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

Abstract

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 ¼ 0.04); the need for oral laxatives and invasive interventions was not reduced (P ¼ 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.

Does regular standing improve bowel function in people with spinal cord injury? A randomised crossover trial

“…15 This outcome reflects the time from commencement of bowel regime to first stool. Commencement was defined by when the participant or participant's carer inserted rectal medication or any form of rectal stimulation.…”

“…15 This outcome reflects the time from commencement of bowel regime to completion of bowel regime. The mean time from the two assessments for each participant was derived and used for all analyses.…”

“…The primary outcome was Time to First Stool (assessor determined). 15 The secondary outcomes were Time to Complete Bowel Care (assessor determined), 15 Time to First Stool (self report), 15 Time to Complete Bowel Care (self report) 15 and four self-report assessments including the Neurogenic Bowel Dysfunction Score, 16 Cleveland Clinic Constipation Score, 17 St Mark's Incontinence Score 18 and the Spinal Cord Injury Spasticity Evaluation tool. 19 The Time to First Stool (assessor determined) and Time to Complete Bowel Care (assessor determined) were measured twice by a blinded assessor on 2 days in close succession at the beginning and end of the stand and no-stand phases.…”

“…The self-report assessments were also administered by a blinded assessor but only once at the beginning and end of each phase. The Time to First Stool (self report) 15 and Time to Complete Bowel Care (self report) were determined by asking participants to record the times to first stool and to complete bowel care each day in diaries over the last 2 weeks of the stand and no-stand phases. 15 In addition, participants were asked open-ended questions at the end of the stand phase about any perceived beneficial or deleterious effects of standing.…”

“…The Time to First Stool (self report) 15 and Time to Complete Bowel Care (self report) were determined by asking participants to record the times to first stool and to complete bowel care each day in diaries over the last 2 weeks of the stand and no-stand phases. 15 In addition, participants were asked open-ended questions at the end of the stand phase about any perceived beneficial or deleterious effects of standing. Bowel regimes during all assessments and throughout the duration of the trial were carried out in accordance with the participants' usual routines and sometimes involved participants' carers.…”