Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

Recent Developments in On-Demand Voiding Therapies

One cannot survive without regularly urinating and defecating. People with neurologic injury (spinal cord injury, traumatic brain injury, stroke) or disease (multiple sclerosis, Parkinson's disease, spina bifida) and many elderly are unable to voluntarily initiate voiding. The great majority of them require bladder catheters to void urine and "manual bowel programs" with digital rectal stimulation and manual extraction to void stool. Catheter-associated urinary tract infections frequently require hospitalization, whereas manual bowel programs are time consuming (1 to 2 hours) and stigmatizing and cause rectal pain and discomfort. Laxatives and enemas produce defecation, but onset and duration are unpredictable, prolonged, and difficult to control, which can produce involuntary defecation and fecal incontinence. Patients with spinal cord injury (SCI) consider recovery of bladder and bowel function a higher priority than recovery of walking. Bladder and bowel dysfunction are a top reason for institutionalization of elderly. Surveys indicate that convenience, rapid onset and short duration, reliability and predictability, and efficient voiding are priorities of SCI individuals. Despite the severe, unmet medical need, there is no literature regarding on-demand, rapid-onset, short-duration, drug-induced voiding therapies. This article provides in-depth discussion of recent discovery and development of two candidates for on-demand voiding therapies. The first, [Lys3,Gly8,-R-γ-lactam-Leu9]-NKA(3-10) (DTI-117), a neurokinin2 receptor agonist, induces both urination and defecation after systemic administration. The second, capsaicin (DTI-301), is a transient receptor potential cation channel subfamily V member 1 (TRPV1) receptor agonist that induces defecation after intrarectal administration. The review also presents clinical studies of a combination drug therapy administered via iontophoresis and preclinical studies of neuromodulation devices that induce urination and defecation. SIGNIFICANCE STATEMENT: A safe and effective, on-demand, rapid-onset, short-duration, drug-induced, voiding therapy could eliminate or reduce need for bladder catheters, manual bowel programs, and colostomies in patient populations that are unable to voluntarily initiate voiding. People with spinal injury place more importance on restoring bladder and bowel control than restoring their ability to walk. This paradigm-changing therapy would reduce stigmatism and healthcare costs while increasing convenience and quality of life.

Bowel and Bladder Dysfunction after SCI: A Comparison between India and Canada

Background

The inclusion of people living with spinal cord injury (SCI) in research has allowed for an informed understanding of priorities of recovery of which bowel dysfunction and bladder dysfunction have been continuously identified. Research has also demonstrated the global disparities in SCI outcomes particularly when comparing high- and low-income countries. Currently, there is a lack of direct comparison between countries when assessing SCI outcomes.

Objectives

This is an exploratory study to better understand bowel and bladder dysfunction amongst individuals with SCI in India and Canada.

Methods

Data from 33 participants were analyzed. Participants completed an online questionnaire assessing demographic information and the Neurogenic Bowel Dysfunction (NBD) score, Wexner score, Neurogenic Bladder Symptom Score (NBSS), and the Incontinence Quality of Life Instrument (I-QOL). Continuous data were compared using t tests. For not normally distributed data, the independent Mann-Whitney U test was used. Categorical variables were evaluated for association using Fisher's exact or chi-square test, depending on the sample size.

Results

Independent Mann-Whitney U test demonstrated that the Canadian participants had poorer bowel function with higher total NBD scores (p = .007) and less frequent bowel movements (p = .036), and they were more likely to experience uneasiness, headaches, and perspiration during bowel movements (p < .001). NBSS results indicated a small but significantly higher proportion of the Indian participants were unsatisfied or unhappy with their bladder function (p = .049). The distribution of Wexner and I-QOL scores were the same across countries.

Conclusion

Potential explanations for differences include lifestyle, management, financial resources, patient and caregiver education, and societal pressures, which are all heavily influenced by cultural, geographical, and economic circumstances.

Bowel Management in the Acute Phase of Spinal Cord Injury

ABSTRACT

BACKGROUND: Neurogenic bowel and bladder are well-known complications of spinal cord injury. During the acute phase of recovery from spinal cord injury, spinal shock occurs, resulting in loss of reflexes and peristalsis of the gastrointestinal tract. These impairments can result in complications in the gastrointestinal tract and, secondarily, the respiratory system due to the distention of the abdomen. Current guidelines for bowel management target the chronic phase of spinal cord injury after a diagnosis of neurogenic bowel dysfunction can be made. METHODS: The purpose of this literature review was to determine evidence-based recommendations for bowel management during the acute phase of spinal cord injury. A systematic search using the databases CINAHL, PubMed, Cochrane Library, and ProQuest was used to identify relevant evidence. RESULTS: The available evidence is based on expert consensus, is dated, and tends to be based on studies conducted during the chronic phase of injury. Careful assessment of the symptoms of bowel dysfunction would indicate that during the acute phase of spinal cord injury, spinal shock causes a patient to experience an areflexive bowel pattern where bowel motility is limited and reflexes are absent. Management of areflexive bowel includes establishment of a daily bowel program including manual removal of stool. To improve emptying of stool, factors such as rectal and oral medications, fluid, fiber, and activity may be adjusted according to need. CONCLUSION: There is limited evidence focused specifically on bowel management in the acute phase of spinal cord injury. Bowel management is complex and multifaceted and needs to be individualized to the patient as well as frequently reevaluated with changes in condition. Further research is needed to evaluate outcomes for bowel management in the acute phase of spinal cord injury to promote best practices.

Autonomic impairment is not explained by neurological level of injury or motor-sensory completeness

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Determine how well common clinical assessments of level and completeness of injury are correlated with symptoms of autonomic blood pressure instability and secondary medical complications after spinal cord injury (SCI).

SETTING

Academic medical center, United States.

METHODS

Eighty-two individuals with (n = 48) and without (n = 34) SCI had symptoms of autonomic blood pressure instability quantified with the Autonomic Dysfunction Following SCI (ADFSCI) survey. Health histories quantified the secondary medical complications through number of urinary tract infections and hospitalizations in the past year, time to complete bowel program, and lifetime pressure injuries. Regression models were completed to identify strengths of associated correlations.

RESULTS

ADFSCI scores were significantly higher in individuals with SCI than controls. Neurological level of injury and ASIA impairment scale were both minimally correlated to symptoms of autonomic blood pressure instability, accounting for only 11.5% of variability in regression models. Secondary medical complications had similar, minimal correlations to level and motor/sensory completeness of SCI (R2 = 0.07 and R2 = 0.03 respectively). Contrasting this, symptoms of blood pressure instability on ADFSCI far outperformed the common clinical motor/sensory bedside exam, with moderately strong correlations to the ranked number of secondary medical complications after SCI (R2 = 0.31).

CONCLUSION

Neurological level of injury and motor/sensory completeness provided limited insights into which individuals with SCI would have blood pressure instability or secondary medical complications. Interestingly, symptoms of blood pressure instability outperform the clinical motor/sensory bedside exam, with higher correlations to secondary medical complications after SCI.

Prevalence and Risk Factors of Constipation in Trauma Patients: A Prospective Cohort Study

BACKGROUND

Hospitalized patients are well described as having a high prevalence of constipation. While the risks associated with constipation in trauma patients are well known, the prevalence rate is not.

OBJECTIVE

This study aims to measure the prevalence of constipation and associated risk factors in trauma patients.

METHODS

This study is a single-center analytic cross-sectional study on constipation in hospitalized trauma patients aged 18-65 years, admitted from January 2021 to July 2021 to the trauma service at The Royal Melbourne Hospital, a Level I major trauma and teaching hospital servicing the state of Victoria, Australia. Exclusion criteria include patients with traumatic brain injury, blunt or penetrating abdominal or spinal injuries, pregnancy, and gastrointestinal comorbidities.

RESULTS

A total of N = 99 patients were studied, of which n = 78 (78.8%) were male with a median (interquartile range) age of 46 years (33-58). The overall prevalence of constipation was 76%. The univariate analysis demonstrated higher constipation rates in males and patients with multisystem injuries. However, in the multivariate analysis, mode of toileting and mobility were not associated with constipation after adjusting for confounding factors.

CONCLUSION

This study demonstrated a high prevalence of constipation in all trauma patients. There is a strong association between the development of constipation in patients with multisystem injuries when compared to those with single system.

Multidisciplinary management of people with spina bifida across the lifespan

The average worldwide prevalence of neural tube defects (NTDs) is 1.0 per 1000 births. Its development is multifactorial due to genetic and non-genetic factors. Spina bifida (SB) is one of main representatives of NTD. The spinal cord lesion level is the main determinant of the level of paralysis, numbness, and difficulties with bladder/bowel functions. Myelomeningocele prenatal repair reduces hydrocephalus and hindbrain herniation and improves motor function. The severity of hydrocephalus is associated with poorer neurodevelopmental outcomes whether operated on prenatally or after birth. People with SB tend to have a lower IQ and cognitive difficulties. Early diagnosis, proactivity, and lifelong multidisciplinary follow-up are key protective issues. Invasive urological interventions should be considered in selected patients after failure of conservative treatment. Transition to adult care should be well planned as it is challenging. Health literacy is directly associated with success at transition. Sexuality and fertility should be addressed before/during puberty. Overall, the rates of fecal and urinary continence and skin breakdown increase with age, whereas the ability to ambulate declines with age. Bowel and urinary incontinence are independent predictors of lower health-related quality of life (HRQoL) in adults with SB. Bowel incontinence has negative impact on HRQoL regardless of frequency or amount. Long-term caregiver support should be offered at diagnosis. Survival at a mean of 50 years is poor, at 32%, due to central nervous system deaths, cancer, urological disease, and sepsis. Challenges to implementation of recommended practices exist, especially in low and middle-income countries.

Role of Rehabilitation in Spine Tumors

ABSTRACT

Primary and metastatic spine tumors can lead to devastating complications, but timely and careful management of these patients can improve outcomes. A multidisciplinary and structured approach is the most effective way to evaluate patients with spine disease and mitigate the risk of complications. The neurologic, oncologic, mechanical and systemic disease framework gives comprehensive guidance to providers regarding appropriate management. Physiatrists play a critical role in these patients' initial evaluation and continued management throughout cancer treatment. Patients with spinal cord involvement have extensive needs, requiring an individualized management approach. Even though patients with nontraumatic spinal cord injury benefit from rehabilitation efforts and have improved outcomes, they are not routinely admitted to inpatient rehabilitation units or referred to outpatient cancer rehabilitation. Ongoing efforts are needed to promote rehabilitation medicine involvement in improving functional outcomes and quality of life for patients with spine involvement.

Experiences of people with spinal cord injuries readmitted for continence-related complications: a qualitative descriptive study

STUDY DESIGN

Qualitative descriptive.

OBJECTIVES

To describe the experiences of people with Spinal Cord Injury (SCI) re-admitted to the hospital due to continence-related complications.

SETTING

Inpatient service of a large spinal unit in North-West of Italy.

METHODS

Semi-structured interviews were conducted on a purposive sample of people with SCI (n = 11; age range 22-66 years, n = 5 females, n = 6 with cervical injuries), audio-recorded, and transcribed verbatim (duration range 38-52 min). Data were analysed inductively using the thematic analysis approach as described by Braun and Clarke.

RESULTS

Three main themes were identified: (i) managing the frustration of continence-related complications; (ii) finding your way to deal with continence-related complications; (iii) identifying precise needs to deal with continence-related complications. Obtained findings highlighted the perceived emotional and physical burden suffered by people with SCI and their caregivers regarding the constant look for solutions and renounces to social participation, the different strategies implemented to address continence-related complications, and the unmet or partially met needs of people with SCI regarding support in transition to the community, infrastructure, and reliable information or education.

CONCLUSIONS

Continence-related complications have a significant impact on the lives of people with SCI and their families. Interventions using technological tools and peer participation could reduce the burden associated with continence-related complications. Specific instruments are needed to facilitate evaluation, goal setting, and promote discussion of continence to allow HCPs to support people with SCI. Structured follow-up for SCI survivors should also focus on their needs to improve knowledge, facilitate decision making, and promote preventive behaviours.

[Rehabilitation after Spinal Cord Injury : Current trends and principles]

Traumatic and non traumatic spinal cord injury are rare and an orphan disease in comparison to common diseases. Those affected represent a very special patient population in the treatment even at the site of the accident and in emergency medicine and require a high level of professional expertise. The rehabilitation with the complexity of a spinal cord injury can only succeed with a multiprofessional team that is less focused on the often similar diagnoses according to the International Classification of Diseases (ICD) but on functional disorders and associated activity impairments. Only then the best possible integration and participation/inclusion in sociocultural and professional life can be achieved. In addition to the importance of classical physiotherapy and occupational therapy, this article highlights important but often missing team players, such as neurourology and electrical stimulation. In addition, the problems of frequent and some less recognized complications, such as autonomic dysfunction and the benefits of airway management are highlighted. For a comprehensive overview of rehabilitation in spinal cord injury, reference textbooks and guidelines are recommended that are cited in the text.

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.

Risk Factors Associated With Suicidal Ideation in Individuals With Spinal Cord Injury

Objective

To assess the frequency of suicidal ideation (SI) among individuals with chronic spinal cord injury (SCI) and to identify risk factors associated with SI.

Design

Cross-sectional.

Setting

Community setting.

Participants

Two hundred and forty-six individuals with chronic SCI participating in the Spinal Cord Injury Model Systems at a Level 1 Trauma center.

Interventions

Not applicable.

Main Outcome Measure

SI, as assessed by question 9 of the Patient Health Questionnaire-9.

Results

Twenty-seven (11.0%) participants endorsed SI; 6 (22.2%) of whom endorsed active SI with a plan of self-harm. Participants who endorsed SI had significantly higher depressive symptoms, lower resilience, and lower satisfaction with life (all Ps<.001). They also had lower perceived health (P<.001), Craig Handicap Assessment & Reporting Technique Short Form (CHART-SF) physical independence (P=.013), and Spinal Cord Injury - Functional Index with Assistive Technology domains of basic mobility (P=.003), self-care (P=.042), and fine motor skills (P=.035). However, participants who endorsed SI were not significantly different in re-hospitalization rates and in other domains of CHART-SF and SCI-AT. Logistic regression, with a forward selection procedure, was used to identify significant predictors of endorsing SI in the context of multiple associated variables. Depressive symptoms (odds ratio [OR]=1.18, P=.020), resilience (OR=0.85, P=.003), and physical independence (OR=0.98, P=.019) remained significant predictors of SI.

Conclusion

Study findings suggest higher levels of SI among people with SCI, a substantial proportion of whom have active SI. Individuals with SCI who endorse SI have greater burden of poor physical and mental health, as well as poorer functional status and adaptation. Interventions targeting multiple dimensions of quality of life may help reduce risk of SI and suicide among individuals with SCI.

Effect of neurogenic bowel dysfunction symptoms on quality of life after a spinal cord injury

BACKGROUND

Neurogenic bowel dysfunction (NBD) is a common problem among people with spinal injury; management of bowel dysfunction and related problems are considered significant factors in daily life after injury. But despite the critical relevance of bowel dysfunction in the daily life of SCI survivors, there have been few published studies on the management of NBD. So, this study aimed to describe the bowel programmers utilized by people with SCI in China and the impact of bowel dysfunction on the quality of life (QoL).

DESIGN

A cross-sectional online survey.

SETTING

Rehabilitation Medicine Department of Wuhan's Tongji Hospital.

PARTICIPANTS

SCI patients who had been diagnosed with neurogenic bowel dysfunction and who were receiving regular medical monitoring at the rehabilitation medicine department were invited to participate in our study.

OUTCOME MEASURES

A neurogenic bowel dysfunction (NBD) score is a questionnaire developed to evaluate the severity of neurogenic bowel dysfunction. A Short Form-12 (SF-12) was designed to measure the quality of life in people with SCI. Demographic and medical status information was extracted from their medical records.

RESULTS

The two questionnaires were sent to 413 SCI patients. Two hundred ninety-four subjects (43.1 ± 14.5 years of age; men, 71.8%) responded. Most of the respondents performed their bowel movement daily 153 (52.0%), a defecation time was 31-60 min among 70 (23.8%) of them, 149 (50.7%) used medication (drops or liquid) to treat constipation, and 169 (57.5%) used digital stimulation more than once per week to boost the bowel evacuation. This study found a significant association between the QoL score and the time used for each defecation, autonomic dysreflexia (AD) symptoms, taking medication to treat fecal incontinence, using digital stimulation, having uncontrollable flatus and perianal skin problems.

CONCLUSION

Management of bowel dysfunction is complex and associated with QoL in people with SCI. Items of the NBD questionnaire that greatly deteriorated the QoL were time in one defecation > 60 min, symptoms of AD during or before defecation, taking medication (drops or liquid), and using digital stimulation. Dealing with those problems can improve the life quality of spinal cord injury survivors.

A Comprehensive Spinal Cord Injury Treatment Protocol Improves Outcomes and Decreases Complications

BACKGROUND

Spinal cord injury (SCI) is a devastating event with a complicated recovery. Through the use of an interdisciplinary team a comprehensive care plan was developed, utilizing all available best practices, to prevent secondary complications. Previous work has shown the benefit of single system protocols or interventions. This study aimed to assess changes in outcomes after implementation of a comprehensive protocol.

MATERIAL AND METHODS

This was a retrospective cohort study performed at an ACS Level I trauma center. It was based on data abstract from the institutions trauma registry over a 10 year period. Patients with quadriplegia after a traumatic injury were included. Data on hospital outcomes and complications was collected and compared before and after the use of the Spinal cord injury protocol.

RESULTS

58 patients were evaluated. Overall, there was a reduction in complications after the implementation, with significant reductions in pneumonia (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). ICU length of stay decreased by 7 days and hospital length of stay decreased 13 days. There was no difference in mortality. Hospital costs also decreased a mean of $42,000.

CONCLUSIONS

A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Lengths of stay and cost were also significantly reduced. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.

Colostomy may offer hope in improving quality of life: a phenomenological qualitative study with patients dependent on a wheelchair

PURPOSE

This study aimed to evaluate the perspectives of patients who had spinal cord injuries and were wheelchair-dependent on colostomy surgery, which is among the bowel movement methods.

METHODS

In this qualitative study, which was based on Heidegger's hermeneutical phenomenological approach, the Van Manen method was used to reveal how patients were affected by their experiences. The data of the study were collected by directly interviewing the patients and using a semi-structured interview guide. The interviews were recorded with a voice recorder device with the permission of the participants. Nine patients who were leading a life dependent on a wheelchair as a result of spinal cord injury made up the sample of the study.

RESULTS

Six of the participants were female. The ages of participants ranged between 32 and 52, and all of them were married. The results of the interviews indicated that the experiences of participants who were dependent on a wheelchair about bowel movement management consisted of three main themes: (a) difficult experiences; (b) coping with difficulties; and (c) colostomy awareness experience.

CONCLUSIONS

Results showed that knowledge of a stoma obtained from different sources was a glimmer of hope for patients but that healthcare professionals did not exhibit a supportive attitude toward this hope.

The gut microbiota and metabolite profiles are altered in patients with spinal cord injury

BACKGROUND

Metabolites secreted by the gut microbiota may play an essential role in microbiota-gut-central nervous system crosstalk. In this study, we explored the changes occurring in the gut microbiota and their metabolites in patients with spinal cord injury (SCI) and analyzed the correlations among them.

METHODS

The structure and composition of the gut microbiota derived from fecal samples collected from patients with SCI (n = 11) and matched control individuals (n = 10) were evaluated using 16S rRNA gene sequencing. Additionally, an untargeted metabolomics approach was used to compare the serum metabolite profiles of both groups. Meanwhile, the association among serum metabolites, the gut microbiota, and clinical parameters (including injury duration and neurological grade) was also analyzed. Finally, metabolites with the potential for use in the treatment of SCI were identified based on the differential metabolite abundance analysis.

RESULTS

The composition of the gut microbiota was different between patients with SCI and healthy controls. At the genus level, compared with the control group, the abundance of UBA1819, Anaerostignum, Eggerthella, and Enterococcus was significantly increased in the SCI group, whereas that of Faecalibacterium, Blautia, Escherichia-Shigella, Agathobacter, Collinsella, Dorea, Ruminococcus, Fusicatenibacter, and Eubacterium was decreased. Forty-one named metabolites displayed significant differential abundance between SCI patients and healthy controls, including 18 that were upregulated and 23 that were downregulated. Correlation analysis further indicated that the variation in gut microbiota abundance was associated with changes in serum metabolite levels, suggesting that gut dysbiosis is an important cause of metabolic disorders in SCI. Finally, gut dysbiosis and serum metabolite dysregulation was found to be associated with injury duration and severity of motor dysfunction after SCI.

CONCLUSIONS

We present a comprehensive landscape of the gut microbiota and metabolite profiles in patients with SCI and provide evidence that their interaction plays a role in the pathogenesis of SCI. Furthermore, our findings suggested that uridine, hypoxanthine, PC(18:2/0:0), and kojic acid may be important therapeutic targets for the treatment of this condition.

Species Differences in Blood Lymphocyte Responses After Spinal Cord Injury

People with spinal cord injury (SCI) get recurrent infections, such as urinary tract infections (UTIs) and pneumonias, that cause mortality and worsen neurological recovery. Over the past decades, researchers have proposed that post-SCI lymphopenia and decreased lymphocyte function increase susceptibility to infections and worsen neurological outcome in humans, leading to a condition called SCI-induced immune depression syndrome (SCI-IDS). In this review, we explore how SCI affects blood lymphocyte homeostasis and function in humans and rodents. Understanding how SCI affects blood lymphocytes will help the management of recurrent infections in spinal cord injured people and shed light on the clinical translation of findings in animal models to humans.

Combined acupuncture and moxibustion therapy for the treatment of neurogenic bladder and bowel dysfunction following traumatic spinal cord injury: A case report

Neurogenic bladder and bowel are two critical autonomic complications following traumatic spinal cord injury (TSCI). Chronic lower urinary tract and bowel dysfunctions can lead to secondary complications, drastically affect the quality of life and significantly increase the risk of hospital readmission and mortality. Other than symptomatic treatments, a few effective therapies are available. Combined acupuncture and moxibustion therapy has positive effects on improving nerve repair and functional recovery in the early phases following TSCI. However, whether it is effective for TSCI-related chronic urinary and bowel dysfunctions remains unknown. This report presents the case of a 26-year-old male patient who experienced neurogenic bladder and bowel dysfunction following TSCI due to an accidental fall from height for more than 10 months and visited our department for combined acupuncture and moxibustion therapy. After 48 treatment sessions, he regained voluntary urination and defecation to a large extent. Urodynamic testing showed recovered bladder compliance and improved detrusor contractility. Symptom assessment with the Qualiveen Short-Form and neurogenic bowel dysfunction scores demonstrated reduced symptom severity. This case suggests that combined acupuncture and moxibustion therapy might help to restore the physiological functions of the lower urinary and digestive tracts following TSCI and might be a promising alternative for the treatment of neurogenic bladder and bowel dysfunction in patients with TSCI.

Effectiveness of Abdominal Functional Electrical Stimulation for Improving Bowel Function in People With a Spinal Cord Injury: A Study Protocol for a Double-Blinded Randomized Placebo-Controlled Clinical Trial

Background

People with a spinal cord injury (SCI) have a high rate of bowel-related morbidity, even compared with people with other neurological disorders. These complications lower quality of life and place a financial burden on the health system. A noninvasive intervention that improves the bowel function of people with an SCI should reduce morbidity, improve quality of life, and lead to cost savings for health care providers.

Objectives

To investigate the effectiveness of noninvasive abdominal functional electrical stimulation (FES) for improving bowel function in people with a chronic SCI.

Methods

A prospective, double-blinded, 1:1 randomized, placebo-controlled intervention trial will be conducted with 80 adults with chronic SCI (>12 months since injury) above T8 single neurological level. The intervention will be a 45-minute abdominal FES (or placebo) session, 3 days per week, for 6 weeks.

Main Study Parameters/Endpoints

Primary endpoint is whole gut transit time before and after 6 weeks of abdominal FES. Secondary endpoints measured before and after 6 weeks of abdominal FES are (1) colonic transit time; (2) quality of life (EQ-5D-5L); (3) participant-reported bowel function (International SCI Bowel Function Basic Data Set Questionnaire and visual analogue scale); (4) respiratory function (forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure); (5) bladder symptoms (Neurogenic Bladder Symptom Score); (6) daily bowel management diary; and (7) unplanned hospital visits.

Conclusion

Safety data will be collected, and a cost utility analysis using quality of life scores will be performed.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000386831.

Nutrient composition influences the gut microbiota in chronic thoracic spinal cord-injured rats

Chronic spinal cord injury (SCI) results in an increased predisposition to various metabolic problems that can be exacerbated by consuming a diet rich in calories and saturated fat. In addition, gastrointestinal symptoms have been reported after SCI, including intestinal dysbiosis of the gut microbiome. The effects of both diet and SCI on the gut microbiome of adult male Long Evans rats euthanized 16 wk after injury were investigated. The rats were either thoracic spinal contused or received sham procedures. After 12 wk of either a low-fat or high-fat diet, cecal contents were analyzed, revealing significant microbial changes to every taxonomic level below the kingdom level. Shannon α diversity analyses demonstrated a significant difference in diversity between the groups based on the surgical condition of the rats. SCI produced a unique signature of changes in commensal bacteria that were significantly different than Sham. Specific changes in commensal bacteria as a result of diet manipulation had high fidelity with reports in the literature, such as Clostridia, Thiohalorhabdales, and Pseudomonadales. In addition, novel changes in commensal bacteria were identified that are unique dietary influences on SCI. Linear regression analysis on body fat and lean mass showed that a consequence of chronic SCI produces uncoupled associations between some commensal bacteria and body composition. In conclusion, despite tightly controlling the protein content and varying the carbohydrate and fat contents, Sham and SCI rats respond uniquely to diet. These data provide potential direction for therapeutic modulation of the microbiome to improve health and wellness following SCI.

Are micro enemas administered with a squeeze tube and a 5 cm-long nozzle as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe in people with a recent spinal cord injury? A non-inferiority, crossover randomised controlled trial

Study design

Double blind, non-inferiority crossover randomised controlled trial.

Objectives

To determine if micro enemas administered with a squeeze-tube and a 5 cm-long nozzle (squeeze-tube method) are as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe (catheter method) in people with a recent spinal cord injury.

Setting

Two inpatient spinal cord injury units located in Sydney, Australia.

Methods

Twenty people admitted to hospital with recent spinal cord injury were randomly assigned to two treatment sequences; 4 weeks of micro enemas delivered by the squeeze-tube method followed by 4 weeks of micro enemas delivered by the catheter method, or vice versa. Each treatment sequence was 8 weeks with a crossover at the end of week 4. The primary outcome was time to complete bowel care. Secondary outcomes reflected faecal incontinence, quality of life, perception of treatment effectiveness and participant reported time to complete bowel care. The primary and secondary outcomes were measured by blinded assessors in week 4 and week 8. A non-inferiority margin of 10 min for time to complete bowel care was set a priori.

Results

The mean between group difference (95% confidence interval) for the time to complete bowel care was −0.5 min (−2.8 to 1.8), where a negative value favours the catheter method. Results were similar for all secondary outcomes.

Conclusions

Micro enemas delivered by the squeeze-tube method are as good or better than micro enemas delivered by the catheter method in people with a recent spinal cord injury.

Traumatic spinal cord injury and the contributions of the post-injury microbiome

Spinal cord injuries are an enormous burden on injured individuals and their caregivers. The pathophysiological effects of injury are not limited to the spine and limb function, but affect numerous body systems. Growing observations in human studies and experimental models suggest that the gut microbiome is altered following spinal cord injury. Given the importance of signals derived from the gut microbiome for host physiology, it is possible that injury-triggered dysbiosis subsequently affects aspects of recovery. Here, we review emerging literature on the role of the microbiome following spinal cord injury. Specifically, we highlight findings from both human and experimental studies that correlate taxonomic changes to aspects of injury recovery. Examination of both observational and emerging interventional studies supports the notion that future therapeutic avenues for spinal cord injury pathologies may lie at the interface of the host and indigenous microbes.

Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

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.

Bowel Management in Patients With Chronic Spinal Cord Injury: A Cross-Sectional Survey

Introduction

Spinal cord injury (SCI) impairs colorectal movement, transit time, and complete evacuation at defecation. Incontinence has been documented to affect quality of life across the globe in different proportions. Bowel management has been recognized as a key factor in SCI patients’ participation in the society and leading a satisfactory life. Limited information on bowel management in SCI patients drove us to study the demographic profile and bowel management in a group of chronic SCI patients at a tertiary care rehabilitation center.

Methods

A total of 42 adults (age: 18-60 years) with SCI and duration > 12 months were enrolled. Patients were evaluated with a semi-structured questionnaire containing both open and closed questions. Data were collected and analyzed using Statistical Package for Social Sciences (SPSS) Version 10.

Results

Most (52.4%) of the patients were manual laborers (85.7% males). Mean age was 37.6 ± 11 years. The injury level was predominantly thoracic level (69%). Only eight (19%) patients had fecal incontinence; 21(50%) patients used suppository and only six patients were using laxatives. Impacted stool was the most common complication followed by hemorrhoids.

Conclusion

Young paraplegics is the most common age group affected by SCI. Most of the patients managed their bowel well conservatively with good adherence to bowel rehabilitation program. The study findings emphasize on patient-centric bowel management in SCI patients to reduce the impact on quality of life and minimize complications.

Iliac occlusion due to covered stent deformation following abdominal massages

Extrinsic compression is a potential cause of stent failure. We have described the case of a 65-year-old paraplegic patient with acute right leg ischemia. His medical history was relevant for aortobifemoral bypass, followed by kissing covered stent reconstruction of a proximal anastomotic false aneurysm. The computed tomography scan showed collapse of the right iliac covered stent with ipsilateral iliofemoral graft thrombosis and partial collapse of the left iliac covered stent. He underwent emergent right iliac limb open thrombectomy and redo covered stent relining. The cause of compression was found to be daily deep abdominal massages for intestinal evacuation. The endovascular device should be tailored to the patient's particularities.

Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease

Introduction

Almost all people with spinal cord injury/disease (SCI/D) suffer from neurogenic bowel dysfunction (NBD), with a considerable impact on quality of life. The Association of the Scientific Medical Societies in Germany (AWMF e.V.) guideline for NBD in SCI/D aims to provide practice-oriented support for the care of patients with NBD resulting from congenital or aquired SCI/D. The guideline describes the diagnosis and bowel management of NBD in people with SCI/D. Thus, treatment processes in acute medical care and rehabilitation as well as for lifelong aftercare are presented.

Methods

The present guideline was developed under the leadership of the German-speaking Medical Society for Paraplegiology in a multiprofessional interdisciplinary guideline team. To exceed the level of expert recommendations, consensus was reached within the framework of a structured nominal group process in defined steps under neutral moderation considering the criteria of the German guideline development instrument (DELBI).

Results

Individual bowel management must be developed on the basis of an adequate diagnosis and considering the different lesion types. Due to the multifactorial influenceability of the intestine and the individual neurological deficit, a simple to-do checklist is not effective. Various and complex bowel management programmes are the basis of the treatment of NBD.

Conclusions

Guidelines can only be successful in so far as they are applied in everyday life. Of course, the selection and application of the measures described must always take into consideration the individual situation of the person concerned, and the correct application is always a prerequisite for success.

Neurogenic Bowel Dysfunction: The Impact of the Central Nervous System in Constipation and Fecal Incontinence

Spinal cord injury and neurogenic bowel dysfunction (NBD) are life-changing events for affected patients. The clinical manifestations of NBD vary depending on the level and severity of the spinal cord lesion. Managing patients with NBD can be complicated by comorbidities, such as immobility, bladder dysfunction, progressive neurologic decline, psychological factors, loss of independence, and social withdrawal, and ideally involves a multimodal, multidisciplinary approach. Evaluation and management should be individualized, depending on the residual neurologic capabilities of the patient and their predominant gastrointestinal symptoms, and commonly involves lifestyle modifications, physical therapy, laxative medications, and surgical interventions.

Improvement in Neurogenic Bowel and Bladder Dysfunction Following Posterior Decompression Surgery for Cauda Equina Syndrome: A Prospective Cohort Study

Objective

The mechanisms of neurogenic bowel dysfunction (NBD) and neurogenic bladder (NB), which are major consequences of spinal cord injury and occasionally degenerative lumbar disease. The following in patients with cauda equina syndrome who underwent posterior decompression surgery was investigated: (1) the preoperative prevalence of NBD and NB, measured using the Constipation Scoring System (CSS) and International Prostate Symptoms Score (IPSS); (2) the degree and timing of postoperative improvement of NBD and NB.

Methods

We administered the CSS and IPSS in 93 patients before surgery and at 1, 3, 6, and 12 months postoperatively. We prospectively examined patient characteristics, Japanese Orthopaedic Association (JOA) score, and postoperative improvements in each score.

Results

The prevalence of symptomatic defecation and urinary symptoms at admission were 37 patients (38.1%) and 31 patients (33.3%), respectively. Among the symptomatic patients with defecation problems, 12 patients had improved at 1 month, 13 at 3 months, 14 at 6 months, and 13 at 12 months postoperatively. Among the symptomatic patients with urinary problems, 5 patients improved at 1 month, 11 at 3 months, 6 at 6 months, and 10 at 1 year postoperatively. Comparing patients with improved versus unimproved in CSS, the degree of JOA score improvement was a significant prognosis factor (p<0.05; odds ratio, 1.05).

Conclusion

The prevalence of symptomatic defecation and urinary symptoms in patients with cauda equina syndrome was 38.1% and 33.3%, respectively. Decompression surgery improved symptoms in 30%–50%. These effects were first observed 1 month after the operation and persisted up to 1 year.

Evaluation the Efficiency of Electrical Stimulation Advanced Methods on Management of Bowel and Bladder Functions in Spinal Cord Injury Subject; A Systematic Review of Literature

OBJECTIVE

To evaluate the efficiency of various methods used for SCI subjects in this regard based on the available literature.

METHODS

A search was done in some data bases such as Google scholar, ISI web of knowledge, PubMed, and Scopus. Some keywords such as bowel, bladder control and management were used in combination with SCI. The studies' quality was evaluated with Pedro scale.

RESULTS

From 100 articles found, 21 papers were selected based on abstracts and titles. The quality of the studies varied between 5 and 7 based on Pedro scale. There were 3 studies on abdominal muscles stimulation, 1 on stimulation of tibial nerve, 8 on stimulation of sacral nerve root, 2 on combination of stimulation and exercise, 4 on Brindley bladder control and 3 on sacralizotomy.

CONCLUSION

The bowel and bladder management functions is not the main problem of SCI subjects anymore. Some advantages of the mentioned procedures used for SCI subjects are including improved quality of life, socialization, and decreased bladder infection.

Longitudinal Trends and Prevalence of Bowel Management in Individuals With Spinal Cord Injury

Background: Neurogenic bowel dysfunction (NBD) following spinal cord injury (SCI) represents a major source of morbidity, negatively impacting quality of life and overall independence. The long-term changes in bowel care needs are not well-reported, preventing consensus on the natural course and optimal management of NBD following injury. Objectives: To understand the changes in bowel management needs over time following SCI. Methods: A retrospective observational study using the National Spinal Cord Injury Model Systems database evaluated the degree of independence with bowel management at discharge from inpatient rehabilitation across time (1988-2016). The prevalence and consecutive trajectory of bowel management was also evaluated at discharge and at each 5-year follow-up period, for 25 years. Results: The majority of individuals discharged from inpatient rehabilitation (n = 17,492) required total assistance with bowel management, a trend that significantly increased over time. However, by 5-years post injury, there was a significant shift in bowel management needs from total assistance to modified independence. In those with consecutive 25-year follow-up data (n = 11,131), a similar shift in bowel management to a less dependent strategy occurred even at chronic time points post injury, primarily in individuals with paraplegia and classified as motor and sensory complete. Conclusion: The findings of this study highlight the need for providing continued multipronged interventions (e.g., rehabilitative, educational, psycho-social) at the different stages of SCI to support individuals not only in the immediate years after discharge but also well into the chronic stages after injury.

Effects of highly selective sympathectomy on neurogenic bowel dysfunction in spinal cord injury rats

Neurogenic bowel dysfunction, including hyperreflexic and areflexic bowel, is a common complication in patients with spinal cord injury (SCI). We hypothesized that removing part of the colonic sympathetic innervation can alleviate the hyperreflexic bowel, and investigated the effect of sympathectomy on the hyperreflexic bowel of SCI rats. The peri-arterial sympathectomy of the inferior mesenteric artery (PSIMA) was performed in T8 SCI rats. The defecation habits of rats, the water content of fresh faeces, the intestinal transmission function, the defecation pressure of the distal colon, and the down-regulation of Alpha-2 adrenergic receptors in colon secondary to PSIMA were evaluated. The incidence of typical hyperreflexic bowel was 95% in SCI rats. Compared to SCI control rats, PSIMA increased the faecal water content of SCI rats by 5–13% (P < 0.05), the emptying rate of the faeces in colon within 24 h by 14–40% (P < 0.05), and the defecation pressure of colon by 10–11 mmHg (P < 0.05). These effects lasted for at least 12 weeks after PSIMA. Immunofluorescence label showed the secondary down-regulation of Alpha-2 adrenergic receptors after PSIMA occurred mainly in rats’ distal colon. PSIMA mainly removes the sympathetic innervation of the distal colon, and can relieve the hyperreflexic bowel in rats with SCI. The possible mechanism is to reduce the inhibitory effect of sympathetic activity, and enhance the regulatory effect of parasympathetic activity on the colon. This procedure could potentially be used for hyperreflexic bowel in patients with SCI.

Profile of gut microbiota in patients with traumatic thoracic spinal cord injury and its clinical implications: a case-control study in a rehabilitation setting

Gut microbiota are the candidate biomarkers for neurogenic bowel dysfunction (NBD) in patients with spinal cord injury (SCI). We aimed to identify the common features between patients with varying degree of thoracic SCI and healthy individuals and subpopulations of microbiota correlated with the serum biomarkers. Twenty-one patients with complete thoracic SCI (CTSCI), 24 with incomplete thoracic SCI (ITSCI), and 24 healthy individuals (HC) were enrolled in this study. Fresh stool samples and clinical data were collected from all participants, and their bowel functions with SCI were assessed. Microbial diversity and composition were analyzed by sequencing the 16S rRNA gene. The features of gut microbiota correlated with the serum biomarkers and their functions were investigated. The mean NBD score of patients with CTSCI was higher than that of patients with ITSCI. Diversity of the gut microbiota in SCI group was reduced, and with an increase in the degree of damage, alpha diversity had decreased gradually. The composition of gut microbiota in patients with SCI was distinct from that in healthy individuals, and CTSCI group exhibited further deviation than ITSCI group compared to healthy individuals. Four serum biomarkers were found to be correlated with most differential genera. Patients with thoracic SCI present gut dysbiosis, which is more pronounced in patients with CTSCI than in those with ITSCI. Therefore, the gut microbiota profile may serve as the signatures for bowel and motor functions in patients with thoracic SCI.

Neurogenic Bowel in Acute Rehabilitation Following Spinal Cord Injury: Impact of Laxatives and Opioids

Objective: To explore the association between bowel dysfunction and use of laxatives and opioids in an acute rehabilitation setting following spinal cord injury (SCI). Methods: Data was collected regarding individuals with acute traumatic/non-traumatic SCI over a two-year period (2012–2013) during both the week of admission and discharge of their inpatient stay. Results: An increase in frequency of bowel movement (BM) (p = 0.003) and a decrease in frequency of fecal incontinence (FI) per week (p < 0.001) between admission and discharge was found across all participants. There was a reduction in the number of individuals using laxatives (p = 0.004) as well as the number of unique laxatives taken (p < 0.001) between admission and discharge in our cohort. The number of individuals using opioids and the average dose of opioids in morphine milligram equivalents (MME) from admission to discharge were significantly reduced (p = 0.001 and p = 0.02, respectively). There was a positive correlation between the number of laxatives and frequency of FI at discharge (r = 0.194, p = 0.014), suggesting that an increase in laxative use results in an increased frequency of FI. Finally, there was a significant negative correlation between average dose of opioids (MME) and frequency of BM at discharge, confirming the constipating effect of opioids (r = −0.20, p = 0.009).

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Faecal Microbiota in Patients with Neurogenic Bowel Dysfunction and Spinal Cord Injury or Multiple Sclerosis-A Systematic Review

Background: Neurogenic bowel dysfunction (NBD) frequently occurs in patients with spinal cord injury (SCI) and multiple sclerosis (MS) with comparable symptoms and is often difficult to treat. It has been suggested the gut microbiota might influence the course of NBD. We systematically reviewed the literature on the composition of the gut microbiota in SCI and MS, and the possible role of neurogenic bowel function, diet and antibiotic use. Methods: A systematic search was conducted in PubMed and Embase, which retrieved studies on the gut microbiota in SCI and MS. The Newcastle–Ottawa Quality Assessment Scale (NOS) was used to assess methodological quality. Results: We retrieved fourteen papers (four on SCI, ten on MS), describing the results of a total of 479 patients. The number of patients per study varied from 13 to 89 with an average of 34. Thirteen papers were observational studies and one study was an intervention study. The studies were case control studies in which the gut microbiota composition was determined by 16S rRNA gene sequencing. The methodological quality of the studies was mostly rated to be moderate. Results of two studies suggested that alpha diversity in chronic SCI patients is lower compared to healthy controls (HC), whereas results from five studies suggest that the alpha diversity of MS patients is similar compared to healthy subjects. The taxonomic changes in MS and SCI studies are diverse. Most studies did not account for possible confounding by diet, antibiotic use and bowel function. Conclusion: Based on these 14 papers, we cannot draw strong conclusions on the composition of the gut microbiota in SCI and MS patients. Putatively, alpha diversity in chronic SCI patients may be lower compared to healthy controls, while in MS patients, alpha diversity may be similar or lower compared to healthy controls. Future studies should provide a more detailed description of clinical characteristics of participants and of diet, antibiotic use and bowel function in order to make valid inferences on changes in gut microbiota and the possible role of diet, antibiotic use and bowel function in those changes.

Effects of Wearable Powered Exoskeletal Training on Functional Mobility, Physiological Health and Quality of Life in Non-ambulatory Spinal Cord Injury Patients

BACKGROUND

Spinal cord injury (SCI) is a serious clinical condition that impacts a patient's physical, psychological, and socio-economic status. The aim of this pilot study was to evaluate the effects of training with a newly developed powered wearable exoskeleton (Hyundai Medical Exoskeleton [H-MEX]) on functional mobility, physiological health, and quality of life in non-ambulatory SCI patients.

METHODS

Participants received 60 minutes of walking training with a powered exoskeleton 3 times per week for 10 weeks (total 30 sessions). The 6-minute walking test (6MWT) and timed-up-and-go test (TUGT) were performed to assess ambulatory function. The physiological outcomes of interest after exoskeleton-assisted walking training were spasticity, pulmonary function, bone mineral density, colon transit time, and serum inflammatory markers. Effects of walking training on subjective outcomes were estimated by the Korean version of the Falls Efficacy Scale-International and the 36-Item Short-Form Health Survey version 2.

RESULTS

Ten participants finished 30 sessions of training and could ambulate independently. No severe adverse events were reported during the study. After training, the mean distance walked in the 6MWT (49.13 m) was significantly enhanced compared with baseline (20.65 m). The results of the TUGT also indicated a statistically significant improvement in the times required to stand up, walk 3 m and sit down. Although not statistically significant, clinically meaningful changes in some secondary physiological outcomes and/or quality of life were reported in some participants.

CONCLUSION

In conclusion, this study demonstrated that the newly developed wearable exoskeleton, H-MEX is safe and feasible for non-ambulatory SCI patients, and may have potential to improve quality of life of patients by assisting bipedal ambulation. These results suggest that the H-MEX can be considered a beneficial device for chronic non-ambulatory SCI patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04055610.

The Addition of Transdermal Delivery of Neostigmine and Glycopyrrolate by Iontophoresis to Thrice Weekly Bowel Care in Persons with Spinal Cord Injury: A Pilot Study

Persons with spinal cord injury (SCI) have neurogenic bowel disorders characterized by difficulty with evacuation (DWE), fecal incontinence, and discoordination of defecation. Six medically stable in-patients with SCI with a mean age of 57 ± 10 years (range: 39–66 years) and time since injury of 18 ± 17 years (range: 3–47 years) were investigated. Standard of care (SOC) for bowel care was followed by two weeks of SOC plus neostigmine (0.07 mg/kg) and glycopyrrolate (0.014 mg/kg) administered transcutaneously by iontophoresis thrice weekly for two weeks while patients continued to receive SOC. The primary endpoint was time to bowel evacuation. Body weights and abdominal radiographs were obtained. Ten questions related to bowel function and the Treatment Satisfaction Questionnaire for Medication were acquired after each arm. Bowel evacuation time decreased after the dual drug intervention arm (106.9 ± 68.4 vs. 40.8 ± 19.6 min; p < 0.0001). Body weight decreased (2.78 ± 0.98 kg; p < 0.0001), a finding confirmed on abdominal radiograph. Both questionnaires demonstrated improvement after the dual drug intervention arm. No major adverse events occurred. The addition of neostigmine and glycopyrrolate by transcutaneous administration to SOC for bowel care in persons with SCI and DWE resulted in the safe, effective, and predictable bowel evacuation with subjective improvement in bowel care.

Gastrointestinal motility disorders in neurologic disease

The extrinsic and autonomic nervous system intricately controls the major functions of the gastrointestinal tract through the enteric nervous system; these include motor, secretory, sensory, storage, and excretory functions. Disorders of the nervous system affecting gastrointestinal tract function manifest primarily as abnormalities in motor (rather than secretory) functions. Common gastrointestinal symptoms in neurologic disorders include sialorrhea, dysphagia, gastroparesis, intestinal pseudo-obstruction, constipation, diarrhea, and fecal incontinence. Diseases of the entire neural axis ranging from the cerebral hemispheres to the peripheral autonomic nerves can result in gastrointestinal motility disorders. The most common neurologic diseases affecting gastrointestinal function are stroke, parkinsonism, multiple sclerosis, and diabetic neuropathy. Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder.

Enterococcus faecalis infective endocarditis arising from chronic rectal prolapse in the setting of spinal cord injury

A 45-year-old man had recurrent presentations with pleuritic chest pain and shortness of breath. Four months prior, he had developed cauda equina syndrome from a spinal epidural abscess in the setting of intravenous drug use, complicated by lasting neurological deficits and a rectal prolapse. On his final presentation, blood cultures taken in the absence of antibiotics grew Enterococcus faecalis from multiple sets. A transoesophageal echocardiogram confirmed tricuspid valve endocarditis. He recovered well post-targeted long-term antibiotics. Endoscopy confirmed a chronic rectal prolapse with multiple ulcers and was hypothesised as the source of bacteraemia. He subsequently underwent perineal rectosigmoidectomy. This uncommon sequela of rectal prolapse highlights several issues, including the management of neurogenic bowel dysfunction following spinal cord injury and the importance of early prolapse recognition and management. Finally, appropriate collection of blood cultures and correct use of echocardiography are critical steps in investigating infective endocarditis.

Targeting axon guidance cues for neural circuit repair after spinal cord injury

At least two-thirds of spinal cord injury cases are anatomically incomplete, without complete spinal cord transection, although the initial injuries cause complete loss of sensory and motor functions. The malleability of neural circuits and networks allows varied extend of functional restoration in some individuals after successful rehabilitative training. However, in most cases, the efficiency and extent are both limited and uncertain, largely due to the many obstacles of repair. The restoration of function after anatomically incomplete injury is in part made possible by the growth of new axons or new axon branches through the spared spinal cord tissue and the new synaptic connections they make, either along the areas they grow through or in the areas they terminate. This review will discuss new progress on the understanding of the role of axon guidance molecules, particularly the Wnt family proteins, in spinal cord injury and how the knowledge and tools of axon guidance can be applied to increase the potential of recovery. These strategies, combined with others, such as neuroprotection and rehabilitation, may bring new promises. The recovery strategies for anatomically incomplete spinal cord injuries are relevant and may be applicable to traumatic brain injury and stroke.

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.

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.

Electroacupuncture at Zusanli (ST36) Repairs Interstitial Cells of Cajal and Upregulates c-Kit Expression in Rats with SCI-Induced Neurogenic Bowel Dysfunction

Background

Electroacupuncture (EA) could improve colonic transit activity in rats with neurogenic bowel dysfunction (NBD) caused by spinal cord injury (SCI). The function of interstitial cells of Cajal (ICCs) and c-Kit expression may play essential roles in this process. Material and Methods. Thirty-six Sprague Dawley rats were randomized to the sham group, the SCI group, or the SCI + EA group (bilateral Zusanli, 30 min/day, 14 days). Changes in the ultrastructural morphology of ICCs were observed. The c-Kit expression on different levels was analyzed by immunohistochemistry, Western blotting, and RT-qPCR, respectively.

Results

Abnormal morphology of ICCs and downregulation of the c-Kit expression occurred after SCI. While the number of ICCs was increased, the ultrastructural morphology was improved significantly in EA rats. They also showed better improvement in c-Kit expression at both protein and gene levels.

Conclusion

Abnormal ICCs in colon tissues and the downregulated expression of c-Kit could be observed after SCI. EA at Zusanli (ST36) could improve the colon function by repairing the morphology and increasing the number of ICCs and upregulating c-Kit expression.

Management of urinary and bowel dysfunction in rabbit model of spinal cord injury using Schwann cells and muscle progenitors: functional study and evidence for novel mechanism of action

PURPOSE

We tried to investigate the role of Schwann and satellite cells in the treatment of neurogenic bladder and bowel dysfunction; following spinal cord injury in the rabbit model.

METHODS

Twelve male New Zealand rabbits underwent induction of neurogenic bladder by spinal cord injury. Rabbits underwent the fiber tractography analysis to confirm the induction of spinal cord injury. Then, animals were randomly divided into two groups. In group I (n = 4), Schwann cells were obtained from autologous peroneal nerve. In group II (n = 4), the co-culture of nerve-muscle cells was obtained from autologous peroneal nerve and quadriceps muscle. Animals in the control group (n = 4) did not undergo any rehabilitation therapy. One and 4 months after injection of cells into the external anal sphincter, electromyography, urethral pressure profiles, urodynamic studies, voiding cystourethrogram, and manometry was performed to confirm the efficacy of treatment in short- (1 month) and long-term (4 months) follow-ups.

RESULTS

The investigations validated that no statistically significant difference was detected between the two experimental groups in a short-term follow-up (p-value > 0.05). However, the functional features were improved in group II in long-term follow-up. In both groups, the external anal sphincter contracted in response to electrical signals delivered to the muscle. However, more signals were detected in group II in electromyography evaluation. The immunohistochemical staining demonstrated that the histological features of the bladder and spinal cord were more satisfactory in group II in all follow-ups compared to group I, in terms of less edema, inflammation, presence of progenitor cells, and expression of muscle and nerve markes.

CONCLUSION

Our results suggested that the injection of nerve-muscle co-culture cells into the external anal sphincter may be a helpful tactic for ameliorating the urological complications; following spinal cord injury induction in the rabbit model.

A Primary Care Provider's Guide to Neurogenic Bowel Dysfunction in Spinal Cord Injury

Spinal cord injury (SCI) affects the gastrointestinal (GI) tract in several ways, most notably by causing impairment of colonic motility and sphincter dysfunction. Altered GI function in the setting of neurological injury-also known as "neurogenic bowel dysfunction" (NBD) -strongly impacts the quality of life (QOL) of individuals living with SCI. Characterizing the severity of NBD, its impact on an individual's QOL, and which interventions have been successful or ineffective is integral to the routine care of people living with SCI. Treatment of NBD is generally multimodal and includes attention to diet, pharmacologic and mechanical stimulation, and possibly surgery. This article discusses the pathophysiology of NBD and specific approaches to its management.