International bowel function extended spinal cord injury data set. Spinal Cord. 2009;47:235-241. [PMID: 18725886 DOI: 10.1038/sc.2008.103]

Are micro enemas administered with a squeeze tube and a 5 cm-long nozzle as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe in people with a recent spinal cord injury? A non-inferiority, crossover randomised controlled trial

STUDY DESIGN

Double blind, non-inferiority crossover randomised controlled trial.

OBJECTIVES

To determine if micro enemas administered with a squeeze-tube and a 5 cm-long nozzle (squeeze-tube method) are as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe (catheter method) in people with a recent spinal cord injury.

SETTING

Two inpatient spinal cord injury units located in Sydney, Australia.

METHODS

Twenty people admitted to hospital with recent spinal cord injury were randomly assigned to two treatment sequences; 4 weeks of micro enemas delivered by the squeeze-tube method followed by 4 weeks of micro enemas delivered by the catheter method, or vice versa. Each treatment sequence was 8 weeks with a crossover at the end of week 4. The primary outcome was time to complete bowel care. Secondary outcomes reflected faecal incontinence, quality of life, perception of treatment effectiveness and participant reported time to complete bowel care. The primary and secondary outcomes were measured by blinded assessors in week 4 and week 8. A non-inferiority margin of 10 min for time to complete bowel care was set a priori.

RESULTS

The mean between group difference (95% confidence interval) for the time to complete bowel care was -0.5 min (-2.8 to 1.8), where a negative value favours the catheter method. Results were similar for all secondary outcomes.

CONCLUSIONS

Micro enemas delivered by the squeeze-tube method are as good or better than micro enemas delivered by the catheter method in people with a recent spinal cord injury.

Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease

Introduction

Almost all people with spinal cord injury/disease (SCI/D) suffer from neurogenic bowel dysfunction (NBD), with a considerable impact on quality of life. The Association of the Scientific Medical Societies in Germany (AWMF e.V.) guideline for NBD in SCI/D aims to provide practice-oriented support for the care of patients with NBD resulting from congenital or aquired SCI/D. The guideline describes the diagnosis and bowel management of NBD in people with SCI/D. Thus, treatment processes in acute medical care and rehabilitation as well as for lifelong aftercare are presented.

Methods

The present guideline was developed under the leadership of the German-speaking Medical Society for Paraplegiology in a multiprofessional interdisciplinary guideline team. To exceed the level of expert recommendations, consensus was reached within the framework of a structured nominal group process in defined steps under neutral moderation considering the criteria of the German guideline development instrument (DELBI).

Results

Individual bowel management must be developed on the basis of an adequate diagnosis and considering the different lesion types. Due to the multifactorial influenceability of the intestine and the individual neurological deficit, a simple to-do checklist is not effective. Various and complex bowel management programmes are the basis of the treatment of NBD.

Conclusions

Guidelines can only be successful in so far as they are applied in everyday life. Of course, the selection and application of the measures described must always take into consideration the individual situation of the person concerned, and the correct application is always a prerequisite for success.

Multisite Transcutaneous Spinal Stimulation for Walking and Autonomic Recovery in Motor-Incomplete Tetraplegia: A Single-Subject Design

OBJECTIVE

This study investigated the effect of cervical and lumbar transcutaneous spinal cord stimulation (tSCS) combined with intensive training to improve walking and autonomic function after chronic spinal cord injury (SCI).

METHODS

Two 64-year-old men with chronic motor incomplete cervical SCI participated in this single-subject design study. They each underwent 2 months of intensive locomotor training and 2 months of multisite cervical and lumbosacral tSCS paired with intensive locomotor training.

RESULTS

The improvement in 6-Minute Walk Test distance after 2 months of tSCS with intensive training was threefold greater than after locomotor training alone. Both participants improved balance ability measured by the Berg Balance Scale and increased their ability to engage in daily home exercises. Gait analysis demonstrated increased step length for each individual. Both participants experienced improved sensation and bowel function, and 1 participant eliminated the need for intermittent catheterization after the stimulation phase of the study.

CONCLUSION

These results suggest that noninvasive spinal cord stimulation might promote recovery of locomotor and autonomic functions beyond traditional gait training in people with chronic incomplete cervical SCI.

IMPACT

Multisite transcutaneous spinal stimulation may induce neuroplasticity of the spinal networks and confer functional benefits following chronic cervical SCI.

Development of a novel neurogenic bowel patient reported outcome measure: the Spinal Cord Injury Patient Reported Outcome Measure of Bowel Function & Evacuation (SCI-PROBE)

STUDY DESIGN

Outcome measure item generation and reduction.

OBJECTIVES

To develop a patient reported outcome measure (PROM) addressing the impact of neurogenic bowel dysfunction (NBD) on individuals living with traumatic or nontraumatic spinal cord injury (SCI).

SETTING

Tertiary rehabilitation center in Toronto, Canada.

METHODS

A PROM based on the International Classification of Functioning, Disability and Health (ICF) framework was developed using the following steps: (a) item generation, (b) item refinement through iterative review, (c) completion of items by individuals living with SCI and NBD followed by cognitive interviewing, and (d) further item refinement, item reduction, and construction of the preliminary PROM.

RESULTS

Following initial item generation and iterative review, the investigative team agreed on 55 initial items. Cognitive interviewing, additional revisions, and item reduction yielded an instrument comprised of 35 items; while ensuring at least two items were retained for each of the 16 previously identified challenges of living with NBD following the onset of a SCI. Scoring for the preliminary PROM ranges from 0 to 140.

CONCLUSIONS

A preliminary PROM informed by the ICF for assessing the impact of NBD post-SCI has been devised, which can be used to inform clinicians and decision-makers on optimal ways to treat this serious secondary health complication. Future work will assess the validity and clinimetric properties of the PROM.

Bioelectric neuromodulation for gastrointestinal disorders: effectiveness and mechanisms

The gastrointestinal tract has extensive, surgically accessible nerve connections with the central nervous system. This provides the opportunity to exploit rapidly advancing methods of nerve stimulation to treat gastrointestinal disorders. Bioelectric neuromodulation technology has considerably advanced in the past decade, but sacral nerve stimulation for faecal incontinence currently remains the only neuromodulation protocol in general use for a gastrointestinal disorder. Treatment of other conditions, such as IBD, obesity, nausea and gastroparesis, has had variable success. That nerves modulate inflammation in the intestine is well established, but the anti-inflammatory effects of vagal nerve stimulation have only recently been discovered, and positive effects of this approach were seen in only some patients with Crohn's disease in a single trial. Pulses of high-frequency current applied to the vagus nerve have been used to block signalling from the stomach to the brain to reduce appetite with variable outcomes. Bioelectric neuromodulation has also been investigated for postoperative ileus, gastroparesis symptoms and constipation in animal models and some clinical trials. The clinical success of this bioelectric neuromodulation therapy might be enhanced through better knowledge of the targeted nerve pathways and their physiological and pathophysiological roles, optimizing stimulation protocols and determining which patients benefit most from this therapy.

Gut microbiota dysbiosis in male patients with chronic traumatic complete spinal cord injury

BACKGROUND

Neurogenic bowel dysfunction (NBD) is a major physical and psychological problem in patients with spinal cord injury (SCI), and gut dysbiosis is commonly occurs in SCI. Here, we document neurogenic bowel management of male patients with chronic traumatic complete SCI in our centre and perform comparative analysis of the gut microbiota between our patients and healthy males.

METHODS

A total of 43 male patients with chronic traumatic complete SCI (20 with quadriplegia and 23 with paraplegia) and 23 healthy male adults were enrolled. Clinical data and fresh stool specimens were collected from all participants. Face-to-face interviews were conducted to survey the neurogenic bowel management of 43 patients with SCI. Gut microbiomes were analysed by sequencing of the V3-V4 region of the 16S rRNA gene.

RESULTS

NBD was common in adult male patients with chronic traumatic complete SCI. Patients with quadriplegia exhibited a longer time to defecate than did those with paraplegia and had higher NBD scores and heavier neurogenic bowel symptoms. The diversity of the gut microbiota in the SCI group was reduced, and the structural composition was different from that of the healthy adult male group. The abundance of Veillonellaceae and Prevotellaceae increased, while Bacteroidaceae and Bacteroides decreased in the SCI group. The abundance of Bacteroidaceae and Bacteroides in the quadriplegia group and Acidaminococcaceae, Blautia, Porphyromonadaceae, and Lachnoclostridium in the paraplegia group were significantly higher than those in the healthy male group. Serum biomarkers (GLU, HDL, CR, and CRP), NBD defecation time and COURSE had significant correlations with microbial community structure. Microbial community structure was significantly associated with serum biomarkers (GLU, HDL, CR, and CRP), NBD defecation time, and COURSE.

CONCLUSIONS

This study presents a comprehensive landscape of the gut microbiota in adult male patients with chronic traumatic complete SCI and documents their neurogenic bowel management. Gut microbiota dysbiosis in SCI patients was correlated with serum biomarkers and NBD symptoms.

Neurogenic bowel management for the adult spinal cord injury patient

BACKGROUND

Bowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a person's quality of life over a lifetime.

PURPOSE

The purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Neurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool.

CONCLUSIONS

By understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.

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.

A Community Perspective on Bowel Management and Quality of Life after Spinal Cord Injury: The Influence of Autonomic Dysreflexia

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p < 0.001) and more severe AD (p = 0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury

OBJECTIVE

Locomotor training (LT) as a therapeutic intervention following spinal cord injury (SCI) is an effective rehabilitation strategy for improving motor outcomes, but its impact on non-locomotor functions is unknown. Given recent results of our labs' pre-clinical animal SCI LT studies and existing overlap of lumbosacral spinal circuitries controlling pelvic-visceral and locomotor functions, we addressed whether LT can improve bladder, bowel and sexual function in humans at chronic SCI time-points (> two years post-injury).

STUDY DESIGN

Prospective cohort study; pilot trial with small sample size.

METHODS

Eight SCI research participants who were undergoing 80 daily one-hour sessions of LT on a treadmill using body-weight support, or one-hour of LT and stand training on alternate days, as part of another research study conducted at the Kentucky Spinal Cord Injury Research Center, University of Louisville, were enrolled in this pilot trial. Urodynamic assessments were performed and International Data Set questionnaire forms completed for bladder, bowel and sexual functions at pre-and post-training time points. Four usual care (non-trained; regular at-home routine) research participants were also enrolled in this study and had the same assessments collected twice, at least 3 months apart.

RESULTS

Filling cystometry documented significant increases in bladder capacity, voiding efficiency and detrusor contraction time as well as significant decreases in voiding pressure post-training relative to baseline. Questionnaires revealed a decrease in the frequency of nocturia and urinary incontinence for several research participants as well as a significant decrease in time required for defecation and a significant increase in sexual desire post-training. No significant differences were found for usual care research participants.

CONCLUSIONS

These results suggest that an appropriate level of sensory information provided to the spinal cord, generated through task-specific stepping and/or loading, can positively benefit the neural circuitries controlling urogenital and bowel functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03036527.

Neural pathways for colorectal control, relevance to spinal cord injury and treatment: a narrative review

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose is to review the organisation of the nerve pathways that control defecation and to relate this knowledge to the deficits in colorectal function after SCI.

METHODS

A literature review was conducted to identify salient features of defecation control pathways and the functional consequences of damage to these pathways in SCI.

RESULTS

The control pathways for defecation have separate pontine centres under cortical control that influence defecation. The pontine centres connect, separately, with autonomic preganglionic neurons of the spinal defecation centres and somatic motor neurons of Onuf's nucleus in the sacral spinal cord. Organised propulsive motor patterns can be generated by stimulation of the spinal defecation centres. Activation of the somatic neurons contracts the external sphincter. The analysis aids in interpreting the consequences of SCI and predicts therapeutic strategies.

CONCLUSIONS

Analysis of the bowel control circuits identifies sites at which bowel function may be modulated after SCI. Colokinetic drugs that elicit propulsive contractions of the colorectum may provide valuable augmentation of non-pharmacological bowel management procedures.

Ageing with neurogenic bowel dysfunction

STUDY DESIGN

Longitudinal study with postal survey.

OBJECTIVES

To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades.

SETTING

Members of the Danish SCI Association.

METHODS

In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires.

RESULTS

Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma.

CONCLUSION

Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.

International spinal cord injury bowel function basic data set (Version 2.0)

STUDY DESIGN

International expert working group.

OBJECTIVES

To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research.

SETTING

Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS).

METHODS

The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set.

RESULTS

The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score.

CONCLUSION

The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

Standardization of Data for Clinical Use and Research in Spinal Cord Injury

Increased survival after spinal cord injury (SCI) worldwide has enhanced the need for quality data that can be compared and shared between centers, countries, as well as across research studies, to better understand how best to prevent and treat SCI. Such data should be standardized and be able to be uniformly collected at any SCI center or within any SCI study. Standardization will make it possible to collect information from larger SCI populations for multi-center research studies. With this aim, the international SCI community has obtained consensus regarding the best available data and measures for use in SCI clinical practice and research. Reporting of SCI data is likewise standardized. Data elements are continuously updated and developed using an open and transparent process. There are ongoing internal, as well as external review processes, where all interested parties are encouraged to participate. The purpose of this review paper is to provide an overview of the initiatives to standardize data including the International Spinal Cord Society's International SCI Data Sets and the National Institutes of Health, National Institute of Neurological Disorders and Stroke Common Data Elements Project within SCI and discuss future opportunities.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury

OBJECTIVES

To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling.

DESIGN

Cross-sectional observational study.

SETTING

A Spinal Cord Injury Model System, with additional participants recruited from other sites.

PARTICIPANTS

Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling.

RESULTS

Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake.

CONCLUSIONS

These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Bowel dysfunction in spinal cord injury: current perspectives

Permanent disruptions of gastrointestinal function are very common sequel of spinal cord injury (SCI). When motor and sensory nervous integrity are severely affected, neurogenic gastrointestinal dysfunction is an inevitable consequence. Autonomic nervous system miss function has significantly diminished or lost sensory sensations followed with incomplete evacuation of stool from the rectal vault, immobility, and reduced anal sphincter tone all of those predisposing to increased risk of fecal incontinence (FI). The FI is, beside paralysis of extremities, one of the symptoms most profoundly affecting quality of life (QOL) in patients with SCI. We are reviewing current perspectives in management of SCI, discussing some pathophysiology mechanisms which could be addressed and pointing toward actual practical concepts in use for evaluation and improvements necessary to sustain SCI patients QOL.

Common data elements for spinal cord injury clinical research: a National Institute for Neurological Disorders and Stroke project

OBJECTIVES

To develop a comprehensive set of common data elements (CDEs), data definitions, case report forms and guidelines for use in spinal cord injury (SCI) clinical research, as part of the CDE project at the National Institute of Neurological Disorders and Stroke (NINDS) of the US National Institutes of Health.

SETTING

International Working Groups.

METHODS

Nine working groups composed of international experts reviewed existing CDEs and instruments, created new elements when needed and provided recommendations for SCI clinical research. The project was carried out in collaboration with and cross-referenced to development of the International Spinal Cord Society (ISCoS) International SCI Data Sets. The recommendations were compiled, subjected to internal review and posted online for external public comment. The final version was reviewed by all working groups and the NINDS CDE team before release.

RESULTS

The NINDS SCI CDEs and supporting documents are publically available on the NINDS CDE website and the ISCoS website. The CDEs span the continuum of SCI care and the full range of domains of the International Classification of Functioning, Disability and Health.

CONCLUSION

Widespread use of CDEs can facilitate SCI clinical research and trial design, data sharing and retrospective analyses. Continued international collaboration will enable consistent data collection and reporting, and will help ensure that the data elements are updated, reviewed and broadcast as additional evidence is obtained.

Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury

OBJECTIVE

To gain greater insight into the lived experience of individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD).

DESIGN

Qualitative (phenomenologic) interviews and analysis.

SETTING

Community.

PARTICIPANTS

Individuals with SCI and NBD (N=19) residing in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Concerns related to living with NBD after SCI.

RESULTS

Challenges related to living with SCI and NBD included costs and requirements, emotional impact, diet, education and employment, intimacy and interpersonal relations, social participation, spontaneity and daily schedule, travel, lack of appropriate and consistent assistance, loss of autonomy (independence, privacy), lack of predictability and fear of incontinence, medical complications, pain or discomfort, physical effort of the bowel routine, physical experience, and time requirements.

CONCLUSIONS

Living with NBD presents many challenges. When categorized according to the International Classification of Functioning, Disability and Health, identified domains include body functions and structures, activity, participation, environmental factors, and personal factors. Identified issues have implications for improving clinical management and should be assessed when determining the impact and efficacy of interventions.

Colorectal transport during defecation in subjects with supraconal spinal cord injury

STUDY DESIGN

Clinical study.

OBJECTIVES

To explore how supraconal spinal cord injury (SCI) affects colorectal emptying at defecation. Further, to relate findings to subject symptomatology expressed by bowel function scores and gastrointestinal transit time (GITT).

SETTING

Aarhus University Hospital, Denmark.

METHODS

Colorectal contents were marked by oral intake of (111)In-coated resin pellets. Movement of stools at defecation was assessed by comparing scintigrams performed before and just after defecation. Results from 15 subjects with SCI (14 males, median age=47 years (range: 22-74 years), SCI level: C5-Th9) were compared with those from 16 healthy volunteers (12 males, median age=31 years (range: 24-42 years)). Bowel symptoms were described from standard symptom scores, and GITT was assessed by radiopaque markers.

RESULTS

Median emptying at defecation was 31% of the rectosigmoid (range: 0% to complete emptying of the rectosigmoid and 49% of the descending colon) in subjects with SCI and 89% of the rectosigmoid (range: 53% to complete emptying of the rectosigmoid and the descending colon, and 3% of the transverse colon) in the control group (P<0.01). Colorectal emptying at defecation was associated with the St Mark's fecal incontinence score (P=0.02) but not with the Cleveland constipation score (P=0.17), the neurogenic bowel dysfunction score (P=0.12) or GITT (P=0.99).

CONCLUSION

Supraconal SCI results in significantly reduced emptying of stools at defecation. This is independent of changes in GITT.

[Spinal cord injury and bowel function]

BACKGROUND

Spinal cord injury (SCI) often causes permanent disruptions of gastrointestinal function, which exacerbates functional disablement.

MATERIAL AND METHOD

The article is based on the authors' own clinical experience at tertiary level in the specialist health service and literature searches in PubMed.

RESULTS

Neurogenic gastrointestinal dysfunction is a common sequela of injury to the spinal cord. Obstipation and faecal incontinence entail treatment that is often time- and resource-consuming. It is not yet possible to treat the cause of the condition. New treatment methods with retrograde and antegrade irrigation of the rectocolon, transanally or by means of appendicostomy, result in a greater degree of self-sufficiency and faster evacuation procedures.

INTERPRETATION

Neurogenic gastrointestinal dysfunction following a spinal cord injury should be assessed and treated in a tertiary level rehabilitation department. The function loss is permanent, and the treatment must be systematically tested and regularly evaluated. The decision as to which treatment is appropriate has to be taken by the patient and the healthcare system. Individual and personal factors must be taken into account. The newly established international consensus, with standardised data sets for evaluating function loss due to spinal cord injuries, paves the way for new and greater possibilities for multi-centre cooperation on quality assurance and research.

[Intestinal alterations in patients with a medullary lesion]

Loss of bowel control is distressing for persons with a medullary lesion and affects their quality of life. The present study aims to provide an updated review of the topic. Impaired neural control of continence and defecation after a medullary lesion provokes bowel dysfunction, with a high prevalence of two main symptoms: fecal incontinence and constipation. The physiopathology of these disorders is correlated with the neurological characteristics of the lesion, and various physiopathologic patterns have been established that correlate with the clinical manifestations. Evaluation of bowel dysfunction in these patients is normally exclusively clinical and complementary examinations are rarely used, although they seem promising. Treatment is based on establishing a program of evacuation. However, despite correct application, the results can be unsatisfactory and consequently other therapeutic alternatives should be developed.

Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease

Exciting new features have been described concerning neurogenic bowel dysfunction, including interactions between the central nervous system, the enteric nervous system, axonal injury, neuronal loss, neurotransmission of noxious and non-noxious stimuli, and the fields of gastroenterology and neurology. Patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease present with serious upper and lower bowel dysfunctions characterized by constipation, incontinence, gastrointestinal motor dysfunction and altered visceral sensitivity. Spinal cord injury is associated with severe autonomic dysfunction, and bowel dysfunction is a major physical and psychological burden for these patients. An adult myelomeningocele patient commonly has multiple problems reflecting the multisystemic nature of the disease. Multiple sclerosis is a neurodegenerative disorder in which axonal injury, neuronal loss, and atrophy of the central nervous system can lead to permanent neurological damage and clinical disability. Parkinson's disease is a multisystem disorder involving dopaminergic, noradrenergic, serotoninergic and cholinergic systems, characterized by motor and non-motor symptoms. Parkinson's disease affects several neuronal structures outside the substantia nigra, among which is the enteric nervous system. Recent reports have shown that the lesions in the enteric nervous system occur in very early stages of the disease, even before the involvement of the central nervous system. This has led to the postulation that the enteric nervous system could be critical in the pathophysiology of Parkinson's disease, as it could represent the point of entry for a putative environmental factor to initiate the pathological process. This review covers the data related to the etiology, epidemiology, clinical expression, pathophysiology, genetic aspects, gastrointestinal motor dysfunction, visceral sensitivity, management, prevention and prognosis of neurogenic bowel dysfunction patients with these neurological diseases. Embryological, morphological and experimental studies on animal models and humans are also taken into account.

Reliability of the international spinal cord injury bowel function basic and extended data sets

STUDY DESIGN

This study was designed as an international validation study.

OBJECTIVE

The objective of this study was to assess the inter-rater reliability of the International Spinal Cord Injury Bowel Function Basic and Extended Data Sets.

SETTING

Three European spinal cord injury centers.

METHODS

In total, 73 subjects with spinal cord injury and a history of bowel dysfunction, out of which 77% were men and median age of the subjects was 49 years (range 20-81), were studied. The inter-rater reliability was estimated by having two raters complete both data sets on the same subject. First and second tests were separated by 14 days. Cohen's kappa was computed as a measure of agreement between raters.

RESULTS

Inter-rater reliability assessed by kappa statistics was very good (≥0.81) in 5 items, good (0.61-0.80) in 11 items, moderate (0.41-0.60) in 20 items, fair (0.21-0.40) in 11 and poor (<0.20) in 5 items.

CONCLUSION

Most items within the International Spinal Cord Injury Bowel Function Data sets have acceptable inter-rater reliability and are useful tools for data collection in international clinical practice and research. However, minor adjustments are recommended.

Recommendations for translation and reliability testing of International Spinal Cord Injury Data Sets

OBJECTIVE

To provide recommendations regarding translation and reliability testing of International Spinal Cord Injury (SCI) Data Sets.

SETTING

The Executive Committee for the International SCI Standards and Data Sets.

RECOMMENDATIONS

Translations of any specific International SCI Data Set can be accomplished by translation from the English version into the target language, and be followed by a back-translation into English, to confirm that the original meaning has been preserved. Another approach is to have the initial translation performed by translators who have knowledge of SCI, and afterwards controlled by other person(s) with the same kind of knowledge. The translation process includes both language translation and cultural adaptation, and therefore shall not be made word for word, but will strive to include conceptual equivalence. At a minimum, the inter-rater reliability should be tested by no less than two independent observers, and preferably in multiple countries. Translations must include information on the name, role and background of everyone involved in the translation process, and shall be dated and noted with a version number.

CONCLUSION

By following the proposed guidelines, translated data sets should assure comparability of data acquisition across countries and cultures. If the translation process identifies irregularities or misrepresentation in either the original English version or the target language, the working group for the particular International SCI Data Set shall revise the data set accordingly, which may include re-wording of the original English version in order to accomplish a compromise in the content of the data set.

Incorporation of the International Spinal Cord Injury Data Set elements into the National Institute of Neurological Disorders and Stroke Common Data Elements

OBJECTIVES

To develop consistent variable names and a common database structure for the data elements in the International Spinal Cord Injury (SCI) Data Sets.

SETTING

National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDE) Project and The Executive Committee of the International SCI Standards and Data Sets committees (ECSCI).

METHODS

The NINDS CDE team creates a variable name for each defined data element in the various International SCI Data Sets. Members of the ECSCI review these in an iterative process to make the variable names logical and consistent across the data sets. Following this process, the working group for the particular data set reviews the variable names, and further revisions and adjustments may be made. In addition, a database structure for each data set is developed allowing data to be stored in a uniform way in databases to promote sharing data from different studies.

RESULTS

The International SCI Data Sets variable names and database specifications will be available through the web sites of the International Spinal Cord Society (http://www.iscos.org.uk), the American Spinal Injury Association (http://www.asia-spinalinjury.org) and the NINDS CDE project web site (http://www.CommonDataElements.ninds.nih.gov).

CONCLUSION

This process will continue as additional International SCI Data Sets fulfill the requirements of the development and approval process and are ready for implementation.

Upper gastrointestinal motility changes following spinal cord injury

Spinal cord injury (SCI) is associated with severe autonomic dysfunction in both the acute and chronic phases. Upper gastrointestinal (GI) motor dysfunction has been previously reported in humans and rats. Gastric emptying (GE) of a solid meal--as measured by the [(13)C]-octanoic acid breath test--is delayed in the first 3 weeks after either spinal cord transection (SCT) or contusion (SCC) in rats. This is one of the main findings of a new paper by Qualls-Creekmore et al. in the current issue of this journal. Previous studies in rats only reported impairment of GE, intestinal and GI transit of liquid after SCI, but the authors observed that the delay of the GE of solid was more prominent after SCT than SCC. Recovery of the delay of GE of solid occurred at 6 weeks after SCC, but not after SCT. However, gastric motility changes persisted despite the functional normalization of the GE in rats with SCC. Bowel dysfunction is a major physical and psychological burden for SCI patients. Collaborative efforts, like the development of international standards to evaluate autonomic function after SCI will likely clarify the mechanisms of dysfunction and lead to the development of new therapeutic strategies.

Neurogenic colorectal and pelvic floor dysfunction

Constipation and faecal incontinence are common symptoms among patients with spinal cord injury (SCI), myelomeningocoele (MMC), multiple sclerosis (MS), Parkinson's disease (PD) and stroke. Faecal incontinence in SCI, MMC and MS is mainly due to abnormal rectosigmoid compliance and rectoanal reflexes, loss of rectoanal sensibility and loss of voluntary control of the external anal sphincter. Constipation in SCI, MMC and MS is probably due to immobilisation, abnormal colonic contractility, tone and rectoanal reflexes or side effects from medication. In PD, dystonia of the external anal sphincter causes difficult rectal evacuation and the loss of dopaminergic neurons in the enteric nervous system probably causes slow-transit constipation. Changes after stroke remain to be studied. Though dietary adjustments, oral laxatives, suppositories and other conservative treatment modalities are commonly used, evidence for their use in patients with central neurological disorders is scarce. For patients with severe symptoms trans-anal irrigation, the Malone appendicostomy or a colostomy can be recommended.