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

Health consequences associated with poor diet and nutrition in persons with spinal cord injuries and disorders

PURPOSE

To describe health consequences associated with poor diet in persons with spinal cord injuries and disorders (SCI/D).

MATERIALS/METHODS

Descriptive qualitative design using in-depth interviews with SCI/D health providers. Audio-recorded and transcribed verbatim transcripts were coded and analyzed using thematic analysis.

RESULTS

Participants (n = 12) were from 11 nationwide VA hospitals. Participants were male (75%), white (67%), 26-49 years of age, and most were dietitians (75%) and physiatrists (17%). Seven key themes identified consequences associated with poor diet in persons with SCI/D, including (1) Weight gain and body composition changes, (2) cardiometabolic conditions, (3) bowel dysfunction, (4) pressure injuries/wounds, (5) other SCI/D secondary conditions/complications (renal/kidney; immune function/susceptibility to infections; autonomic dysreflexia; bone health/osteoporosis; pain), (6) physical fatigue, and (7) poor mental health.

CONCLUSIONS

Excess weight, cardiometabolic conditions, SCI/D secondary conditions/complications (e.g., bowel dysfunction, pressure injuries), and poor mental health were identified as health consequences of inadequate nutrition. Health providers should make individuals with SCI/D aware of the risks and health consequences to incentivize healthier dietary behaviors. Efforts to identify nutrition shortcomings and to develop interventions and tailored care plans are needed to improve a myriad of health consequences due to poor diet and nutrition in persons with SCI/D.

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.

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.

Spinal Cord-Gut-Immune Axis and its Implications Regarding Therapeutic Development for Spinal Cord Injury

Spinal cord injury (SCI) affects ∼1,300,000 people living in the United States. Most research efforts have been focused on reversing paralysis, as this is arguably the most defining feature of SCI. The damage caused by SCI, however, extends past paralysis and includes other debilitating outcomes including immune dysfunction and gut dysbiosis. Recent efforts are now investigating the pathophysiology of and developing therapies for these more distal manifestations of SCI. One exciting avenue is the spinal cord-gut-immune axis, which proposes that gut dysbiosis amplifies lesion inflammation and impairs SCI recovery. This review will highlight the most recent findings regarding gut and immune dysfunction following SCI, and discuss how the central nervous system (CNS), gut, and immune system all coalesce to form a bidirectional axis that can impact SCI recovery. Finally, important considerations regarding how the spinal cord-gut-immune axis fits within the larger framework of therapeutic development (i.e., probiotics, fecal transplants, dietary modifications) will be discussed, emphasizing the lack of interdepartmental investigation and the missed opportunity to maximize therapeutic benefit in SCI.

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.

Who recovers independent bowel management during the first year following a traumatic spinal cord injury? A case-control study

OBJECTIVES

1) document the characteristics of patients with impaired bowel functioning during the subacute and chronic phases; 2) identify factors associated with recovery of independent bowel functioning during the first year following TSCI in patients who present impaired bowel functioning during the subacute phase, when bowel rehabilitation is completed.

DESIGN

Case-control study on 123 adult TSCI patients. Bowel function assessments using item 7 of the SCIM-III were obtained 3-months following TSCI and during the early chronic phase. Univariate and multivariate analyses were conducted to identify predictors associated with recovery of independent bowel functioning between the initial assessment and follow-up.

RESULTS

Of the 110 patients available for analysis, 54 (49%) displayed impaired bowel functioning 3-months following TSCI. Of these, 19 (35%) recovered independent bowel functioning over the following 9 months. The total motor score (TMS) was the only significant predictor of this outcome. A TMS lower than 42 was 100% predictive of absence of recovery.

CONCLUSION

Recovering independent bowel management 1-year after TSCI was possible in 35% of patients despite impaired bowel functioning during the subacute phase. TMS measured 3-months post-injury could be useful for prognosticating potential for bowel functioning recovery since patients with TMS < 42 are unlikely to recover.

Rehabilitation of neurogenic bladder and bowel after spinal cord injury

Neurogenic bladder and bowel refers to the dysfunction of bladder and bowel caused by neurogenic etiology. Spinal cord injury is a major cause of this dysfunction, which seriously affects the injured person’s quality of life. The injury causes not only motor weakness of abdominal and perineal muscles, but also sensory changes and autonomic dysfunction of bladder and bowel. Spinal cord injuries involve multiple systems, and thus affect the normal functioning of the bowel and bladder in several ways: difficulty in urination and defecation, frequent or infrequent voiding, decrease of the sensation of fullness, incontinence, autonomic dysreflexia, perineal hygiene, deterioration of renal function, fecal impaction, psychological burden, etc. Thus, this review aims to provide updated practical guidance for the evaluation and management of neurogenic bowel and bladder by the clinicians who want to provide better care for their patients. Management of neurogenic bowel and bladder starts with carefully recording the patient’s history, including their bowel habits prior to the spinal injury. In general, evaluation of the neurogenic bladder requires more clinical tests than for the neurogenic bowel. The patients’ problems can be alleviated by adopting various measures: proper daily water and food intake, simultaneous pharmacologic treatments for the bowel and bladder, physiologic reflexes, bladder catheterization, rectal irrigation, surgical measures, etc. Priority should be given to the management of the neurogenic bladder with clean intermittent catheterization and decompression of the bladder pressure, and management of the neurogenic bowel by pharmacological treatment.

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.