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.

Quantitative assessment-based nursing intervention improves bowel function in patients with neurogenic bowel dysfunction after spinal cord injury: Study protocol for a randomized controlled study.

BACKGROUND: The neurogenic bowel dysfunction is a kind of familiar sequelae of the spinal cord injury (SCI), occurring in 70 to 80 percent of the SCI patients. The nursing intervention based on quantitative evaluation is to fully consider and assess the disease condition of patients, implement the personalized programs of nursing intervention, meet the patient's nursing needs to the maximum extent, improve the quality of nursing, and then facilitate the rehabilitation of patients. Our aim is to implement this program to evaluate the impact of this nursing intervention based on quantitative evaluation on the quality of life and bowel function in the neurogenic bowel dysfunction patients after SCI. METHODS: The experiment is a randomized clinical research which will be implemented from May 2021 to October 2021 at the First Affiliated Hospital of Soochow University. The experiment was granted through the Research Ethics Committee of the First Affiliated Hospital of Soochow University (No.100238765). Fifty neurogenic bowel dysfunction patients after SCI confirmed via the imaging are included in this study. The patients with the history of bowel diseases or patients who are unwilling to cooperate with the evaluation will be excluded. The primary outcomes are bowel function recovery and satisfaction of the patients. The secondary outcomes are quality of life evaluated by SF-36 questionnaire. The questionnaire involves physical pain, role physiology, physiological functions, social functions, vitality, general health, mental health and role-motional. RESULTS: Comparison of clinical parameters between the 2 groups will be shown in Table 1. CONCLUSION: Nursing intervention based on the quantitative evaluation can improve the quality of life and recovery of intestinal function for the neurogenic intestinal dysfunction patients after SCI. TRIAL REGISTRATION NUMBER: researchregistry6143.

An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome.

BACKGROUND: Data regarding long-term outcomes following surgery for cauda equina syndrome (CES) is scarce. In addition, these studies rely on patient descriptions of the presence or absence of symptoms, with no gradation of severity. This study aimed to assess long-term bladder, bowel, sexual and physical function using validated questionnaires in a CES cohort. METHODS: A pre-existing ethically approved database was used to identify patients who had undergone surgery for CES between August 2013 and November 2014. Patients were contacted over a 1-month period between August and September 2017 and completed validated questionnaires via telephone, assessing bladder (Urinary Symptom Profile), bowel (Neurogenic Bowel Dysfunction Score), sexual dysfunction (Arizona Sexual Experiences Scale) and physical function (Physical Component Summary of SF-12 Questionnaire), with scores compared between those presenting with incomplete CES (CES-I) and CES with retention (CES-R). Patients were also asked which of their symptoms currently they would most value treatment for and what healthcare services they had accessed post-operatively. RESULTS: Forty-six of 77 patients (response rate 72%, inclusion rate 60%) with a mean age of 45 years (21-83) and mean time since admission of 43 months (range 36-60) took part in the follow-up study. The prevalence of bladder dysfunction was 76%, bowel dysfunction 13%, sexual dysfunction 39% and physical dysfunction 48%. Patients presenting with CES-R had significantly worse long-term outcomes in bladder (stream domain), bowel and sexual function in compared to those with CES-I. Pain was chosen as the symptom patients would most value treatment for by 57%, but only 7% reported post-operative pain management referral. CONCLUSIONS: With a mean follow-up time of 43 months, these findings confirm the high prevalence of long-term bladder, sexual and physical dysfunction in CES patients and that a diagnosis of CES-R confers poorer outcomes. This study provides useful, objective data to guide the expectations of patients and clinicians.

Using a Decision Tree to Guide Bowel Management in Spina Bifida.

BACKGROUND: When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1]. METHODS: Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR. RESULTS: Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports. CONCLUSION: Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Abdominal massage plus advice, compared with advice only, for neurogenic bowel dysfunction in MS: a RCT.

BACKGROUND: Between 50% and 80% of people with multiple sclerosis (PwMS) experience neurogenic bowel dysfunction (NBD) (i.e. constipation and faecal incontinence) that affects quality of life and can lead to hospitalisation. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of abdominal massage plus advice on bowel symptoms on PwMS compared with advice only. A process evaluation investigated the factors that affected the clinical effectiveness and possible implementation of the different treatments. DESIGN: A randomised controlled trial with process evaluation and health economic components. Outcome analysis was undertaken blind. SETTING: The trial took place in 12 UK hospitals. PARTICIPANTS: PwMS who had 'bothersome' NBD. INTERVENTION: Following individualised training, abdominal massage was undertaken daily for 6 weeks (intervention group). Advice on good bowel management as per the Multiple Sclerosis Society advice booklet was provided to both groups. All participants received weekly telephone calls from the research nurse. MAIN OUTCOME MEASURES: The primary outcome was the difference between the intervention and control groups in change in the NBD score from baseline to week 24. Secondary outcomes were measured via a bowel diary, adherence diary, the Constipation Scoring System, patient resource questionnaire and the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). RESULTS: A total of 191 participants were finalised, 189 of whom were randomised (two participants were finalised in error) (control group, n = 99; intervention group, n = 90) and an intention-to-treat analysis was performed. The mean age was 52 years (standard deviation 10.83 years), 81% (n = 154) were female and 11% (n = 21) were wheelchair dependent. Fifteen participants from the intervention group and five from the control group were lost to follow-up. The change in NBD score by week 24 demonstrated no significant difference between groups [mean difference total score -1.64, 95% confidence interval (CI) -3.32 to 0.04; p = 0.0558]; there was a significant difference between groups in the change in the frequency of stool evacuation per week (mean difference 0.62, 95% CI 0.03 to 1.21; p = 0.039) and in the number of times per week that participants felt that they emptied their bowels completely (mean difference 1.08, 95% CI 0.41 to 1.76; p = 0.002), in favour of the intervention group. Of participant interviewees, 75% reported benefits, for example less difficulty passing stool, more complete evacuations, less bloated, improved appetite, and 85% continued with the massage. A cost-utility analysis conducted from a NHS and patient cost perspective found in the imputed sample with bootstrapping a mean incremental outcome effect of the intervention relative to usual care of -0.002 quality-adjusted life-years (QALYs) (95% CI -0.029 to 0.027 QALYs). In the same imputed sample with bootstrapping, the mean incremental cost effect of the intervention relative to usual care was £56.50 (95% CI -£372.62 to £415.68). No adverse events were reported. Limitations include unequal randomisation, dropout and the possibility of ineffective massage technique. CONCLUSION: The increment in the primary outcome favoured the intervention group, but it was small and not statistically significant. The economic analysis identified that the intervention was dominated by the control group. Given the small improvement in the primary outcome, but not in terms of QALYs, a low-cost version of the intervention might be considered worthwhile by some patients. FUTURE WORK: Research is required to establish possible mechanisms of action and modes of massage delivery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN85007023 and NCT03166007. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 58. See the NIHR Journals Library website for further project information.

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.

Effect of quantitative assessment-based nursing intervention on the bowel function and life quality of patients with neurogenic bowel dysfunction after spinal cord injury.

AIMS AND OBJECTIVES: To study the effect of quantitative assessment-based nursing intervention on the bowel function and life quality of patients with neurogenic bowel dysfunction after spinal cord injury. BACKGROUND: Neurogenic bowel dysfunction after spinal cord injury was clinically manifested by abdominal distension, intractable constipation, prolonged defecation and faecal incontinence, which seriously affected the normal life of patients. Traditional ways of nursing for these patients focused on basic care, but lacked sufficient recognition of disease severity and individual needs. DESIGN: One hundred and eighty-four patients with neurogenic bowel dysfunction after spinal cord injury were randomly allocated into observation group (n = 92) and control group (n = 92). METHODS: The patients in the control group were given regular nursing, and the patients in the observation group were given quantitative assessment-based nursing intervention. Recovery of bowel function, quality of life and satisfaction were compared between the two groups. RESULTS: Scores for bowel function including bloating, constipation, prolonged defecation, defecation drug dependence and faecal incontinence in the observation group were significantly lower than those in the control group (p < .05). The scores for the quality of life including physical function, general health, social functioning, role-motional, mental health in the observation group were significantly higher than those in the control group (p < .001). Finally, the satisfaction rate in the observation group was 95.56%, which was significantly higher than that in the control group (83.7%) (p < .01). CONCLUSION: We concluded that quantitative assessment-based nursing intervention contributed to recovery of bowel function and improvement of life quality and satisfaction. RELEVANCE TO CLINICAL PRACTICE: Our finding can increase the rational allocation of nurse-patient ratio and provide personalised nursing for severe patients to reduce complications and promote the rehabilitation of the disease. Our findings can also serve as a reference for other countries to develop the nurse practitioner role.

Development, reliability and validation of a neurogenic bowel dysfunction score in pediatric patients with spina bifida.

OBJECTIVE: To develop a reliable and valid questionnaire to monitor neurogenic bowel symptoms in children. PATIENTS: Thirty-four children aged 6-18 with neurogenic bowel and their caregivers. Eighteen control patients. METHODS: An expert panel generated a domain of observables and formative/reflective content. Response options were scaled following Likert-type items. Key informant interviews revised the measures. A final questionnaire was given to patients twice to calculate intra-rater reliability using Cohen's Kappa Coefficient (k) and paired t-test. Blinded interviews were conducted after physical examination and health assessment and questionnaires completed by a nurse to determine construct validity and inter-rater reliability using k and Spearman's rank-order correlation. Control patients completed the questionnaire once, their results were used to determine discriminate validity and a receiver operating characteristic (ROC) curve. RESULTS: Intra-rater reliability showed 85% of the questionnaires having k >0.6. Paired t-test results of t(33) = 1.997, P = 0.054, d = 0.53, confirmed there was not a significant difference between the scores of the two completed questionnaires. Inter-rater reliability showed 97% of the questionnaires having k >0.6 between the nurse and the patient/caregiver responses. Scores had a strong positive correlation at rs (32) = 0.943, P < 0.0005. Mean score with neurogenic bowel was 15.18(STD ± 5.77) and control group 4.68(STD ± 2.98). ROC analysis showed an area under the curve of 0.9. A score of 8.5 correlated with presence of neurogenic bowel with sensitivity of 94% and specificity of 87%. CONCLUSION: The questionnaire shows positive reliability and validity when used for pediatric neurogenic bowel patients. The questionnaire differentiates between normal and neurogenic patients. Larger studies are necessary to conduct further validation.

Cost-effectiveness of transanal irrigation versus conservative bowel management for spinal cord injury patients.

STUDY DESIGN: Cost-effectiveness analysis following international guidelines and taking the societal viewpoint. OBJECTIVES: To estimate the cost-effectiveness of transanal irrigation using a self-administered irrigation system when compared with conservative bowel management. SETTING: A randomized clinical trial was conducted at five spinal centres situated in Denmark, Germany, Italy, United Kingdom and Sweden. Estimates of resources and unit costs were made for the German health care system. METHODS: Efficacy outcomes were drawn from a randomized controlled trial conducted in 2003-2005. Adult spinal cord-injured patients with neurogenic bowel dysfunction were randomized to 10 weeks with either transanal irrigation using Peristeen Anal Irrigation or to conservative bowel management. Costs were calculated based on results from the clinical trial and on 24 interviews conducted in Germany. Unit costs were obtained from the Federal Statistical Office Germany and product list prices. RESULTS: When comparing outcome measures at termination, transanal irrigation significantly reduced symptoms of neurogenic bowel dysfunction. Product-related costs were higher for transanal irrigation using the self-administered system; however, costs for a carer to help with bowel management and changes/washing due to leakage were lower. For transanal irrigation, costs associated with urinary tract infections and patient time spent were reduced. Thus, the total cost to society is lower when patients use transanal irrigation. The results were shown to be robust in the sensitivity analysis. CONCLUSION: Transanal irrigation using a self-administered system reduces symptoms of neurogenic bowel dysfunction and results in a lower total cost to society than conservative bowel management. SPONSORSHIP: The study was supported by Coloplast A/S.