Coggrave & Norton 2009a; United Kingdom
Pedro = 7
RCT
N = 68

Population: Experimental group: 24 male, 11 female; Median age = 49.5; 17 subjects with diagnosis of AIS-A, 5 AIS-B, 4 with diagnosis of AIS-C, with diagnosis of AIS-D. Control group: 21 male, 12 female; Median age = 47; 19 subjects with diagnosis of AIS-A, 3 with diagnosis of AIS-B, 2 with diagnosis of AIS-C, 9 with diagnosis of AIS-D.
Treatment: 6-week, 8-stepwise protocol designed by Badiali et al. (2007) (steps: 0) simulation of gastro-colic reflex 20 min before starting bowel care: 1) abdominal massage; 2) perianal digitation; 3) anorectal digitation; 4) glycerin suppositories; 5) rectal stimulants; 6) manual evacuation; 7) stimulant oral laxative.  The control group undertook their usual type, number and order of interventions to achieve evacuation.
Outcome Measures: duration of bowel movement and level of the 8-stepwise protocol to complete evacuation.

1. Bowel care was consistently longer in the experimental group throughout the study. Significantly longer at week 6 (p=0.05)
2. Less invasive interventions (ie. steps 0-4) did not reduce the need for more invasive interventions (ie. steps 5-7).
3. Time to first stool was consistently longer in the experimental group (p=0.2-0.5)

Population: 14 males and 3 females; Age: mean 41.24 years, range 19-59; 8 subjects with cervical injuries; 8 with thoracic injuries, and 1 with conus medularis; all subjects had motor compete SCI.
Treatment: Pre and post study; baseline bowel management (2 weeks observation)  was compared with bowel management following introduction of the modified progressive protocol (4 weeks of observation) designed by Badiali et al. (1997) – the manual evacuation step (step 6) was added to the protocol.
Outcome Measures: Comparison of the number of episodes requiring laxative use at baseline and under the progressive protocol; duration of bowel management episodes 

1. For 12 subjects, use of the progressive protocol resulted in an increase in the number of successful bowel management episodes without the use of laxatives.
2. The total number of successful bowel management episodes requiring laxative decreased from 62.8% (baseline observation) to 23.1% (in protocol phase) (p<0.0001)
3. In 3 subjects, there were fewer successful bowel management episodes with use of the protocol
4. Mean duration of bowel management episodes was less with use of the protocol than in baseline (51.81 vs. 73.54 minutes)
5. There was a significant decrease in proportion of the bowel management episodes requiring manual evacuation in the protocol phase than in the baseline phase (87.6% versus 27%)

Population: age range=19-71yrs; 21 subjects with complete injuries, 10 with incomplete injuries, and 7 with conus medullaris and cauda equine injuries; 2 subjects with tetraplegia and 19 with  paraplegia (complete lesions); length of injury range=5 months-16yrs
Treatment: Intestinal program administration and 6-month follow-up.
Outcome Measures: Difficult Intestinal Evacuation (DIE) scale; colonic transit time; anorectal manometry; recto-colonoscopy; gastrointestinal (GI) symptoms

1. Subjects felt their DIE scores after their SCI worsened (from 2.6% to 26.3%) compared to before their SCI (based on recall from memory).
2. The most frequent GI symptom was abdominal distention.
3. With the intestinal program, the incidence of DIE was reduced to 8.8% and manual extraction was reduced from 53% to 37%.

Population: Gender: 5 male and  5 female; Age range= 20 to 60 years, mean 33yrs; Level of injury: C3 to L4
Treatment: Multifaceted intervention including diet, water intake, and evacuation schedule
Outcome Measures: 3 variables were assessed: bowel movement frequency, bowel habit, total and segmental large-bowel transit time.

1. Bowel frequency was reported to have increased at the end of training.
2. By the end of the study period of the gastrointestinal transit time was reduced.