dysfunction in SCI. Management of bowel dysfunction in SCI requires a comprehensive and individualized approach, encompassing lifestyle, toileting routine, stimulation, diet, medications, and surgery. Further high-quality research is required to inform best practice.

Identifying and Classifying Quality of Life Tools for Assessing Neurogenic Bowel Dysfunction After Spinal Cord Injury

Objectives: To identify and classify tools for assessing the influence of neurogenic bowel dysfunction (NBD) on quality of life (QoL) after spinal cord injury (SCI). Methods: In this systematic review, MEDLINE/PubMed, CINAHL, and PsycInfo were searched to identify studies assessing the influence of NBD on QoL (or related construct) after SCI. Two independent reviewers screened titles and abstracts, and both reviewers classified tools as subjective or objective according to Dijkers' theoretical QoL framework. Results: Seventy-two studies were identified, and 35 studies met the inclusion criteria. Five objective measures assessed the influence of NBD on QoL, which were validated for use in SCI, but no measure was condition-specific to NBD. Eight measures were classified as subjective tools; two had an established reliability and validity for SCI while six had some psychometric evidence for use in the SCI population. Five subjective measures (NBD score, Burwood QoL Questionnaire, Impediments to Community Integration [ICI] Scale, SCI-QoL Bowel Management Difficulties, and Survey of Neurogenic Bowel Characteristics) were developed specifically for SCI. The NBD score showed sensitivity to the influence of NBD on QoL in experimental trials. Conclusion: Thirteen tools assessed the influence of NBD on QoL in SCI. Although not developed specifically for SCI, the Health Utility Index (HUI-III) was the only tool identified that provided data on "QoL as utility" on the impact of NBD. The validated NBD score was the only condition-specific tool to assess QoL as "subjective well-being." Further validation of existing tools could help to inform practice and policy related to resource allocation for bowel care post SCI.

Assessment of neurogenic bowel dysfunction impact after spinal cord injury using the International Classification of Functioning, Disability and Health

BACKGROUND

Bowel function is frequently compromised after spinal cord injury (SCI). Regardless of this crucial importance in patients' lives, there is still scarce literature on the Neurogenic Bowel Dysfunction (NBD) deleterious impact on SCI patient's lives and only few studies correlating NBD severity with quality of life (QoL). To our knowledge there are no studies assessing the impact of NBD on the context of ICF domains.

AIM

To assess NBD after SCI using ICF domains and to assess its impact in QoL.

DESIGN

Retrospective data analysis and cross-sectional phone survey.

SETTING

Outpatient spinal cord injury setting.

POPULATION

Portuguese adult spinal cord injury patients.

METHODS

Retrospective analysis of demographic data, lesion characteristics and bowel management methods at last inpatient discharge. Cross-sectional phone survey assessing current bowel management methods, the Neurogenic Bowel Dysfunction Score and a Likert Scale questionnaire about the impact on ICF domains and QoL.

RESULTS

Sixty-four patients answered the questionnaire. The majority was male (65.6%), mean age 56.6±15.6 years, AIS A lesion (39.1%), with a traumatic cause (71.9%). The main bowel management methods were contact laxatives, suppositories and osmotic laxatives. 50.1% of patients scored moderate or severe NBD. Considering ICF domains, the greatest impact was in personal and environmental factors, with 39.1% reporting impact in financial costs, 45.3% in need of assistance, 45.3% in emotional health and 46.9% in loss of privacy. There was a significant association between severity of NBD and negative impact on QoL (P<0.05).

CONCLUSIONS

The study confirms the major impact of NBD on personal and environmental factors of ICF and on the quality of life of SCI population.

CLINICAL REHABILITATION IMPACT

These findings confirm that it is relevant to identify the main ICF domains affected by NBD after SCI in order to address targeted interventions, working toward changes in health policies and psychosocial aspects.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Stigma and self-management: an Interpretative Phenomenological Analysis of the impact of chronic recurrent urinary tract infections after spinal cord injury

Study design

Qualitative, phenomenological design.

Objectives

Neurogenic bladder dysfunction and urinary tract infection (UTI) are common secondary consequences to neurological damage to the spinal cord. This study sought to establish the impact of chronic, recurrent UTIs on people with spinal cord injury (SCI).

Setting

Community sample, United Kingdom.

Methods

Twelve participants with SCI, aged between 28 and 68 years, who had experienced at least three recurrent UTI events within the previous 12 months were recruited. Detailed qualitative information was obtained from semi-structured interviews, which lasted between 30 and 60 min. Interpretative Phenomenological Analysis was performed to explore the lived experience of UTIs.

Results

Interview findings identified a range of factors related to the experience of recurrent UTIs in people with SCI. These were classified into the following themes: (1) Symptom Management Precedence, (2) Stigma-Motivated Risk Management and (3) Exhaustive Exploration of Treatment Options. Participants discussed management of acute exacerbations. Distress arose from perceptions of UTIs as potentially stigmatizing and fear of relying on antibiotics. Arising from this fear, many participants sought alternative prevention and management strategies.

Conclusions

These results suggest that chronic recurrent UTIs act as major barriers to social participation, with adverse effects on quality of life of people with a neurogenic bladder after SCI. People with SCI would benefit from additional assessment of the impact of recurrent UTIs, so that healthcare professionals can address specific concerns, such as the psychosocial impact of urinary incontinence and stigmatizing views. Additional support to enhance self-management and facilitate social participation should be provided.

Neural pathways for colorectal control, relevance to spinal cord injury and treatment: a narrative review

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose is to review the organisation of the nerve pathways that control defecation and to relate this knowledge to the deficits in colorectal function after SCI.

METHODS

A literature review was conducted to identify salient features of defecation control pathways and the functional consequences of damage to these pathways in SCI.

RESULTS

The control pathways for defecation have separate pontine centres under cortical control that influence defecation. The pontine centres connect, separately, with autonomic preganglionic neurons of the spinal defecation centres and somatic motor neurons of Onuf's nucleus in the sacral spinal cord. Organised propulsive motor patterns can be generated by stimulation of the spinal defecation centres. Activation of the somatic neurons contracts the external sphincter. The analysis aids in interpreting the consequences of SCI and predicts therapeutic strategies.

CONCLUSIONS

Analysis of the bowel control circuits identifies sites at which bowel function may be modulated after SCI. Colokinetic drugs that elicit propulsive contractions of the colorectum may provide valuable augmentation of non-pharmacological bowel management procedures.

Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury

STUDY DESIGN

Exploratory qualitative.

OBJECTIVES

The aim of this study was to describe the experiences of bowel and bladder dysfunction on social activities and relationships in people with spinal cord injury living in the community.

SETTING

People living with spinal cord injury experiencing bowel and bladder dysfunction.

METHODS

Participants were recruited through the Australian Quadriplegic Association Victoria. Semi-structured in-depth interviews were undertaken with purposively selected participants to ensure representation of age, gender, spinal cord injury level and compensation status. A thematic analysis was performed to interpret patient experiences.

RESULTS

Twenty-two participants took part in the study. Bladder and bowel dysfunction altered relationships because of issues with intimacy, strained partner relationships and role changes for family and friends. A lack of understanding from friends about bladder and bowel dysfunction caused frustration, as this impairment was often responsible for variable attendance at social activities. Issues with the number, location, access and cleanliness of bathrooms in public areas and in private residences negatively affected social engagement. Social activities were moderated by illness, such as urinary tract infections, rigid and unreliable bowel routines, stress and anxiety about incontinence and managing the public environment, and due to continuous changes in plans related to bowel and bladder issues. Social support and adaptation fostered participation in social activities.

CONCLUSION

Tension exists between managing bowel and bladder dysfunction and the desire to participate in social activities. Multiple intersecting factors negatively affected the social relationships and activities of people with spinal cord injury and bowel and bladder dysfunction.

Factors Which Facilitate or Impede Interpersonal Interactions and Relationships after Spinal Cord Injury: A Scoping Review with Suggestions for Rehabilitation

Interpersonal interactions and relationships can influence an individual's perceptions of health and quality of life in the presence of disability. In the case of people with spinal cord injury (SCI), positive interpersonal interactions and relationships have been shown to contribute to resilience and adaptability. Understanding factors which facilitate or impede the development and maintenance of relationships after SCI may form the basis for proactive relationship support for people with SCI. To gain a broad insight into these factors, a scoping review was undertaken. Databases were searched for English language studies published between 2000 and 2015 that informed the review question. Sixty-two (62) studies were identified. Thematic analysis was conducted on data extracted from the studies and 51 factors which may facilitate relationships and 38 factors which may impede relationships after SCI were noted. The majority of factors could be categorized as environmental or personal according to the domains of the International Classification of Functioning, Disability, and Health (ICF). The facilitating factors included partner and social support, reciprocity in relationships, and presenting oneself positively. Impeding factors included physical environmental barriers, real and perceived social biases, and poor self-image. Factors identified may inform the provision of supportive, holistic rehabilitation for people with SCI.

Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury

OBJECTIVES

To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI).

DESIGN

Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews.

SETTING

Community.

PARTICIPANTS

Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time.

RESULTS

At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05).

CONCLUSIONS

Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Effects of disability on pregnancy experiences among women with impaired mobility

OBJECTIVE

Little is known about how functional impairments might affect the pregnancies of women with mobility disability. We aimed to explore complications that arise during pregnancy that are specifically related to physical functional impairments of women with significant mobility disabilities.

DESIGN

Qualitative descriptive analysis.

SETTING

Telephone interviews with women from 17 USA states.

SAMPLE

22 women with significant mobility difficulties who had delivered babies within the prior 10 years; most participants were recruited through social networks.

METHODS

We conducted 2-h, in-depth telephone interviews using a semi-structured, open-ended interview protocol. We used NVIVO software to sort interview transcript texts for conventional content analyses.

MAIN OUTCOME MEASURES

Functional impairment-related complications during pregnancy.

RESULTS

The women's mean (standard deviation) age was 34.8 (5.3) years. Most were white, well-educated, and higher income; eight women had spinal cord injuries, four cerebral palsy, and 10 had other conditions; 18 used wheeled mobility aids; and 14 had cesarean deliveries (eight elective). Impairment-related complications during pregnancy included: falls; urinary tract and bladder problems; wheelchair fit and stability problems that reduced mobility and compromised safety; significant shortness of breath, sometimes requiring respiratory support; increased spasticity; bowel management difficulties; and skin integrity problems (this was rare, but many women greatly increased skin monitoring during pregnancy to prevent pressure ulcers).

CONCLUSIONS

In addition to other pregnancy-associated health risks, women with mobility disabilities appear to experience problems relating to their functional impairments. Pre-conception planning and in-depth discussions during early pregnancy could potentially assist women with mobility disabilities to anticipate and address these difficulties.