Ageing with neurogenic bowel dysfunction. Spinal Cord. 2017;55:769-773. [PMID: 28290468 DOI: 10.1038/sc.2017.22]

Conservative, physical and surgical interventions for managing faecal incontinence and constipation in adults with central neurological diseases

BACKGROUND

People with central neurological disease or injury have a much higher risk of both faecal incontinence (FI) and constipation than the general population. There is often a fine line between the two symptoms, with management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. This is an update of a Cochrane Review first published in 2001 and subsequently updated in 2003, 2006 and 2014.

OBJECTIVES

To assess the effects of conservative, physical and surgical interventions for managing FI and constipation in people with a neurological disease or injury affecting the central nervous system.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (searched 27 March 2023), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles.

SELECTION CRITERIA

We included randomised, quasi-randomised (where allocation is not strictly random), cross-over and cluster-randomised trials evaluating any type of conservative, physical or surgical intervention against placebo, usual care or no intervention for the management of FI and constipation in people with central neurological disease or injury.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the risk of bias in eligible trials using Cochrane's 'Risk of bias' tool and independently extracted data from the included trials using a range of prespecified outcome measures. We produced summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 25 studies with 1598 participants. The studies were generally at high risk of bias due to lack of blinding of participants and personnel to the intervention. Half of the included studies were also at high risk of bias in terms of selective reporting. Outcomes were often reported heterogeneously across studies, making it difficult to pool data. We did not find enough evidence to be able to analyse the effects of interventions on individual central neurological diseases. Additionally, very few studies reported on the primary outcomes of self-reported improvement in FI or constipation, or Neurogenic Bowel Dysfunction Score. Conservative interventions compared with usual care, no active treatment or placebo Thirteen studies assessed this comparison. The interventions included assessment-based nursing, holistic nursing, probiotics, psyllium, faecal microbiota transplantation, and a stepwise protocol of increasingly invasive evacuation methods. Conservative interventions may result in a large improvement in faecal incontinence (standardised mean difference (SMD) -1.85, 95% confidence interval (CI) -3.47 to -0.23; 3 studies; n = 410; low-certainty evidence). We interpreted SMD ≥ 0.80 as a large effect. It was not possible to pool all data from studies that assessed improvement in constipation, but the evidence suggested that conservative interventions may improve constipation symptoms (data not pooled; 8 studies; n = 612; low-certainty evidence). Conservative interventions may lead to a reduction in mean time taken on bowel care (data not pooled; 5 studies; n = 526; low-certainty evidence). The evidence is uncertain about the effects of conservative interventions on condition-specific quality of life and adverse events. Neurogenic Bowel Dysfunction Score was not reported. Physical therapy compared with usual care, no active treatment or placebo Twelve studies assessed this comparison. The interventions included massage therapy, standing, osteopathic manipulative treatment, electrical stimulation, transanal irrigation, and conventional physical therapy with visceral mobilisation. Physical therapies may make little to no difference to self-reported faecal continence assessed using the St Mark's Faecal Incontinence Score, where the minimally important difference is five, or the Cleveland Constipation Score (MD -2.60, 95% CI -4.91 to -0.29; 3 studies; n = 155; low-certainty evidence). Physical therapies may result in a moderate improvement in constipation symptoms (SMD -0.62, 95% CI -1.10 to -0.14; 9 studies; n = 431; low-certainty evidence). We interpreted SMD ≥ 0.5 as a moderate effect. However, physical therapies may make little to no difference in Neurogenic Bowel Dysfunction Score as the minimally important difference for this tool is 3 (MD -1.94, 95% CI -3.36 to -0.51; 7 studies; n = 358; low-certainty evidence). We are very uncertain about the effects of physical therapies on the time spent on bowel care, condition-specific quality of life and adverse effects (all very low-certainty evidence). Surgical interventions compared with usual care, no active treatment or placebo No studies were found for surgical interventions that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There remains little research on this common and, for patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other. Understanding whether there is a clinically-meaningful difference from the results of available trials is largely hampered by the lack of uniform outcome measures. This is due to an absence of core outcome sets, and development of these needs to be a research priority to allow studies to be compared directly. Some studies used validated constipation, incontinence or condition-specific measures; however, others used unvalidated analogue scales to report effectiveness. Some studies did not use any patient-reported outcomes and focused on physiological outcome measures, which is of relatively limited significance in terms of clinical implementation. There was evidence in favour of some conservative interventions, but these findings need to be confirmed by larger, well-designed controlled trials, which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

Literature review on noninvasive central nervous system (brain and spinal cord) stimulation to improve bladder and pelvic floor function in the aging population

PURPOSE OF REVIEW

The literature was reviewed for all noninvasive central nervous system (CNS) stimulation techniques, which includes transcranial brain or trans-spinal stimulation, in the aging population. Given the rising ubiquity of this technology, noninvasive nature, and low side-effect profile reported, this technology can have a big impact on the aging population. As patients afflicted with neurogenic disorders are living longer lives, a special emphasis is placed on the aging neurogenic population.

RECENT FINDINGS

Noninvasive CNS stimulation techniques have been applied to major bladder and pelvic floor disorders such as voiding dysfunction, chronic pelvic pain, urgency and urge incontinence, lower urinary tract dysfunction, and situational urge incontinence in both the idiopathic and neurogenic populations. Overall, these noninvasive technologies demonstrate effectiveness for the treatment of these conditions with some studies showing effectiveness with longer-term follow-up suggesting lasting CNS remodeling.

SUMMARY

Most manuscripts had a generally small number of patients and an even smaller number of geriatric patients represented. No studies were specifically designed to investigate geriatric outcomes. It is the hope of this systematic review to help model future studies according to existing literature, but with a focus on the geriatric population as they stand to gain the most from noninvasive technologies with limited adverse events.

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.

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.

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.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

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.

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.

Changes over 6 years in secondary health conditions and activity limitations in older adults aging with long-term spinal cord injury

BACKGROUND

The number of individuals aging with long-term spinal cord injury (SCI) is increasing. Still, there is limited knowledge about changes in secondary health conditions (SHCs) and activity limitations over time.

OBJECTIVES

To determine changes in SHCs and activity limitations in older adults aging with long-term SCI over 6 years, and to investigate how changes in SHCs and activity limitations are associated with gender, age, and injury characteristics.

DESIGN

Longitudinal cohort study from the Swedish Aging with Spinal Cord Injury Study (SASCIS).

SETTING

Community settings, Sweden.

PARTICIPANTS

From the initial 123 participants in the SASCIS: 78 individuals (32% women); mean age 68 years; mean time since injury 31 years; injury levels C1-L3, AIS A-D.

INTERVENTIONS

Not applicable MAIN OUTCOME MEASURE: Bowel and bladder function and problems, pain, spasticity, and the Spinal Cord Independence Measure (SCIM III).

RESULTS

Over 6 years, bowel-related problems increased (31% to 47%, p = .015) and the occurrence of constipation doubled to 24% (p = .013). There were increases in frequent urinary tract infections (10% to 26%, p = .004), use of indwelling urinary catheters (15% to 23%, p = .031), and other bladder-related problems (4% to 22%, p < .001). The occurrence of pain was high (85%), with no significant change. Spasticity increased from 41% to 62% (p < .001). Activity limitations increased (SCIM III total score mean 67 to 61, p < .001, with significant decreases in all subscales). The increase in bowel-related problems was greater in males, and the deterioration in self-care was greater in participants with longer time since injury and with traumatic injuries.

CONCLUSIONS

These findings support the notion that SHCs and activity limitations increase over time in older adults aging with long-term SCI. The results can inform clinicians and call for a proactive, holistic approach in the long-term follow-up to support healthy and active aging.

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.

Neurokinin 2 receptor-mediated bladder and colorectal responses in aged spinal cord injured rats

STUDY DESIGN

Animal proof of principle study.

OBJECTIVES

Bladder and bowel dysfunction are common after spinal cord injury (SCI) and in the elderly. Neurokinin 2 receptor agonists are known to produce on-demand urination and defecation in adult SCI rats. This study compared the ability of a neurokinin 2 receptor (NK2R) agonist to produce bladder and colorectal contractions in both young adult and aged SCI rats.

SETTING

Dignify Therapeutics and Integrated Laboratory Systems, Durham, NC USA.

METHODS

Bladder and colorectal pressure and voiding efficiency were measured in response to the NK2R agonist, [Lys5,Me,Leu9,Nle10]-NKA_(4-10) (LMN-NKA), in anesthetized animals. The potency and efficacy of LMN-NKA was examined in young adult and aged SCI (T3 or T9 transected) rats, with young adult and aged spinal intact rats included as controls.

RESULTS

LMN-NKA (3-300 μg/kg i.v.) produced dose-dependent increases in bladder and colorectal pressure in all anesthetized rats. No differences in the bladder or colorectal pressure responses or voiding efficiency were observed with age or after SCI. The level of SCI did not change the pharmacodynamic responses to the agonist.

CONCLUSIONS

An NK2R agonist produced similar responses in young adult and aged SCI rats, suggesting this class of agonists could be used as a potential therapy to induce on-demand urination and defecation in aged populations, with or without SCI.

3D-Printed Ostomy Flange Stabilizer

BACKGROUND

One of the coauthors with tetraplegia (quadriplegia) and a colostomy invented an ostomy flange stabilizer to act as a temporary backplate and aid in pouch changes.

DEVICE DEVELOPMENT

In an interactive design process, a 3D-printed ostomy flange stabilizer device was created. The resulting device can be adapted to 3 standard stoma appliance sizes. The stabilizer is reversible, allowing right- and left-handed people to use it on right- or left-sided stomas. Anyone with a 3D printer can print this device from an open-access Web site.

CONCLUSION

This device may be of use to many with ostomies and especially those with impaired dexterity.A 3D-printed ostomy flange stabilizer is described. 3D printing allows patient inventions to be disseminated without commercialization.

Validation of the Monitoring Efficacy of Neurogenic Bowel Treatment on Response (MENTOR) Tool in a Japanese Rehabilitation Setting

Study design: Prospective observational study. Objective: To validate the Monitoring Efficacy of NBD Treatment On Response (MENTOR) tool in individuals with a spinal cord injury (SCI) or spina bifida, suffering from neurogenic bowel dysfunction (NBD) in a rehabilitation center in Japan. Methods: First, the MENTOR tool was translated from English to Japanese using a validated translation process. Second, the MENTOR tool was validated in a rehabilitation clinic in Japan. Participants completed the MENTOR tool prior to a consultation with an expert physician. According to the results of the tool, each participant was allocated to one of three categories regarding change in treatment: “adequately treated,” “further discussion,” and “recommended change.” The results of the MENTOR tool were compared with the treatment decision made by an expert physician, who was blinded to the results of the MENTOR tool. Results: A total of 60 participants completed the MENTOR tool. There was an acceptable concordance between individuals allocated as respectively, being adequately treated (100%) and recommended change in treatment (61%) and the physicians’ decision on treatment. The concordance was lower for individuals allocated as requiring further discussion (48%). Conclusions: In this study the MENTOR tool was successfully validated in a Japanese rehab setting. The tool will help identify individuals with SCI that need further treatment of their NBD symptoms.

[The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]

BACKGROUND

Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important.

OBJECTIVE

This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment.

MATERIAL AND METHODS

Targeted literature search in Medline and Cochrane library (German and English, 1985-2020).

RESULTS AND CONCLUSION

The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.

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.

[Guidelines: neurogenic bowel dysfunction in spinal cord injury (long version)]

The guidelines (AWMF register number: 179-004) on neurogenic bowel dysfunction (NBD) in spinal cord injury of the German-speaking Medical Society for Paraplegiology is addressed to all persons who care for people with congenital or acquired paraplegia with NBD. In particular, doctors, nurses and therapists are addressed. The multiprofessionally developed guidelines (involving neurourologists, visceral surgeons, gastroenterologists, health and nursing staff, nutritionists and associated professional societies in the review process) provides practical support for the care of patients with NBD. Definitions and up to date knowledge on the diagnostics of NBD as well as on the necessary conservative bowel management are conveyed in order to ensure the competent treatment of patients with NBD. The concept of NBD and its clinical implications are described. Drug interventions and surgical procedures are explained in brief and recommendations are given. The main objective of the present guidelines is to prevent complications including fecal incontinence and constipation and thus to positively influence the quality of life of those affected. Helpful appendices, which can be used in everyday life, complete the guidelines.

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.

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.

Neurogenic bowel dysfunction

The symptoms of neurogenic bowel dysfunction (NBD) comprise constipation and fecal incontinence. These have a major impact on quality of life and dignity. Bowel symptoms occur in the majority of patients with chronic neurological diseases like multiple sclerosis, spinal cord injury, and Parkinson’s disease. Management relies on obtaining a careful bowel history, including assessment of bowel function prior to the onset of neurological symptoms. Objective measures of NBD are available and important in terms of monitoring response for what are often intensely personal and difficult-to-elicit symptoms. Conservative management begins by establishing an effective and regular bowel regime by optimizing diet and laxative use. If this is insufficient, as seen in about half of patients, transanal irrigation has been shown to reduce NBD symptoms and improve quality of life. Failing that, there are more invasive surgical options available. This review aims to provide practical guidance for the clinician who encounters these patients, focusing on a stepwise approach to assessment, interventions, and monitoring.

MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury

STUDY DESIGN

A prospective single arm study.

OBJECTIVES

Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI.

SETTING

A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center.

METHODS

Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated.

RESULTS

The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score.

CONCLUSIONS

MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.

Investigating neurogenic bowel in experimental spinal cord injury: where to begin?

The devastating losses following traumatic spinal cord injury (SCI) encompass the motor, sensory and autonomic nervous systems. Neurogenic bowel is a slow transit colonic dysfunction marked by constipation, rectal evacuation difficulties, decreased anorectal sensation, fecal incontinence or some combination thereof. Furthermore, neurogenic bowel is one of the most prevalent comorbidities of SCI and is recognized by afflicted individuals and caregivers as a lifelong physical and psychological challenge that profoundly affects quality of life. The restoration of post-injury control of movement has received considerable scientific scrutiny yet the daily necessity of voiding the bowel and bladder remains critically under-investigated. Subsequently, physicians and caregivers are rarely presented with consistent, evidence-based strategies to successfully address the consequences of dysregulated voiding reflexes. Neurogenic bowel is commonly believed to result from the interruption of the supraspinal control of the spinal autonomic circuits regulating the colon. In this mini-review, we discuss the clinical challenges presented by neurogenic bowel and emerging pre-clinical evidence that is revealing that SCI also initiates functional remodeling of the colonic wall concurrent with a decrease in local enteric neurons. Since the enteric input to the colonic smooth muscle is the final common pathway for functional contractions of the colon, changes to the neuromuscular interface must first be understood in order to maximize the efficacy of therapeutic interventions targeting colonic dysfunction following SCI.

Early Colostomy Formation Can Improve Independence Following Spinal Cord Injury and Increase Acceptability of Bowel Management

Background: Colostomy formation can solve complications of bowel management following spinal cord injury (SCI). Newly injured patients at this spinal unit have chosen colostomy as a preferred option for bowel management. Objectives: To discover the reasons patients choose colostomy formation early following SCI and make comparison with those choosing it later, and to establish whether early colostomy is safe and advisable. Methods: Medical and nursing records of patients with SCI who chose to have a colostomy during the period 2005-2016 were examined retrospectively. Data were gathered concerning reasons for choosing a colostomy, early and later complications, the need for further surgery, and independence with bowel care before and after surgery. Patients were divided into two groups: those who chose a colostomy "early" during inpatient rehabilitation and those who chose it "later" as is traditional. Results: Reasons for choosing colostomy differed. Reducing reliance on caregiver and independence were of more importance to the early group; the later group chose colostomy to solve bowel care problems. Early complication rates in both groups were low. Longer term complications were higher in the early group, with the most common complication being rectal discharge. Parastomal hernia rates were low in both groups, as was the need for further surgery. Colostomy formation led to 20.8% of all patients gaining independence with bowel care. Conclusion: This study found colostomy to be a safe and effective option when performed early after SCI and demonstrates colostomy can be a means of gaining independence and making bowel care easier and more acceptable to the newly injured patient.

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.

Novel method for restoration of anorectal function following spinal cord injury via nerve transfer in rats

OBJECTIVES

Nerve transfer has been developed to restore partial function after serious nerve injuries, for example, restoring bladder control after spinal cord injury (SCI). Our aim here was to establish a preclinical proof-of-concept model using nerve transfer for restoring anorectal function after SCI.

SETTING

We used laminectomy to model SCI, and bilateral spinal ventral and dorsal nerve root anastomosis to re-establish connectivity to the anorectal musculature.

METHODS

Multidisciplinary methods were used to assess the anatomical and functional integrity of the alternative spinal-to-anorectal nerve circuit. Adult rats were used to establish the model. Bilateral anterior and posterior L5 nerve roots were surgically matched with anterior and posterior of S1 nerve roots by microscopic anastomosis to establish an artificial rectal reflex arc with complete sensory and motor pathways. Twelve weeks later, we used retrograde nerve tracing and neurohistomorphological analysis to assess anatomical integrity of the new artificial rectal reflex arc. Anorectal manometry was used to assess the function of the new nerve circuit.

RESULTS

Retrograde tracing with recombinant attenuated pseudo rabies virus indicated that the new neural pathway was successfully established to the anorectal musculature after experimental SCI. Toluidine blue-stained sections of the anastomosis site revealed normal-appearing nerve fiber morphology and regeneration, and transmission electron microscopy revealed myelinated axons. Anorectal manometry revealed significant anorectal functional recovery.

CONCLUSION

These results suggest that our model is a feasible first step in developing an alternative reflex pathway after laminectomy at L4 to S2 and shows promise for effective restoration of anorectal function.

Long-term bladder and bowel management after spinal cord injury: a 20-year longitudinal study

STUDY DESIGN

Prospective observational.

AIM

The aim of this study was to analyse changes in bladder and bowel management methods in persons with long-standing spinal cord injury (SCI).

SETTING

Two spinal centres in UK.

METHOD

Data were collected through interviews and examinations between 1990 and 2010 in a sample of persons injured more than 20 years prior to 1990.

RESULTS

For the 85 participants who completed the 2010 follow-up, the mean age was 67.7 years and the mean duration of injury was 46.3 years, 80% were male, 37.7% had tetraplegia AIS grade A, B, or C, 44.7% paraplegia AIS A, B, or C, and 17.6% an AIS D grade regardless of level. In all, 50.6% reported having changed their bladder method, 63.1% their bowel method, and 40.5% both methods since they enroled in the study. The reasons for change were a combination of medical and practical. In men, condom drainage remained the most frequent bladder method, and in women, suprapubic catheter replaced straining/expressing as the most frequent method. The use of condom drainage and straining/expressing bladder methods decreased, whereas the use of suprapubic and intermittent catheters increased. Manual evacuation remained the most frequent bowel management method. The percentage of participants on spontaneous/voluntary bowel emptying, straining and medications alone decreased, whereas the use of colostomy and transanal irrigation increased over time.

CONCLUSIONS

More than half the sample, all living with SCI for more than 40 years, required change in their bladder and bowel management methods, for either medical or practical reasons. Regular follow-ups ensure adequate change of method if/when needed.

International standards to document remaining autonomic Function in persons with SCI and neurogenic bowel dysfunction: Illustrative cases

INTRODUCTION

Neurogenic bowel dysfunction (NBD) is a highly prevalent problem after spinal cord injury, with potential for significant impact on health and quality of life. The international standards to document remaining autonomic function after SCI were developed to standardize communication between professionals regarding neurogenic bowel and other autonomic function after SCI. To improve understanding of the bowel subsection, illustrative cases are presented.

CASE PRESENTATION

Three cases are presented which illustrate differences in presentation and scoring of the elements in the data set based upon varying injury severity and location.

DISCUSSION

Determination of neurologic level of injury is insufficient for assessment of autonomic function and there is no direct method of assessment. Hence, surrogate makers are needed. The bowel subsection of the International standards to document remaining autonomic function in persons with SCI is an easy-to-use tool for this purpose.