Actionable Nuggets for SCI (2nd ed., 2013)
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 constipation. Unlike in the general elderly population, increased dietary fibre and fluids does not uniformly improve constipation in individuals with a neurogenic bowel. 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). 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. A recommendation of 15-18 gms. of fibre per day is a general rule. Fluid intake must also be monitored to take into account the manner and frequency of bladder emptying, since neurogenic bowel and bladder often occur coincidentally. A diary of intake (diet and fluid) and output (urine and stool) may provide 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. The Bristol Stool Scale describes seven types of stool:
- 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
Types 3 and 4 are ideal, as they are easy to defecate without containing any excess liquid.
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