1. Spinal Cord Injury and Bowel Dysfunction Glen W. White, Ph.D. Melissa Gard, M.A. and Sam Ho Research and Training Center on Independent Living at the University of Kansas This training sponsored through a grant from the Christopher and Dana Reeve Foundation

2. Special thanks to… The Christopher and Dana Reeve Foundation Centers for Disease Control Ann Sullivan Center of Perú Dra. Liliana Mayo and Staff members Scott Richards, Ph.D. – Spain Rehabilitation Center, University of Alabama at Birmingham Suzanne Groah, M.D., M.S.P.H. – National Rehabilitation Hospital, Rehabilitation Research & Training Center on Secondary Conditions in the Rehabilitation of Individuals with Spinal Cord Injury

3. Special thanks to… Sam Ho Jaime Huerta Monica Ochoa

4. And special thanks to Julio Chojeda for translation of materials from English to Spanish…

5. Acknowledgement of sources used for this presentation: Yes You Can! (Paralyzed Veterans of America) SCI: A Manual for Healthy Living (TIRR) Bowel Dysfunction (RTC/IL & PVA) Neurogenic Bowel: What You Should Know (by the Consortium for Spinal Cord Medicine)

6. Presentation Review Discuss significance of the problem Define bowel dysfunction Describe how the digestive system works Discuss neurogenic bowel Identify personal risk factors Identify environment risk factors Autonomic dysreflexia Management of bowel programs Some cautions about bowel programs Other more invasive considerations Question and Answer session

7. Bowel Dysfunction - A Serious Problem More than 33% of people with SCI state that bowel problems are major issues resulting from their injury. About 25-30% of people with SCI living independently say their digestive problems have changed their lifestyle and has required medical intervention. People with complete SCI that occurred 5 or more years ago are most likely to experience problems.

8. Bowel Dysfunction - A Serious Problem A source of social embarrassment if an effective bowel program is not followed Limits social participation in the community in terms of work, and leisure Can cause discomfort, pain, and even death if not managed properly

9. Bowels How are they defined? –The dictionary defines them as “the seat of the gentler emotions” –Anatomically speaking the bowels is another name for the intestines or colon –Also derived from the Old French “boiel,” which is taken from the Latin word “botellus,” which means “sausage”

10. Digestive System: How does it Work? Food is chewed, swallowed and goes to stomach It then goes to the small intestine where food is broken down further and absorbed by the intestinal walls Peristalsis action moves the waste down the large intestine or colon, which is shaped like a large “S.” At the end of the large intestine is the anus

11. Digestive System: How does it Work? The function of the colon (large intestine) is to move the waste or feces out of the body The internal and external sphincters are the “gatekeepers” that allow feces to pass out of the body through the anus

12. SCI and the Neurogenic Bowel Brain signals are not able to communicate below the area of injury Many SCI individuals cannot sense when their bowel is full or when a bowel movement is about to occur This loss of sensation and function is called “neurogenic bowel”

13. Upper and Lower Motor Neuron Bowels: What’s the Difference?

14. The Spine The figure to the left illustrates the human spine. There are two types of bowels that are affected by the level of the spinal injury. The dividing point for these is T-12 or the 12 th thoracic vertebrae.

15. High Level SCI: Reflex Bowel Those with SCI injury above T12 have a reflex or upper motor neuron bowel –Local nerves that connect with rectum still communicate with one another –Internal and external anal sphincters retain tone reducing “accidents” between regularly scheduled bowel programs –Person is not usually aware when bowel is full –Bowel movements occur every 2-3 days –Main issue is incomplete bowel emptying

16. Low Level SCI: Flaccid Bowel Those with SCI injury below T11 have a flaccid or lower motor neuron bowel –Anal sphincter always relaxed –The colon does not normally contract when the bowel is full –There is greater risk for incontinence and impaction –Bowel movements occur almost every day

17. Person factors Environment factors Protective factors against bowel problems    

18. Knowledge Does not know how to perform a bowel program Knows how, but does not perform it routinely Is not aware of medications and other technology available to help make bowel management more successful Health Beliefs Does not take personal responsibility for self- health Believes in fate versus empowered approach to maintaining health

19. Personal Risk Factors Risk Behaviors Poor nutrition/eating habits—not eating enough fiber can lead to constipation Doesn’t drink enough water. Low activity levels—can lead to a sluggish bowel Does not perform regular routine to empty bowel to avoid incontinence. Stress and mood—affects people differently; some become more constipated, others not.

20. Personal Risk Factors Aging –Increased risk for bowel dysfunction –Why? The lining of the bowel is not as lubricated as it was in young adulthood There is decreased motility or peristalsis of the intestine Sphincter muscles may not be as tight and toned

21. Medications Some medications can make the stool softer (Colace or Surfak) Some medications can make stool more firm (Imodium) Narcotics can also lead to constipation. Some antibiotics (Augmentin) can kill all bacteria (good and bad) and can result in diarrhea, unless good bacteria is re-introduced into the digestive system (acidophilus, cultured yogurt)

22. Environmental Risk Factors Availability of foods that are a good source of fiber Opportunity and place to increase physical activity Availability of materials needed to perform bowel program (gloves, lubricant, suppositories) Personal assistance, if needed, to help perform bowel program

23. Potential Problems with the Neurogenic Bowel Constipation Fecal Impaction Diarrhea Hemorrhoids Autonomic Dysreflexia Involuntary bowel movements

24. Potential Problems with the Neurogenic Bowel Involuntary bowel movements –Can occur after you eat certain foods Caffeine, chocolate, and spicy foods stimulate the bowels –Evaluate entire bowel program Is the program frequent enough? Is it thorough and complete? –Plan for unanticipated “events”

25. Potential Problems with the Neurogenic bowel Constipation –Not eating proper diet Low intake of fluid Low intake of fiber Not using laxatives to assist –Medication side effects –Incomplete emptying of bowel

26. Dietary Effects on Bowel Management FOOD GROUP FOODS THAT HARDEN STOOLS FOODS THAT SOFTEN STOOLS MilkMilk, cheese, cottage cheese, ice cream Yogurt with seeds or fruit Bread and Cereal White bread or rolls, pancakes, white rice Whole grain breads and cereals Fruits and Vegetables Strained fruit juice, apple sauce, potatoes without skins All vegetables except potatoes without the skin MeatAny meat, fish, poultryNuts, dried beans, peas, seeds, lentils, chunky peanut butter FatsNoneAny Desserts and Sweets Any without seeds or fruitAnymade with cracked wheat, seeds or fruit SoupsAny creamed or broth- based with nothing else Soups with vegetables, beans, or lentils

27. Potential Problems with the Neurogenic Bowel Fecal Impaction –Chronic constipation can lead to impaction –Occurs when hardened feces collects in the colon –Laxatives and manual removal of stool may be required –In serious cases, surgery may be needed to remove impaction and possible damaged colon

28. Potential Problems with the Neurogenic Bowel Diarrhea –Can be caused by medications such as antibiotics –Overuse of laxatives –If using antibiotics, does not re- introduce healthy bacteria in colon (e.g., yogurt with live culture or acidophilus) –May be the result of a fecal impaction (leaking around the impacted area)

29. Potential Problems with Neurogenic Bowel Hemorrhoid Facts: Similar to vericose veins seen on the legs When irritated, tends to swell causing pain, itching, discomfort, burning and bleeding. Can be internal or external Internal hemorrhoids cause fewer problems than external hemorrhoids

30. Potential Problems with Neurogenic Bowel Hemorrhoid Causes: Constipation and chronic straining Diet low in vegetables, fruits, and other fiber sources Genetic factors Pregnancy and childbirth Aging Chronic diarrhea and/or chronic coughing Sitting for long periods of time

31. Potential Problems with the Neurogenic Bowel Autonomic Dysreflexia Over-activity of autonomic nervous system leading to high-blood pressure Potentially life-threatening High risk if SCI at upper back or neck –T6 level or higher

32. Autonomic Dysreflexia Frequent causes –Bowel Full of stool or gas Impaction Any stimulus to the rectum Develops suddenly Triggered by anything causing pain –e.g., bowel over-stretching Untreated can lead to stroke, seizure, and ultimately, death www.sci-info-pages.com/uti.html

33. Autonomic Dysreflexia How it starts –Uncomfortable or irritating stimulus Example: Over-stretched bowel Nerve impulse sent to spinal cord from stimulus Impulse stopped at injury level Nerve impulse unable to reach brain Reflex activated increasing activity in sympathetic nervous system www.sci-info-pages.com/uti.html

34. Autonomic Dysreflexia Warning signs –Sweating on face, arms or chest above injury –Bad headache –Red, blotchy skin above level of injury –Sudden high blood pressure –Blurry vision or spots –Goosebumps on arms or chest above injury –Slow pulse –A feeling of doom

35. Autonomic Dysreflexia If experiencing symptoms –Remove tight clothing or pressure immediately –Sit up in bed Keep head elevated –Empty bowel –Go to hospital emergency room REMOVE THE STIMULUS SOURCE

36. Managing a Bowel Program The word SELF can remind you of the elements of a successful bowel program S = Schedule E = Exercise L = Liquids F = Fiber

37. Managing a Bowel Program S = Schedule Establish a regular time to do your program –Time of day –Times per week –When to take laxatives –When to insert suppository

38. Managing a Bowel Program E = Exercise Significant increases or decreases in exercise can affect the movement of the bowels (peristalsis) Long periods of bedrest can cause constipation Regular exercise helps keep you regular

39. Managing a Bowel Program L = Liquids How much you drink is as important as what you drink Liquids containing caffeine or alcohol will help stimulate bowel activity Prune juice or apricot nectar promotes bowel regularity, but too much can cause diarrhea Drinking at least 2400 cc’s per day helps keep stool soft

40. Managing a Bowel Program F = Fiber Fiber adds bulk to the diet and improves regularity 15 grams of fiber daily is recommended to maintain regularity Examples of Fiber:

41. How to do a Bowel Program Start your program after a meal or hot drink (this stimulates peristalsis) Check your rectal area to see if there is any loose stool in it, if so remove Insert well-lubricated suppository high up into your rectum with gloved finger and place next to intestinal wall If possible, transfer to toilet or commode as gravity helps the evacuation process Wait 20-30 minutes after insertion

42. How to do a Bowel Program Then do digital stimulation using a lubricated gloved finger placed into your rectum Using a circular motion, massage the anal muscle until it becomes relaxed Repeat the process every 5- 10 minutes, to allow stool to pass through the rectum Once rectum is clear of any stool, wash and dry area

43. Cautions when doing a Bowel Program Enemas are used to flush out the contents of the lower intestines. Enemas should NEVER be considered the only solution to emptying the bowels. Repeated enemas can make the bowel dependent and not respond to the body’s own way of moving stool through the intestines.

44. Colostomy: A Treatment of Last Choice? Colostomy may be an option if: There are repeated bowel complications –Infections –Chronic leakage –Bloating –Extensive limitation of social life –Skin problems with the buttocks due to chronic bowel incontinence

45. Colostomy: A Treatment of Last Choice? To perform a colostomy, a cut is made in the colon and connected to another opening in the abdominal wall (called a “stoma”). The lower end of the colon is sewn shut. Instead of proceeding to the rectum, stool exits out of the stoma into a colostomy pouch attached to the outside of the body to collect the stool. Stoma

46. Future Possibilities for Bowel Management This picture displays an electronic device that activates an artificial sphincter that opens and releases the intestines at times when the user chooses. This device is adapted from a similar device used to treat urinary incontinence. Research in this area is still basic and expensive.

47. Future Possibilities for Bowel Management (Experimental Research) Electrostimulation therapy may become a viable treatment option in the future Stimulation of the anterior sacral root is most likely candidate This technique is already used to empty bladder in some patients

48. Review of Today’s Session Today we: Discussed the significance of the problem Defined bowel dysfunction Described how the digestive system works Discussed neurogenic bowel Identified personal and environmental risk factors Discussed autonomic dysreflexia Outlined options for bowel programs Mentioned other more invasive treatments