Progressive protocol in the bowel management of spinal cord injuries

Neurogenic Bowel Dysfunction in Patients with Spinal Cord Injury and Multiple Sclerosis-An Updated and Simplified Treatment Algorithm

Neurogenic bowel dysfunction (NBD) is a common condition in individuals with spinal cord injury (SCI) or multiple sclerosis (MS). It usually entails constipation, difficult evacuation of the rectum, and fecal incontinence (FI); often in combination. It is highly burdensome for affected patients and is correlated with poor quality of life. The current treatment algorithm, or treatment pyramid, does not completely correspond to actual clinical practice, and the known and classical pyramid contains both treatments still in their experimental stage as well as several treatments which are not available at all treatment centers. Thus, an updated treatment algorithm is called upon, and the authors of this paper therefore propose a simplified version of the treatment pyramid, aiming to guide clinicians in treating NBD.

Nursing Interventions for Patients With Neurogenic Bowel Dysfunction Arising From Complete Spinal Cord Injury: A Scoping Review

PURPOSE

We mapped key concepts and identified 4 fundamental nursing interventions for patients with neurogenic bowel dysfunction due to complete spinal cord injury (SCI).

METHODS

A scoping review was conducted according to the recommendations of the Joanna Briggs Institute.

SEARCH STRATEGY

Searches were performed in PubMed, LILACS, CINAHL, COCHRANE, and SCOPUS electronic databases. We use searched the gray literature using the Google Scholar search engine. We formulated a question to guide the search, based on the participants, concept, and context format: "What are the key manual nursing interventions performed in patients with neurogenic bowel dysfunction resulting from complete spinal cord injury?" We included nursing intervention strategies that may be performed by health professionals, patients, or caregivers. Two reviewers independently participated in the selection; disagreements were resolved by a third reviewer and 5 experts.

FINDINGS

Thirteen studies conducted between 1998 and 2019 were selected; 5 were randomized clinical trials. Four main interventions were identified for conservative management of neurogenic bowel dysfunction in patients with complete SCI. They were digital-anal stimulation, manual extraction of feces, abdominal massage, and strategies used to stimulate the gastrocolic reflex.

CONCLUSIONS

Research suggests that each of these interventions, administered alone or in combination, supports bowel evacuation in patients with a complete SCI. Each of these interventions may be performed by a nurse, and taught to the patient and/or lay caregiver.

IMPLICATIONS FOR PRACTICE

An individualized bowel management program for patients with neurogenic bowel dysfunction due to SCI is necessary to ensure regular bowel evacuation, preserve fecal continence, and support dignity and health-related quality of life. The conservative interventions identified in this scoping review should be incorporated in protocols or guidelines for management of neurogenic bowel dysfunction in this vulnerable population.

Spanish validation of the Neurogenic Bowel Dysfunction score -NBD score- in patients with central neurological injury

OBJECTIVE

to validate into Spanish the Neurogenic Bowel Dysfunction score (NBD score) that quantifies intestinal dysfunction severity in patients with disabilities due to central neurological injury and satisfaction with bowel management.

MATERIAL

59 patients, 30 patients affected by intestinal disability due to spinal cord injury and 29 patients with intestinal disability due to stroke.

RESULTS

The result of the reliability of the construction of the Spanish translation of the NBD score for the whole group of patients shows a Cronbach's α for all the variables of 0.970 and the result of the reliability of the NBD score for the whole group in test-retest, using the interclass correlation coefficient, was 0.970 (95% CI 0.954-0.980).

CONCLUSIONS

The Spanish version of the NBD score is a valid tool for use in our environment; it will allow a more real approach to the disability situation of each patient in relation to neurogenic intestinal dysfunction and knowledge of the degree and the involvement and effectiveness of management through different therapeutic proposals.

Treatments in neurogenic bowel dysfunctions: evidence reviews and clinical recommendations in adults

INTRODUCTION

Neurogenic bowel dysfunction (NBD) is an impairment of defecation control due to any nervous system lesion negatively affecting physical health status and quality of life. We aimed at systematically assessing all available evidence on NBD treatment in adults and providing clinical management guidance and recommendations.

EVIDENCE ACQUISITION

PICOs and questions (N.=7) were identified by an expert panel. We searched for and retrieved evidence from the PUBMED and EMBASE databases, limited to the English language and the Western countries context, related to any type of setting and published from 2009 to 2019. Health effects, patient values, preferences and resource use were assessed. Of all, only RCTs, observational studies and systematic reviews on adult population (≥18 years) were analyzed. The study was conducted according to PRISMA guidelines and Cochrane recommendations. The effect size, if possible, was calculated for the interpretation of the outcomes, and evidence was assessed through the GRADE method.

EVIDENCE SYNTHESIS

Thirty-one studies were included in our qualitative synthesis. Evidence is generally scarce. Most of the outcomes are narratively described and therefore defined by imprecision. Besides, most of the included studies are affected by risk of bias. Digital stimulation was found to be effective in short term follow-up. The pharmacological treatment choice, combined or alone, needs to be balanced case by case considering clinical history, setting of use and bowel management protocol. According to only one RCT supporting evidence mainly in persons affected by spinal cord injury (SCI), trans-anal irrigation (TAI) improves QoL and patient independency with a significant reduction of time spent for defecation and daily bowel program. History of urinary infections predicts the choice of using TAI. Patient-reported efficacy of colostomy alone or in combination with other surgeries appears evident in terms of patient's satisfaction and QoL over time. Nonetheless, perioperative and late complications can occur and may result in reduced acceptability over time.

CONCLUSIONS

Evidence is somehow weak and mainly reported in SCI. The systematic use of assistive interventions does not reduce the need of conservative or invasive approaches. Studies are needed on the role of bowel management in protecting patients from complications secondary to NBD in long term follow-ups.

Experience of Nurses Caring for Patients With Neurogenic Bowel Dysfunction: A Qualitative Study

PURPOSE

The purpose of this study was to explore the experience and perceptions of nurses providing bowel care to patients after spinal cord injury.

DESIGN

Qualitative study using thematic analysis of semistructured interviews.

SUBJECTS AND SETTING

Eleven RNs who provided bowel care to patients following spinal cord injury and were deemed competent to do so by their employer were invited to participate. The study setting was a large, London NHS Trust providing acute hospital care to a population of around 1 million people.

METHODS

Semistructured interviews were digitally audio-recorded and transcribed verbatim. Analysis of data was undertaken using Braun and Clark's 6 stages of thematic analysis.

RESULTS

Four main themes emerged: (1) unpleasantness of task; (2) perceived patient experience; (3) motivation and avoidance; and (4) barriers to care. There was stoic acceptance of the unpleasant nature of bowel care for the nurse, but unpleasantness for patients was not as readily acknowledged. Perceived patient experience ranged from descriptions of positive aspects of comfort and continence to negative aspects of embarrassment and discomfort. Nurses were motivated by the medical need for bowel care but often saw it as low priority due to the unpleasant nature and displayed avoidance tactics. The barriers concerned inadequate training, the taboo nature of bowel care, and potential sexual interpretations of care.

CONCLUSION

Nurses described bowel care as unpleasant but accepted its physiologic need and importance. The standardization of bowel care training and increasing the numbers of nurses trained in bowel care may decrease stigma surrounding provision of care. Study findings suggest that male nurses' experience may differ from female nurses' experience, but this result requires further investigation.

Evidence-Based Continence Care: An Integrative Review

PURPOSE

The purpose of this integrative review is to identify the best nurse-managed continence care strategies among rehabilitation patients from the current body of evidence.

DESIGN

The newly designed 2015 Competency Model for Professional Rehabilitation Nursing serves as a conceptual framework to categorize evidence-based recommendations for continence care into the four domains of the model.

METHODS

A search of the evidence was completed in December 2015. Literature reviewed was limited to articles published from 2005-2015 in the English language. Search priority was given to systematic reviews and randomized controlled trials.

FINDINGS

Nurse-led interventions include evidence-based clinical assessments with use of validated instruments following step-wise algorithms derived from clinical practice guidelines. The interprofessional team emphasizes role-based continence interventions with shared work to reach goals. Leadership recommendations call for administrative support and allocation of resources for continence care and also empower select bedside nurses to become continence champions. Finally, nurse-patient education and caregiver training target the promotion of successful living. System-based continence recommendations are identified to include rehab-oriented electronic documentation systems, written continence policies and procedures, and ongoing nursing education emphasizing accountability to high performance standards.

CONCLUSIONS

Rehabilitation nurses are the team leaders in promoting continence in the rehabilitation setting. They are the cultivators of hope and foster resilience among patients to move forward despite acute or chronic illness and disability. This article is intended to support rehabilitation nurses in their review of clinical evidence in effort to move toward a more uniform approach to bowel and bladder management.

CLINICAL RELEVANCE

This review equips rehabilitation nurses who seek to improve their practice by identifying the best evidence-based approaches to continence care.

The Caring-Disability Creation Process model: a new way of combining 'Care' in nursing and 'Rehabilitation' for better quality of services and patient safety

In an effort to continuously improve the quality of the services provided to persons in rehabilitation and patient safety, this article presents a model for the development of a Caring-Disability Creation Process that combines two elements that, in the past, have often been separated: care in nursing and rehabilitation. This new model and its underlying concepts introduce to a comprehensive approach in the recognition of the added value of caring by the contribution of rehabilitation nurses making an optimal development of the individual's potential and achieving successful social participation.

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

STUDY DESIGN

Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included.

OBJECTIVE

To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.

SETTING

Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.

METHODS

Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.

RESULTS

A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications.

CONCLUSIONS

Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: a randomized controlled trial of a stepwise protocol

STUDY DESIGN

Randomised controlled trial.

OBJECTIVES

High-quality evidence for interventions in bowel management (BM) after spinal cord injury (SCI) is lacking and BM programs are developed empirically. This randomized, controlled trial compared usual care with a stepwise protocol based on earlier published work to examine whether systematic use of less invasive interventions could reduce the need for oral laxatives and invasive interventions such as manual evacuation, and improve BM outcomes in individuals with chronic SCI.

SETTING

United Kingdom.

METHODS

In all, 68 individuals were recruited (35 in intervention group), median age 47 years (range 24-73 years), median duration of injury 16 years (range 1-47 years). Bowel diaries were maintained for a maximum of 6 weeks while the intervention group followed a stepwise protocol designed to test interventions singly and in combination. Measures of quality of life and preferences for different bowel care interventions were recorded.

RESULTS

The stepwise protocol did not improve BM outcomes; fecal incontinence was more frequent (P=0.04); the need for oral laxatives and invasive interventions was not reduced (P=0.4). Bowel care took consistently longer in the intervention group.

CONCLUSIONS

The study findings support the need for manual evacuation in BM and provide evidence of acceptability of the technique to SCI individuals. For some individuals oral laxatives are an essential part of management. The results are in contrast with previous studies in younger samples with shorter duration of injury.