There are several factors that may influence bowel function including diet, fluid consumption, and routine bowel evacuations. Multifaceted programs target more than one factor in an attempt to reduce colonic transit time as well as decrease the incidences of difficult evacuations.

Table 2: Multifaceted Bowel Management Programs

Discussion

Improving the movement of stool through the GI tract is the most important part of any bowel management protocol following SCI. An array of interventions, as components of a bowel routine, is recommended for the management of neurogenic bowel following SCI. These include dietary recommendations, anorectal/perianal stimulation, timing the performance of the bowel routine with food intake (thus taking advantage of gastro-colonic and recto-colonic reflexes), and a variety of pharmacological agents.  Unfortunately, only a limited number of studies evaluated the effects of different protocols on bowel function following SCI. From the results of three pre-post studies, it is apparent that response to the protocols is highly individualized.  However, Badiali et al.’s (1997) multifaceted bowel management program effectively reduced gastrointestinal transit time while Correa and Rotter’s (2000) program reduced the incidence of difficult intestinal evacuation. Coggrave et al. (2006) modified the bowel management program originally proposed by Badiali et al. (1997) by including an additional step of manual evacuation and found a significant decrease in the number of bowel movement episodes requiring laxatives (from 62.8% to 23.1%).  These authors also reported a significant decrease in the mean duration of bowel management episodes with the introduction of this protocol (Coggrave et al. 2006). As these three studies incorporated several factors into the bowel management programs including diet, fluid consumption, and routine bowel practice, it is not possible to determine the key factor. In using the same management program in their 2006 pre-post study (Coggrave et al. 2006), Coggrave et al. (2009a) more recently conducted a 6-week randomized controlled trial in which the management program was compared to the control group’s usual bowel careconsisting of each subject’s usual type, number and order of interventions to achieve evacuation. The authors wanted to examine whether systematic use of less invasive interventions (ie the first few steps in the management program:simulation of gastro-colic reflex 20 min before starting bowel care; abdominal massage; perianal digitation; anorectal digitation; and glycerin suppositories), could reduce the need for oral laxatives or more invasive interventions such as rectal stimulants and manual evacuations.Findings revealed that bowel care took longer in the intervention group, fecal incontinence was more frequent (p=0.04), and the need for oral laxatives and invasive interventions was not reduced (p=0.4). The findings in this RCT (Coggrave et al. 2009a) are in contrast with other published findings in which the use of a multifaceted program reduced the level of intervention needed for evacuation and duration of bowel management. (Coggrave et al. 2006, Badiali et al. 1997). The samples in the earlier studies, however, were younger and injured for a shorter period of time, which both are associated with less frequent use of medicated rectal stimulants, manual evacuation, and oral laxatives (Coggrave et al. 2009b).

Conclusion

• There is level 1 evidence (from one RCT; N=68) (Coggrave et al. 2009) that systematic use of less invasive interventions do not reduce the need for oral laxatives and invasive interventions. There is also level 1 evidence (Coggrave et al. 2009 that use of multifaceted bowel management programs increase the duration of time required for bowel management. This is in contrast with  level 4 evidence (from three pre-post studies; aggregate N=65) (Coggrave et al. 2006; Correa and Rotter 2000; Badiali et al. 1997;) that multifaceted bowel management programs reduce gastrointestinal transit time, incidences of difficult evacuations, and duration of time required for bowel management.

• There is limited evidence in support of multifaceted programs for managing a neurogenic bowel.