Actionable Nuggets for SCI (3rd ed., 2016)
Refer spinal cord injured patients with persistent constipation to a specialist with experience with spinal cord injury or neurogenic bowel.
An estimated 39-58% of patients with spinal cord injury (SCI) suffer from severe constipation. Unlike in the general elderly population, increased dietary fibre and fluids does not uniformly improve constipation in individuals with a neurogenic bowel. Studies have shown that dietary fibre does not have the same effect on bowel function in individuals with SCI as in those whose bowels function normally. It may in fact exacerbate bowel problems by increasing overall transit time and the probability of both bowel and bladder incontinence.
Evidence-based Best Practice:
Bowel management in SCI is aimed at maximizing independence, maintaining social continence, and increasing efficiency and satisfactory results (see Nugget #8). This is accomplished by balancing stool consistency, minimizing transit time and maintaining overall nutrition.
- 15-18 gms. of fibre per day is recommended, along with 35 ml of fluid (preferably plain water) per kg. of body weight. This results in a daily intake about 500 ml higher than the general population.
- Fluid intake must be modulated as it will have consequences for bladder emptying. An ideal level produces urine the colour of champagne!
- Since neurogenic bowel and bladder often occur coincidentally, a daily diary of intake (diet and fluid) and output (urine and stool) provides useful information for monitoring in primary care.
For those with an Upper Motor Neuron lesion (UMN; above T12), diet and fluid management is usually aimed at producing softer stools, whereas for those with a Lower Motor Neuron lesion (LMN; T12 or lower), slightly firmer stool is preferred to avoid incontinence. Rehabilitation specialists use the Bristol Stool Scale to describe seven types of stool. Types 3 and 4 are ideal, as they are easy to defecate without containing any excess liquid.
- Type 1: Separate hard lumps, like nuts (hard to pass)
- Type 2: Sausage-shaped, but lumpy
- Type 3: Like a sausage but with cracks on its surface
- Type 4: Like a sausage or snake, smooth and soft
- Type 5: Soft blobs with clear cut edges (passed easily)
- Type 6: Fluffy pieces with ragged edges, a mushy stool
- Type 7: Watery, no solid pieces. Entirely liquid
Coggrave, M., Ash, D., & Adcock, C. (2012). Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions. Initiated by the Multidisciplinary Association of Spinal Cord, 1–60. Retrived from http://www.mascip.co.uk/wp-content/uploads/2015/02/CV653N-Neurogenic-Guidelines-Sept-2012.pdf
Additional References (chronological order):
Abramson, C. (2014). Neurogenic Bowel after Spinal Cord Injury, 1–52. Retrieved from papers2://publication/uuid/F712958B-91F7-41BE-B8F2-C2860E2A2E26
Canadian Agency for Drugs and Technologies in Health. (2014). Treatments for Constipation: A Review of Systematic Reviews. Canadian Agency for Drugs and Technologies in Health.
Fisher, M., Middleton, J., & Pryor, J. (2014). Management of the Neurogenic Bladder for Adults with Spinal Cord Injuries. Agency for Clinical Innovation. Chatswood NSW.
Lim, Y.H., Kim, D.H., Lee, M.Y., & Joo, M.C. (2012). Bowel dysfunction and colon transit time in brain-injured patients. Annals of Rehabilitation Medicine, 36(3), 371-8.
Coggrave, M. J., & Norton, C. (2010). 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. Spinal Cord, 48(46), 504-510.
Krassioukov, A., Eng, J. J., Claxton, G., Sakakibara, B. M., & Shum, S. (2010). Neurogenic bowel management after spinal cord injury: A systematic review of the evidence. Spinal Cord, 48(10), 718-733.
Lombardi, G., Del Popolo, G., Cecconi, F., Surrenti, E., & Macchiarella, A. (2010). Clinical outcome of sacral neuromodulation in incomplete spinal cord-injured patients suffering from neurogenic bowel dysfunctions. Spinal Cord, 48(2), 154-159.
Coggrave, M., Norton, C., & Wilson-Barnett, J. (2009). Management of neurogenic bowel dysfunction in the community after spinal cord injury: A postal survey in the United Kingdom. Spinal Cord, 47(4), 323-30.
Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice and Research. Clinical Gastroenterology (of Publication: August 2009), 23(24): 531-543.
Spinal Cord Injury Centres of the United Kingdom and Ireland (2009). Guidelines for management of neurogenic bowel dysfunction in the community after spinal cord injury. United Kingdom: Coloplast.
Walters, J.L., Buchholz, A.C., Martin Ginis, K.A., & SHAPE Research Group. (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4): 318-22.
Christensen, P., et al. (2006). A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord-Injured Patients. Gastroenterology, 131(3): 738-747. http://dx.doi.org/10.1053/j.gastro.2006.06.004
Ng, C., Prott, G., Rutkowski, S., Li, Y., Hansen, R., Kellow, J., & Malcolm, A. (2005). Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors. Diseases of the Colon & Rectum, 48(8), 1562-8.
Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury (1998). Spinal Cord Medicine Consortium. Journal of Spinal Cord Medicine, 21(3), 248-93. http://www.pva.org/site/News2?page=NewsArticle&id=7651
Consortium for Spinal Cord Medicine (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Journal of Spinal Cord Medicine, 21(3), 248-93.
De Looze, D., et al. (1998). Constipation and other gastrointestinal problems in spinal cord injury patients. Spinal Cord, 36(1), 63-6.
Cameron, K.J., et al. (1996). Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord, 34(5), 277-83.
Menardo, G., et al. (1987). Large-bowel transit in paraplegic patients. Diseases of the Colon & Rectum, 30(12), 924-8.