Steven A. Stiens

Neurogenic bowel dysfunction after spinal cord injury: Clinical evaluation and rehabilitative management

Neurogenic bowel dysfunction (NBD) is one of many impairments that result from spinal cord injury (SCI). The experience of persons with SCI reveals that the risk and occurrence of fecal incontinence and difficulty with evacuation are particularly significant life-limiting problems. This review relates the anatomy and physiology of colon function to the specific pathophysiology that detracts from the quality of life of persons after SCI. There are two patterns of NBD after SCI: the upper motor neuron bowel, which results from a spinal cord lesion above the sacral level, and the lower motor neuron bowel, which results from a lesion to the sacral spinal cord, roots, or peripheral nerve innervation of the colon. Rehabilitation evaluation consists of a comprehensive history and examination to define impairments, disabilities, and handicaps pertinent to NBD. Rehabilitation goals include continence of stool, simple willful independent defecation, and prevention of gastrointestinal complications. Intervention consists of derivation and implementation of an individualized person-centered bowel program, which may include diet, oral/rectal medications, equipment, and scheduling of bowel care. Bowel care is a procedure devised to initiate defecation and accomplish fecal evacuation. Digital-rectal stimulation is a technique utilized during bowel care to open the anal sphincter and facilitate reflex peristalsis. Recent advances in rehabilitation practices, equipment, pharmacology, and surgery have offered patients new bowel program alternatives. Interdisciplinary development of solutions for problems of NBD are evolving rapidly.

Incomplete spinal cord injury : Neuronal mechanisms of motor recovery and hyperreflexia

OBJECTIVE To understand neuronal mechanisms of motor recovery and hyperreflexia after incomplete spinal cord injury (SCI), and their role in rehabilitation. DESIGN Reviewed and compared clinical, neurophysiologic, and neuropathologic data from human SCI patients with behavioral, neurophysiologic, and neuroanatomic data from animals to postulate underlying neuronal mechanisms. OUTCOME A postulation that two neuronal mechanisms-receptor up-regulation and synapse growth-act sequentially, to explain the gradual appearance of motor recovery after incomplete SCI. These same mechanisms may also act in spinal reflex pathways to mediate hyperreflexia caudal to SCI. RESULTS After incomplete SCI, walking ability and hyperreflexia often develop. Initially, cord neurons are hyperpolarized and less excitable because of loss of normal descending facilitation; this is spinal shock. Then, gradually, voluntary movement recovers and hyperreflexia develops. Early (hours to days), these changes develop simultaneously, suggesting a common postsynaptic mechanism-likely, an increase in postsynaptic receptor excitability, possibly receptor up-regulation. Late (weeks to months), recovery and reflex changes occur at a slow rate, are no longer simultaneous, and are long-lasting, which suggests a presynaptic mechanism, such as local synapse growth in spared descending pathways and in reflex pathways. This presumed synapse growth is seemingly enhanced by active use of the growing pathway. Also, developing hyperreflexia appears to limit motor recovery. CONCLUSIONS These observations suggest that rehabilitation for incomplete SCI should (1) increase activity in spared descending motor pathways, (2) initially use reflex facilitation or central nervous system stimulants to assist spared descending inputs in depolarizing cord neurons, and (3) later minimize reflex input, when spared descending inputs can depolarize cord neurons without reflex facilitation. Better understanding of neuronal mechanisms that underlie motor recovery after incomplete SCI promises better outcomes from rehabilitation.

The impact of spinal cord injury on sexual function: concerns of the general population.

Study Design:Secure, web-based survey.Objectives:Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues.Setting:Worldwide web.Methods:Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey.Results:The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity.Conclusion:Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.Sponsorship:Christopher Reeve Foundation (#36708, KDA); Reeve-Irvine Research Center.

Spinal cord injury influences psychogenic as well as physical components of female sexual ability

Study design:Secure, web-based survey.Objectives:Elicit specific information about sexual function from women with spinal cord injuries (SCI).Setting:World-wide web.Methods:Individuals 18 years or older living with SCI obtained a pass code to enter a secure website and then answered survey questions.Results:Bladder and/or bowel incontinence during sexual activity and/or sexual intercourse were significant concerns and prevented some women from seeking sexual activity. Autonomic dysreflexia (AD) during sexual activity was interpreted negatively by many and was found to interfere with sexual activity. Most subjects reported difficulty becoming psychologically aroused as well as physically aroused, which were both correlated with feeling that their SCI had altered their sexual sense of self. An inverse relationship existed between developing new areas of arousal above the level of lesion and not having sensation or movement below the lesion. The most commonly reported sexual stimulation leading to the best arousal involved stimulation of the head/neck and torso areas. The majority of subjects reported having experienced intercourse postinjury. Most participants reported difficulty with positioning during foreplay and intercourse, vaginal lubrication, and spasticity during intercourse. Almost half reported experiencing orgasm postinjury and this was positively associated with the presence of genital sensation.Conclusion:SCI significantly impairs psychological and physical aspects of female sexual arousal. In addition, bladder and bowel incontinence as well as AD negatively impact sexual activity and intercourse.Sponsorship:Christopher Reeve Foundation (#36708, KDA); Reeve-Irvine Research Center.

Lifestyle Physical Activity for Individuals With Spinal Cord Injury: A Pilot Study

Purpose. To evaluate the acceptability and feasibility of a lifestyle physical activity program for people with spinal cord injury (SCI). Methods. Sixteen nonexercising adult volunteers with SCI participated in a single group pre-post–test of the “Be Active in Life Program” comprising stage-matched educational materials, home visit by a nurse, construction of a personal plan to increase activity, and four follow-up phone calls. Program acceptability, stage of change, barriers to health-promoting activities, abilities for health practices, health, depression, and muscle strength were rated. Physical activity was monitored using actigraphy and a self-report record. Results. Participants rated the program positively, although some preferred a structured exercise approach. Eighty-one percent of participants progressed in stage of change and 60% increased physical activity. There were significant changes in motivational barriers, exercise self-efficacy, self-rated health, and muscle strength. Discussion. Lifestyle physical activity is feasible and acceptable and could be effective in promoting greater physical activity among people with SCI.

Intersection syndrome in Buriram Hospital: a 4-yr prospective study.

Pantukosit S, Petchkrua W, Stiens SA: Intersection syndrome in Buriram Hospital: a 4-yr prospective study. Am J Phys Med Rehabil 2001;80:656–661. Objective: To determine the prevalence, demographic characteristics, symptoms, treatment, and outcome of patients who presented to Buriram Provincial hospital and were diagnosed with intersection syndrome. Design: This was a 4-yr prospective study that included all patients with new complaints of forearm and hand pain who presented to Buriram hospital as inpatients or outpatients. Results: The prevalence of intersection syndrome was found to be 0.37% of all patients (8080) with arm or hand pain. Of the 30 patients presenting with intersection syndrome, all had forearm pain, 22 (73.3%) had swelling, and 12 (40%) had crepitus noted in the intersected region. Fourteen (46.7%) patients reported pain provoked with twisting hand motions with radial deviations, 4 (13.3%) with pulling, and 12 (40%) with combinations of multiple hand movements (threshing, planting, hammering, hand washing, spraying and cementing). The majority of the patients were male (70%) farmers (60%). Twenty-nine patients received nonoperative treatment, including modified work activities to reduce stress on the wrist, nonsteroidal anti-inflammatory, and analgesic medications. One patient received only analgesic medication. One patient additionally required a resting hand splint. Every patient was seen for follow-up within the next 7 days. By 12–18 months posttreatment, there were only 14 patients (46.6%) remaining in follow-up, none with any symptom recurrence. Conclusion: Intersection syndrome is a relatively uncommon, overused syndrome that is associated with repeated radial deviation of the wrist and responds favorably to conservative treatment.

Polyethylene glycol versus vegetable oil based bisacodyl suppositories to initiate side-lying bowel care: A clinical trial in persons with spinal cord injury

Introduction: Neurogenic bowel dysfunction resulting from spinal cord injury (SCI) frequently requires bowel care (BC) with stimulant suppositories for initiation of effective defecation. The excessive time required for BC and bowel complications have limited quality of life after SCI. Objective: To test the hypothesis that: the time required for bowel care with bisacodyl suppositories can be reduced by substituting a polyethylene glycol base (PGB) for the traditional hydrogenated vegetable oil base (HVB) in the suppository. Setting: Inpatient SCI medicine unit. Subjects: Fourteen persons with SCI with chronic stable paralysis from upper motor neuron SCI for greater than one year with a stable HVB bisacodyl suppository initiated BC. Design: Crossover Controlled. Method: Subjects received HVB bisacodyl suppositories for six sequential BC sessions and then were crossed over to PGB bisacodyl suppositories for six more BCs. Outcome measures: BC event times were utilized to derive BC intervals: suppository insertion to first flatus=Time to flatus, first flatus until the beginning of stool flow=Flatus to stool flow, begin stool flow until end stool flow=Defecation period, end stool flow until end of clean up=Clean up, and suppository insertion until end clean up=Total bowel care time. Results: The data included two groups of BC sessions: HVB (n=84) and PGB (n=81). Mean times in minutes and P values from t tests for paired samples yielded: Time to flatus: (HVB 31, PGB 12.8 P<0.002), Defecation period: (HVB 58, PGB 32, P<0.0005), Clean up: (HVB 1.9, PGB 3.2 P=0.165), Total bowel care time: (HVB 102, PGB 51.2 P<0.0005). Conclusion: This analysis suggests that PGB based bisacodyl suppositories may stimulate reflex defecation sooner and shorten the Total BC Time as compared with HVB bisacodyl suppositories.

4. Individual experience, personal adaptation, and social perspectives

This learner-directed module highlights contemporary perspectives on personal success in the adjustment and adaptation of patients with spinal cord injury (SCI). It is the fourth in a series of five modules within the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This module explores models of the multisystem effects on a person after SCI, disablement, theories of adjustment, patient autonomy, quality of life, community experience, adaptations enhancing sexuality, and minimization of pain after SCI. Perspectives of the patients experience in disablement, interdisciplinary person-centered rehabilitation, and success of the individual in chosen life roles are emphasized. The module is designed to update SCI issues reviewed in past syllabi.

Pharmacologically initiated defecation for persons with spinal cord injury: Effectiveness of three agents

OBJECTIVE To compare the effectiveness of hydrogenated vegetable oil-based bisacodyl (HVB) suppositories, polyethylene glycol-based bisacodyl (PGB) suppositories, and polyethylene glycol-based, glycerine, docusate sodium mini-enemas (TVC) in subjects with upper motor neuron spinal cord lesions. STUDY DESIGN Prospective randomized double blind. Fifteen subjects received one of 3 HVB and 3 PGB suppositories in randomized sequence for each of six scheduled bowel care sessions. Additionally, 10 subjects received 3 TVC. The analysis used timed events that divided the bowel care sessions into discrete intervals. The analysis also compared digital simulations, incontinence, and quantity of stool. Wilcoxon rank sum tests and paired t tests were used to compare the means of intervals during bowel care initiated by HVB, PGB, and TVC. RESULTS (means in minutes and p values): Time to Flatus-HVB, 32; PGB, 15; TVC, 15; p < .026, HVB-PGB; p < .983, PGB-TVC; Flatus to Stool Flow-HVB, 6.7; PGB, 5.5; TVC, 3.9; p < .672, HVB-PGB; p < .068, PGB-TVC; Defecation Period-HVB, 36; PGB, 20; TVC, 17; p < .037, HVB-PGB; p < .479, PGB-TVC; Wait Until Transfer-HVB, 10.9; PGB, 10.7; TVC, 7.4; p < .932, HVB-PGB; p < .043, PGB-TVC; Total Time for the bowel program-HVB, 74.5; PGB, 43; TVC, 37; p < .010, HVB-PGB; p < .458, PGB-TVC; percent incidence of incontinence between bowel care sessions-HVB, .067; PGB, .067; TVC, .033; p < 1.0, HVB-PGB; p < .678, PGB-TVC; amount of stool produced-HVB, 3.30; PGB, 3.49; TVC, 3.38; p < .276, HVB-PGB; p < .630, PGB-TVC; average number of digital stimulations per bowel care procedure-HVB, 4.4; PGB, 4.1; TVC, 3.8; p < .411, HVB-PGB; p < .293, PGB-TVC; time per digital stimulation in seconds-HVB, 107; PGB, 40; TVC, 83; p < .149, HVB-PGB; p < .352, PGB-TVC; and the total time, in minutes, spent performing digital stimulations during bowel care-HVB, 10.0; PGB, 2.7; TVC, 5.9; p < .151, HVB-PGB; p < .325, PGB-TVC. CONCLUSION Bowel care took less time when initiated with the PGB bisacodyl suppository or TVC mini-enema as compared with the HVB bisacodyl suppository (p < .01).

The prevalence and natural history of gallstones in spinal cord injured patients

BACKGROUND Individuals with a spinal cord injury are at increased risk for the development of gallstones. Because these patients cannot reliably manifest classic symptoms of biliary colic, they may be more likely to present with advanced biliary complications than patients with intact abdominal innervation. The natural history of gallstones in spinal cord injured patients has not been described. STUDY DESIGN All spinal cord injured patients seen at the Seattle Veterans Affairs Medical Center from January 1, 1993, to December 31, 1997 were included in the study. For each patient, the presence or absence of gallstones had been determined previously through screening abdominal ultrasonographic evaluations. Pertinent demographic information was obtained from medical records and patient interviews. Patients with gallstones were followed until death, cholecystectomy, or the conclusion of the study, and the annual incidence of biliary complications and patients requiring a cholecystectomy were determined. The prevalence of gallstones was established by studying the subset of patients seen at the Seattle Spinal Cord Injury Unit from January 1, 1995 to December 31, 1997. RESULTS Among the spinal cord injured patients, 31% either had gallstones or had undergone a cholecystectomy at some point after their injury. Increasing age, female gender, and greater severity of injury were risk factors for the formation of gallstones. Over the first 5 years after the diagnosis of gallstones, the annual incidence of cholecystectomy or biliary complications was 6.3% and 2.2%, respectively. CONCLUSIONS Spinal cord injured patients are at increased risk for the development of gallstones. Patients with gallstones are at an increased risk for the development of biliary complications compared with neurologically intact patients, but the magnitude of this risk does not warrant prophylactic cholecystectomy.