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Ju C, Liu R, Ma Y, Dong H, Xu R, Hu H, Hao D. Targeted microbiota dysbiosis repair: An important approach to health management after spinal cord injury. Ageing Res Rev 2025; 104:102648. [PMID: 39725357 DOI: 10.1016/j.arr.2024.102648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2024] [Revised: 12/18/2024] [Accepted: 12/21/2024] [Indexed: 12/28/2024]
Abstract
Current research primarily focuses on the pathological mechanisms of spinal cord injury (SCI), seeking to promote spinal cord repair and restore motorial and sensory functions by elucidating mechanisms of cell death or axonal regeneration. However, SCI is almost irreversible, and patients often struggle to regain mobility or self-care abilities after injuries. Consequently, there has been significant interest in modulating systemic symptoms following SCI to improve patients' quality of life. Neuron axonal disconnection and substantial apoptotic events following SCI result in signal transmission loss, profoundly impacting various organ and systems, including the gastrointestinal tract. Dysbiosis can lead to severe bowel dysfunction in patients, substantially lowering their quality of life and significantly reducing life expectancy of them. Therefore, researches focusing on the restoration of the gut microbiota hold promise for potential therapeutic strategies aimed at rehabilitation after SCI. In this paper, we explore the regulatory roles that dietary fiber, short-chain fatty acids (SCFAs), probiotics, and microbiota transplantation play in patients with SCI, summarize the potential mechanisms of post-SCI dysbiosis, and discuss possible strategies to enhance long-term survival of SCI patients. We aim to provide potential insights for future research aimed at ameliorating dysbiosis in SCI patients.
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Affiliation(s)
- Cheng Ju
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Renfeng Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Yanming Ma
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Hui Dong
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Ruiqing Xu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Huimin Hu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Youyidong Road, Xi'an, Shaanxi 710000, China; Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, Shaanxi 710000, China.
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Hu X, Feng J, Lu J, Pang R, Zhang A, Liu J, Gou X, Bai X, Wang J, Chang C, Yin J, Wang Y, Xiao H, Wang Q, Cheng H, Chang Y, Wang W. Effects of exoskeleton-assisted walking on bowel function in motor-complete spinal cord injury patients: involvement of the brain-gut axis, a pilot study. Front Neurosci 2024; 18:1395671. [PMID: 38952922 PMCID: PMC11215087 DOI: 10.3389/fnins.2024.1395671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/27/2024] [Indexed: 07/03/2024] Open
Abstract
Evidence has demonstrated that exoskeleton robots can improve intestinal function in patients with spinal cord injury (SCI). However, the underlying mechanisms remain unelucidated. This study investigated the effects of exoskeleton-assisted walking (EAW) on intestinal function and intestinal flora structure in T2-L1 motor complete paraplegia patients. The results showed that five participants in the EAW group and three in the conventional group reported improvements in at least one bowel management index, including an increased frequency of bowel evacuations, less time spent on bowel management per day, and less external assistance (manual digital stimulation, medication, and enema usage). After 8 weeks of training, the amount of glycerol used in the EAW group decreased significantly (p <0.05). The EAW group showed an increasing trend in the neurogenic bowel dysfunction (NBD) score after 8 weeks of training, while the conventional group showed a worsening trend. Patients who received the EAW intervention exhibited a decreased abundance of Bacteroidetes and Verrucomicrobia, while Firmicutes, Proteobacteria, and Actinobacteria were upregulated. In addition, there were decreases in the abundances of Bacteroides, Prevotella, Parabacteroides, Akkermansia, Blautia, Ruminococcus 2, and Megamonas. In contrast, Ruminococcus 1, Ruminococcaceae UCG002, Faecalibacterium, Dialister, Ralstonia, Escherichia-Shigella, and Bifidobacterium showed upregulation among the top 15 genera. The abundance of Ralstonia was significantly higher in the EAW group than in the conventional group, and Dialister increased significantly in EAW individuals at 8 weeks. This study suggests that EAW can improve intestinal function of SCI patients in a limited way, and may be associated with changes in the abundance of intestinal flora, especially an increase in beneficial bacteria. In the future, we need to further understand the changes in microbial groups caused by EAW training and all related impact mechanisms, especially intestinal flora metabolites. Clinical trial registration: https://www.chictr.org.cn/.
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Affiliation(s)
- Xiaomin Hu
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Jing Feng
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiachun Lu
- Chengdu Eighth People’s Hospital (Geriatric Hospital of Chengdu Medical College), Chengdu, China
| | - Rizhao Pang
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Anren Zhang
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiancheng Liu
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Xiang Gou
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Xingang Bai
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Junyu Wang
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cong Chang
- Chengdu Eighth People’s Hospital (Geriatric Hospital of Chengdu Medical College), Chengdu, China
| | - Jie Yin
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yunyun Wang
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Hua Xiao
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Qian Wang
- Care Alliance Jinchen Rehabilitation Hospital of Chengdu, Chengdu, China
| | - Hong Cheng
- School of Automation Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Youjun Chang
- Sichuan Provincial Rehabilitation Hospital, Affiliated Rehabilitation Hospital of Chengdu University of T.C.M., Chengdu, China
| | - Wenchun Wang
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
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Colasante C, Brose SW, Gustafson K, Bourbeau D. Minimally invasive electrical rectal stimulation promotes bowel emptying in an individual with spinal cord injury. J Spinal Cord Med 2023; 46:975-979. [PMID: 37195173 PMCID: PMC10653754 DOI: 10.1080/10790268.2023.2212335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
CONTEXT Individuals with SCI typically live with neurogenic bowel dysfunction and impaired colonic motility that may significantly impact health and quality of life. Bowel management often includes digital rectal stimulation (DRS) to modulate the recto-colic reflex to promote bowel emptying. This procedure can be time-consuming, caregiver-intensive, and lead to rectal trauma. This study presents a description of using electrical rectal stimulation as an alternative to DRS to help manage bowel emptying in a person with SCI. METHODS We conducted an exploratory case study with a 65-year-old male with a T4 AIS B SCI who normally relies on DRS as the main component of his regular bowel management strategy. In randomly selected bowel emptying sessions during a 6-week period, the participant received burst-pattern electrical rectal stimulation (ERS) (50 mA, 20 pulses/s at 100 Hz), via a rectal probe electrode until bowel emptying was achieved. The primary outcome measure was number of cycles of stimulation required to complete the bowel routine. RESULTS 17 sessions were performed using ERS. In 16 sessions, a bowel movement was produced after only 1 cycle of ERS. In 13 sessions, complete bowel emptying was achieved with 2 cycles of ERS. CONCLUSIONS ERS was associated with effective bowel emptying. This work represents the first time ERS has been used to affect bowel emptying in someone with SCI. This approach could be investigated as a tool to evaluate bowel dysfunction, and it could be further refined as a tool for improving bowel emptying.
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Affiliation(s)
- Cesar Colasante
- SCI/D Center, Syracuse VA, Syracuse, New York, USA
- Department of Physical Medicine and Rehabilitation, SUNY Upstate, Syracuse, New York, USA
| | - Steven W. Brose
- SCI/D Center, Syracuse VA, Syracuse, New York, USA
- Department of Physical Medicine and Rehabilitation, SUNY Upstate, Syracuse, New York, USA
| | - Kenneth Gustafson
- Biomedical Engineering Department, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dennis Bourbeau
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
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Chu CY, Su YC, Hsieh PC, Lin YC. Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis. Toxicon 2023; 235:107311. [PMID: 37816487 DOI: 10.1016/j.toxicon.2023.107311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 10/12/2023]
Abstract
Dyssynergic defecation (DD) is a common cause of chronic constipation. Owing to the lack of a comprehensive synthesis of available data on the effectiveness of botulinum neurotoxin (BoNT) for treating DD, we performed a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane databases from inception to May 9, 2023. The outcomes comprise short-term and long-term symptom improvement, various anorectal function measurements, complications of fecal incontinence, and symptom improvement after repeated BoNT injections. A meta-analysis comparing BoNT injection with either surgery or biofeedback (BFB) therapy in treating DD was also conducted. Subgroup analysis and meta-regression were performed to identify possible moderator effects. We included five randomized controlled trials, seven prospective studies, and two retrospective observational studies. Short-term potential improvement in symptoms (event rate [ER], 66.4%; 95% CI, 0.513 to 0.783) was identified, but in the long-term (>12 months), this effect was decreased (ER, 38.2%; 95% CI, 0.267 to 0.511). Short-term improvements in objective anorectal physiologic parameters were also observed. Repeated BoNT injection was effective for patients with symptom recurrence. Subgroup analysis revealed enhanced long-term symptom improvement with high-dose BoNT, but this treatment also increased the risk of complications and recurrence compared with low doses. The effectiveness, complications, and recurrence of symptoms associated with BoNT injection and surgery did not differ significantly. BoNT injection significantly provided short-term symptom improvement but also heightened the risk of incontinence compared with BFB therapy. Our systematic review and meta-analysis indicated that BoNT could be beneficial for short-term symptom improvement in patients with DD, but this effect tended to decline 12 months after injection. Standardized BoNT intervention protocols remain warranted. Among the several treatments for DD, we concluded that BoNT injection is not inferior to other options considering its effectiveness in relieving symptoms, the associated complication development, and the risk of symptom recurrence.
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Affiliation(s)
- Ching-Yu Chu
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Chun Hsieh
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Neurophysiological Effects of Electrical Stimulation on a Patient with Neurogenic Bowel Dysfunction and Cauda Equina Syndrome after Spinal Anesthesia: A Case Report. Medicina (B Aires) 2023; 59:medicina59030588. [PMID: 36984589 PMCID: PMC10051071 DOI: 10.3390/medicina59030588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Neurogenic bowel dysfunction (NBD) is common in patients with cauda equina syndrome (CES). Previous studies have reported that electrical stimulation (ES) improves NBD but more neurophysiologic evidence is required. This case report describes a patient who experienced difficulty with defecation as a result of cauda equina syndrome (CES) that developed after a cesarean section performed 12 years ago under spinal anesthesia. The neurophysiological effects were assessed using the bulbocavernosus reflex (BCR) and electromyography (EMG). Two ES treatments, interferential current therapy and transcutaneous electrical stimulation, were used to stimulate the intestine and the external anal sphincter, respectively. The BCR results showed right-side delayed latency and no response on the left side. Needle EMG revealed abnormal spontaneous activities of the bilateral bulbocavernosus (BC) muscles. Electrodiagnostic testing revealed chronic bilateral sacral polyradiculopathy, compatible with CES. After treatment, the patient reported an improved perianal sensation, less strain and time for defecation than before, and satisfaction with her bowel condition. At the follow-up electrodiagnosis, the BCR latency was normal on the right side—needle EMG revealed reductions in the abnormal spontaneous activities of both BC muscles and re-innervation of the right BC muscle. Electrodiagnostic testing can offer insight into the neurophysiological effects of ES, which can help in understanding the mechanism of action and optimizing the therapy for patients with NBD.
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Wulf MJ, Tom VJ. Consequences of spinal cord injury on the sympathetic nervous system. Front Cell Neurosci 2023; 17:999253. [PMID: 36925966 PMCID: PMC10011113 DOI: 10.3389/fncel.2023.999253] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Spinal cord injury (SCI) damages multiple structures at the lesion site, including ascending, descending, and propriospinal axons; interrupting the conduction of information up and down the spinal cord. Additionally, axons associated with the autonomic nervous system that control involuntary physiological functions course through the spinal cord. Moreover, sympathetic, and parasympathetic preganglionic neurons reside in the spinal cord. Thus, depending on the level of an SCI, autonomic function can be greatly impacted by the trauma resulting in dysfunction of various organs. For example, SCI can lead to dysregulation of a variety of organs, such as the pineal gland, the heart and vasculature, lungs, spleen, kidneys, and bladder. Indeed, it is becoming more apparent that many disorders that negatively affect quality-of-life for SCI individuals have a basis in dysregulation of the sympathetic nervous system. Here, we will review how SCI impacts the sympathetic nervous system and how that negatively impacts target organs that receive sympathetic innervation. A deeper understanding of this may offer potential therapeutic insight into how to improve health and quality-of-life for those living with SCI.
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Affiliation(s)
| | - Veronica J. Tom
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
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[Analysis of anorectal manometry data in central and peripheral neurological deseases: Review of the literature]. Prog Urol 2022; 32:1505-1518. [PMID: 36030152 DOI: 10.1016/j.purol.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/26/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Peripheral or central neurological deseases are providers of anorectal disorders of variable clinical expression (constipation, dyschezia, faecal incontinence (FI)…). Anorectal manometry (ARM) participates in their exploration to determine the underlying mechanisms, guide and optimize treatments. The objective of this work was to determine if there is a pattern of ARM data in neurological populations. MATERIALS ET METHODS Literature review from PubMed, Cochrane and Google scholar databases, using the following keywords: parkinsonian disorders; parkinson's disease; multiple slcerosis; neurolog*; spinal cord injury; spina bifida occulta; stroke; pudendal; endometriosis; peripheral nervous system diseases. 196 articles were isolated and finally 45 retained after reading the title and the abstract. RESULTS Data comparison was difficult due to the heterogeneity of techniques and thresholds used. In central lesions, resting and squeeze anal pressures were often altered. The presence of FI or constipation, the sex and the lesion level were factors influencing these data (low if complete injury, women or EDSS>5.5). In case of peripheral lesion, it is the anal tone and the contraction that varied the symptomatology. The sensory thresholds were variable regardless of the impairment. CONCLUSION This review did not identify a data pattern of ARM in central and peripheral neurological deseases. Gradual standardization of techniques and protocols will allow better comparison of data.
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Rodriguez GM, Gater DR. Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review. J Pers Med 2022; 12:1141. [PMID: 35887638 PMCID: PMC9324073 DOI: 10.3390/jpm12071141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/02/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.
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Affiliation(s)
- Gianna M. Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan College of Medicine, Ann Arbor, MI 48108, USA
| | - David R. Gater
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA;
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Volumetric Rectal Perception Testing: Is It Clinically Relevant? Results From a Large Patient Cohort. Am J Gastroenterol 2021; 116:2419-2429. [PMID: 34608885 DOI: 10.14309/ajg.0000000000001526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Rectal perception testing is a recommended component of anorectal physiology testing. Although recent consensus (London) guidelines suggested criteria for categorizing hyporectal and hyper-rectal sensitivity, these were based on scant evidence. Moreover, data regarding diagnostic capabilities and clinical utility of rectal perception testing are lacking. The aims of this study were to determine the association between rectal perception testing and both clinical and physiological variables to enhance the analysis and interpretation of real-life test results. METHODS Prospectively documented data from 1,618 (92% female) patients referred for anorectal physiology testing were analyzed for 3 rectal perception thresholds (first, urge, and maximal tolerated). Normal values derived from healthy female subjects were used to categorize each threshold into hyposensitive and hypersensitive to examine the clinical relevance of this categorization. RESULTS There was poor to moderate agreement between the 3 thresholds. Older age, male sex, and constipation were associated with higher perception thresholds, whereas irritable bowel syndrome, fecal incontinence, connective tissue disease, and pelvic radiation were associated with lower perception thresholds to some, but not all, thresholds (P < 0.01 on multivariate analysis for all). The clinical utility and limitations of categorizing thresholds into "hypersensitivity" and "hyposensitivity" were determined. DISCUSSION Commonly practiced rectal perception testing is correlated with several disease states and thus has clinical relevance. However, most disease states were correlated with 2 or even only 1 abnormal threshold, and agreement between thresholds was limited. This may suggest each threshold measures different pathophysiological pathways. We suggest all 3 thresholds be measured and reported separately in routine clinical testing.
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Vallès M, Albu S, Kumru H, Mearin F. Botulinum toxin type-A infiltration of the external anal sphincter to treat outlet constipation in motor incomplete spinal cord injury: pilot cohort study. Scand J Gastroenterol 2021; 56:777-783. [PMID: 34000949 DOI: 10.1080/00365521.2021.1921255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Outlet constipation is a major problem in spinal cord injury (SCI) patients. We aimed to study the efficacy of external anal sphincter (EAS) infiltration with type-A botulinum toxin (BTX-A) in motor incomplete SCI patients with outlet constipation. METHODS Double blind, randomized, placebo controlled, comparative study in 16 motor incomplete SCI subjects. Patients were randomly assigned toreceive100 UI of BTX-A (n = 9) or physiologic serum infiltration (n = 7) in the EAS under electromyographic guidance. Outcome measures included a questionnaire for clinical bowel function evaluation, colonic transit time and anorectal manometry. All assessments were done at baseline, 1 and 3 months after treatment. RESULTS Fourteen patients completed the study. In the BTX-A group we observed an improvement of subjective perception of bowel function (p = 0.01), constipation (p = 0.02) and neurogenic bowel dysfunction score (p = 0.02). The anorectal manometry revealed are duction of EAS voluntary contraction pressure (p = 0.01). No changes were observed in the placebo group. No significant side effects were observed in none of the groups. CONCLUSION BTX-A infiltration of the EAS is a safe technique that in motor incomplete SCI, decreases the EAS contraction and the anal canal pressure during straining, and improves outlet constipation symptoms. Future studies in larger populations are needed.
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Affiliation(s)
- Margarita Vallès
- Unit of Functional Digestive Rehabilitation, Institut Guttmann, University of Barcelona, Badalona, Spain.,Spinal Cord Injury Unit, Institut Guttmann, University of Barcelona, Badalona, Spain
| | - Sergiu Albu
- Spinal Cord Injury Unit, Institut Guttmann, University of Barcelona, Badalona, Spain
| | - Hatice Kumru
- Spinal Cord Injury Unit, Institut Guttmann, University of Barcelona, Badalona, Spain
| | - Fermín Mearin
- Unit of Functional Digestive Rehabilitation, Institut Guttmann, University of Barcelona, Badalona, Spain
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Johns J, Krogh K, Rodriguez GM, Eng J, Haller E, Heinen M, Laredo R, Longo W, Montero-Colon W, Korsten M. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury Suggested citation: Jeffery Johns, Klaus Krogh, Gianna M. Rodriguez, Janice Eng, Emily Haller, Malorie Heinen, Rafferty Laredo, Walter Longo, Wilda Montero-Colon, Mark Korsten. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury: Clinical Practice Guideline for Healthcare Providers. Journal of Spinal Cord Med. 2021. Doi:10.1080/10790268.2021.1883385. J Spinal Cord Med 2021; 44:442-510. [PMID: 33905316 PMCID: PMC8115581 DOI: 10.1080/10790268.2021.1883385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Jeffery Johns
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Gianna M Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Janice Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily Haller
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Malorie Heinen
- University of Kansas Health Care System, Kansas City, Kansas, USA
| | | | - Walter Longo
- Department of Surgery, Division of Gastrointestinal Surgery, Yale University, New Haven, Connecticut, USA
| | | | - Mark Korsten
- Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, Division of Gastroenterology, New York, New York, USA
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Mosiello G, Safder S, Marshall D, Rolle U, Benninga MA. Neurogenic Bowel Dysfunction in Children and Adolescents. J Clin Med 2021; 10:1669. [PMID: 33924675 PMCID: PMC8069792 DOI: 10.3390/jcm10081669] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/07/2023] Open
Abstract
Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.
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Affiliation(s)
- Giovanni Mosiello
- Department of Surgery, Division of Urology, Bambino Gesù Pediatric and Research Hospital, 00165 Rome, Italy
| | - Shaista Safder
- College of Medicine, Center for Digestive, Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL 32806, USA;
| | - David Marshall
- Department of Pediatric Surgery and Pediatric Urology, Royal Belfast Hospital for Sick Children, Belfast BT97AB, UK;
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, Goethe-University Frankfurt, 60596 Frankfurt, Germany;
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
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Vallès M, Antuori A, Mearin F, Serra J. Small intestinal bacterial overgrowth in spinal cord injury patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 44:539-545. [PMID: 33640466 DOI: 10.1016/j.gastrohep.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
AIM Spinal cord injury (SCI) patients may have intestinal dysmotility and digestive symptoms that are associated with small intestinal bacterial overgrowth (SIBO). The aim of this study is to describe the prevalence of SIBO in SCI patients and the risk factors of its development. METHODS Twenty-nine consecutive SCI patients were studied (10 women/19 men; mean age 47 years), 16 with subacute injuries (<9 months) and 13 with chronic injuries (>1 year). Nine patients were affected by tetraplegia and 15 by paraplegia. Each patient underwent a glucose breath test according to the North American Consensus and the presence of abdominal symptoms was evaluated during the test. The results were compared with 15 non-neurological patients with SIBO. RESULTS Six patients tested positive for SIBO (21%), all of them affected by SCI in the subacute phase, 6/16 vs. 0/13 in the chronic phase (P<.05) and the majority with tetraplegia, 5/9 vs. 1/19 with paraplegia (P<.05). No statistically significant relationship was found with other clinical characteristics. All the tests were positive for methane or mixed (methane and hydrogen), while only 67% of the controls had methane-predominant production (P>.05). CONCLUSION SCI patients can develop SIBO, more frequently in the subacute phase and in tetraplegic patients, highlighting a high production of methane. This complication should be considered in neurogenic bowel management.
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Affiliation(s)
- Margarita Vallès
- Institut Guttmann (adscrito a la Universitat Autònoma de Barcelona), Badalona, Barcelona, España.
| | - Alexandra Antuori
- Institut Guttmann (adscrito a la Universitat Autònoma de Barcelona), Badalona, Barcelona, España
| | - Fermín Mearin
- Institut Guttmann (adscrito a la Universitat Autònoma de Barcelona), Badalona, Barcelona, España
| | - Jordi Serra
- Unidad de Motilidad y Trastornos Funcionales Digestivos, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Badalona, Barcelona, España
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14
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Seifert J, Böthig R, Wolter S, Izbicki JR, Thietje R, Tachezy M. [The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]. Chirurg 2021; 92:551-558. [PMID: 33630122 PMCID: PMC8159781 DOI: 10.1007/s00104-021-01364-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important. OBJECTIVE This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment. MATERIAL AND METHODS Targeted literature search in Medline and Cochrane library (German and English, 1985-2020). RESULTS AND CONCLUSION The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.
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Affiliation(s)
- Julia Seifert
- Abteilung für Allgemein und Viszeralchirurgie, BG Klinikum Hamburg, Hamburg, Deutschland
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Ralf Böthig
- Abteilung für Neuro-Urologie des Querschnittgelähmten-Zentrum, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Stefan Wolter
- Abteilung für Allgemein und Viszeralchirurgie, BG Klinikum Hamburg, Hamburg, Deutschland
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Jakob R Izbicki
- Abteilung für Allgemein und Viszeralchirurgie, BG Klinikum Hamburg, Hamburg, Deutschland
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Roland Thietje
- Querschnittgelähmten-Zentrum, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Michael Tachezy
- Abteilung für Allgemein und Viszeralchirurgie, BG Klinikum Hamburg, Hamburg, Deutschland.
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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15
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Pharmacological Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury and Multiple Sclerosis: A Systematic Review and Clinical Implications. J Clin Med 2021; 10:jcm10040882. [PMID: 33671492 PMCID: PMC7926827 DOI: 10.3390/jcm10040882] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
Neurogenic bowel dysfunction (NBD) is a common problem for people with spinal cord injury (SCI) and multiple sclerosis (MS), which seriously impacts quality of life. Pharmacological management is an important component of conservative bowel management. The objective of this study was to first assemble a list of pharmacological agents (medications and medicated suppositories) used in current practice. Second, we systematically examined the current literature on pharmacological agents to manage neurogenic bowel dysfunction of individuals specifically with SCI or MS. We searched Medline, EMBASE and CINAHL databases up to June 2020. We used the GRADE System to provide a systematic approach for evaluating the evidence. Twenty-eight studies were included in the review. We found a stark discrepancy between the large number of agents currently prescribed and a very limited amount of literature. While there was a small amount of literature in SCI, there was little to no literature available for MS. There was low-quality evidence supporting rectal medications, which are a key component of conservative bowel care in SCI. Based on the findings of the literature and the clinical experience of the authors, we have provided clinical insights on proposed treatments and medications in the form of three case study examples on patients with SCI or MS.
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16
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Johns J, Krogh K, Rodriguez GM, Eng J, Haller E, Heinen M, Laredo R, Longo W, Montero-Colon W, Wilson C, Korsten M. Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Top Spinal Cord Inj Rehabil 2021; 27:75-151. [PMID: 34108835 PMCID: PMC8152174 DOI: 10.46292/sci2702-75] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jeffery Johns
- Vanderbilt University Medical Center, Nashville, Tennessee USA
| | | | | | - Janice Eng
- University of British Columbia, Vancouver Canada
| | | | - Malorie Heinen
- University of Kansas Health Care System, Kansas City, Kansas USA
| | | | | | | | - Catherine Wilson
- Diplomate, American Board of Professional Psychology (RP) Private Practice, Denver, Colorado
| | - Mark Korsten
- Icahn School of Medicine @ Mt Sinai, New York, New York USA
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17
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Lefèvre C, Bessard A, Aubert P, Joussain C, Giuliano F, Behr-Roussel D, Perrouin-Verbe MA, Perrouin-Verbe B, Brochard C, Neunlist M. Enteric Nervous System Remodeling in a Rat Model of Spinal Cord Injury: A Pilot Study. Neurotrauma Rep 2020; 1:125-136. [PMID: 34223537 PMCID: PMC8240894 DOI: 10.1089/neur.2020.0041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The physiopathology of digestive disorders in patients with spinal cord injury (SCI) remains largely unknown, particularly the involvement of the enteric nervous system (ENS). We aimed in a rat model of chronic thoracic SCI to characterize (1) changes in the neurochemical coding of enteric neurons and their putative consequences upon neuromuscular response, and (2) the inflammatory response of the colon. Ex vivo motility of proximal and distal colon segments of SCI and control (CT) rats were studied in an organ chamber in response to electrical field stimulation (EFS) and bethanechol. Immunohistochemical analysis of proximal and distal segments was performed using antibodies again Hu, neuronal nitric oxide synthase, (nNOS), and choline acetyltransferase. Colonic content of acetylcholine and acetylcholinesterase was measured; messenger RNA (mRNA) expression of inflammatory cytokines was measured using reverse transcription quantitative polymerase chain reaction (RT-qPCR) approaches. Compared with the CT rats, the contractile response to bethanechol was significantly decreased in the proximal colon of SCI rats but not in the distal colon. The proportion of nNOS immunoreactive (IR) neurons was significantly reduced in the proximal but not distal colon of SCI rats. No change in proportion of choline acetyltransferase (ChAT)-IR was reported; the tissue concentration of acetylcholine was significantly decreased in the proximal colon of SCI rats. The expression of tumor necrosis factor alpha (TNF-α) and intercellular adhesion molecule-1 (ICAM-1) was significantly reduced in the proximal and distal colon of SCI rats. This study demonstrates that functional motor and enteric neuroplastic changes affect preferentially the proximal colon compared with the distal colon. The underlying mechanisms and factors responsible for these changes remain to be discovered.
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Affiliation(s)
- Chloë Lefèvre
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France.,Neurological Physical and Rehabilitation Medicine Department, University Hospital of Nantes, Nantes, France
| | - Anne Bessard
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France
| | - Philippe Aubert
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France
| | - Charles Joussain
- UMR Inserm 1179, Research Unit, Neuromuscular Disability, Physiopathology, Biotherapy, and Applied Pharmacology (END-ICAP), University of Versailles-St-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
| | - François Giuliano
- UMR Inserm 1179, Research Unit, Neuromuscular Disability, Physiopathology, Biotherapy, and Applied Pharmacology (END-ICAP), University of Versailles-St-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
| | - Delphine Behr-Roussel
- Pelvipharm, University of Versailles-St-Quentin-en-Yvelines, Montigny-le-Bretonneux, France
| | - Marie-Aimée Perrouin-Verbe
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France.,Urology Unit, University Hospital of Nantes, Nantes, France
| | - Brigitte Perrouin-Verbe
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France.,Neurological Physical and Rehabilitation Medicine Department, University Hospital of Nantes, Nantes, France
| | - Charlène Brochard
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France.,Digestive Physiology Unit, University Hospital of Rennes, Rennes, France
| | - Michel Neunlist
- UMR Inserm 1235, Research Unit, The Enteric Nervous System in Gut and Brain Diseases (TENS), University of Nantes, Nantes, France
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18
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Albu S, Kumru H, Coll R, Vives J, Vallés M, Benito-Penalva J, Rodríguez L, Codinach M, Hernández J, Navarro X, Vidal J. Clinical effects of intrathecal administration of expanded Wharton jelly mesenchymal stromal cells in patients with chronic complete spinal cord injury: a randomized controlled study. Cytotherapy 2020; 23:146-156. [PMID: 32981857 DOI: 10.1016/j.jcyt.2020.08.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/01/2020] [Accepted: 08/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AIMS Spinal cord injury (SCI) represents a devastating condition leading to severe disability related to motor, sensory and autonomic dysfunction. Stem cell transplantation is considered a potential emerging therapy to stimulate neuroplastic and neuroregenerative processes after SCI. In this clinical trial, the authors investigated the safety and clinical recovery effects of intrathecal infusion of expanded Wharton jelly mesenchymal stromal cells (WJ-MSCs) in chronic complete SCI patients. METHODS The authors designed a randomized, double-blind, crossover, placebo-controlled, phase 1/2a clinical trial (NCT03003364). Participants were 10 patients (7 males, 3 females, age range, 25-47 years) with chronic complete SCI (American Spinal Injury Association A) at dorsal level (T3-11). Patients were randomly assigned to receive a single dose of intrathecal ex vivo-expanded WJ-MSCs (10 × 106 cells) from human umbilical cord or placebo and were then switched to the other arm at 6 months. Clinical evaluation (American Spinal Injury Association impairment scale motor and sensory score, spasticity, neuropathic pain, electrical perception and pain thresholds), lower limb motor evoked potentials (MEPs) and sensory evoked potentials (SEPs), Spinal Cord Independence Measure and World Health Organization Quality of Life Brief Version were assessed at baseline, 1 month, 3 months and 6 months after each intervention. Urodynamic studies and urinary-specific quality of life (Qualiveen questionnaire) as well as anorectal manometry, functional assessment of bowel dysfunction (Rome III diagnostic questionnaire) and severity of fecal incontinence (Wexner score) were conducted at baseline and at 6 months after each intervention. RESULTS Intrathecal transplantation of WJ-MSCs was considered safe, with no significant side effects. Following MSC infusion, the authors found significant improvement in pinprick sensation in the dermatomes below the level of injury compared with placebo. Other clinically relevant effects, such as an increase in bladder maximum capacity and compliance and a decrease in bladder neurogenic hyperactivity and external sphincter dyssynergy, were observed only at the individual level. No changes in motor function, spasticity, MEPs, SEPs, bowel function, quality of life or independence measures were observed. CONCLUSIONS Intrathecal transplantation of human umbilical cord-derived WJ-MSCs is a safe intervention. A single intrathecal infusion of WJ-MSCs in patients with chronic complete SCI induced sensory improvement in the segments adjacent to the injury site.
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Affiliation(s)
- Sergiu Albu
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| | - Hatice Kumru
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain.
| | - Ruth Coll
- Research and Education, Banc de Sang i Teixits, Barcelona, Spain
| | - Joaquim Vives
- Cell Therapy Service, Banc de Sang i Teixits, Barcelona, Spain
| | - Margarita Vallés
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| | - Jesús Benito-Penalva
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| | | | | | - Joaquim Hernández
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Barcelona, Spain
| | - Xavier Navarro
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Barcelona, Spain
| | - Joan Vidal
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Hospital de Neurorehabilitació, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
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19
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Geng V, Böthig R, Hildesheim A, Kurze I, Leder ED. [Guidelines: neurogenic bowel dysfunction in spinal cord injury (long version)]. COLOPROCTOLOGY 2020; 42:375-389. [PMID: 32934429 PMCID: PMC7484609 DOI: 10.1007/s00053-020-00482-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The guidelines (AWMF register number: 179-004) on neurogenic bowel dysfunction (NBD) in spinal cord injury of the German-speaking Medical Society for Paraplegiology is addressed to all persons who care for people with congenital or acquired paraplegia with NBD. In particular, doctors, nurses and therapists are addressed. The multiprofessionally developed guidelines (involving neurourologists, visceral surgeons, gastroenterologists, health and nursing staff, nutritionists and associated professional societies in the review process) provides practical support for the care of patients with NBD. Definitions and up to date knowledge on the diagnostics of NBD as well as on the necessary conservative bowel management are conveyed in order to ensure the competent treatment of patients with NBD. The concept of NBD and its clinical implications are described. Drug interventions and surgical procedures are explained in brief and recommendations are given. The main objective of the present guidelines is to prevent complications including fecal incontinence and constipation and thus to positively influence the quality of life of those affected. Helpful appendices, which can be used in everyday life, complete the guidelines.
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Affiliation(s)
- Veronika Geng
- Beratungszentrum für Ernährung und Verdauung Querschnittgelähmter, Manfred-Sauer-Stiftung, Neurott 20, 74931 Lobbach, Deutschland
| | - Ralf Böthig
- Abteilung Neuro-Urologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | | | - Ines Kurze
- Querschnittgelähmten-Zentrum, Klinik für Paraplegiologie und Neuro-Urologie, Zentralklinik Bad Berka, Bad Berka, Deutschland
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20
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Hoey RF, Hubscher CH. Investigation of Bowel Function with Anorectal Manometry in a Rat Spinal Cord Contusion Model. J Neurotrauma 2020; 37:1971-1982. [PMID: 32515264 DOI: 10.1089/neu.2020.7145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.
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Affiliation(s)
- Robert F Hoey
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Charles H Hubscher
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, Kentucky, USA.,Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
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21
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Neurogenic Bowel: Traditional Approaches and Clinical Pearls. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00269-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Bernardi M, Fedullo AL, Bernardi E, Munzi D, Peluso I, Myers J, Lista FR, Sciarra T. Diet in neurogenic bowel management: A viewpoint on spinal cord injury. World J Gastroenterol 2020; 26:2479-2497. [PMID: 32523306 PMCID: PMC7265150 DOI: 10.3748/wjg.v26.i20.2479] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/14/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.
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Affiliation(s)
- Marco Bernardi
- Department of Physiology and Pharmacology "V. Erspamer", Sapienza University of Rome, Rome 00185, Italy
- Italian Paralympic Committee, Rome 00191, Italy
- Federazione Italiana Pallacanestro In Carrozzina (FIPIC), Rome 00188, Italy
| | - Anna Lucia Fedullo
- Federazione Italiana Pallacanestro In Carrozzina (FIPIC), Rome 00188, Italy
| | - Elisabetta Bernardi
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari "Aldo Moro", Bari 70121, Italy
| | - Diego Munzi
- Joint Veteran Center, Scientific Department, Army Medical Center, Rome 00184, Italy
| | - Ilaria Peluso
- Research Centre for Food and Nutrition, Council for Agricultural Research and Economics (CREA-AN), Rome 00178, Italy
| | - Jonathan Myers
- VA Palo Alto Health Care System and Stanford University, Cardiology Division, Palo Alto, CA 94025, United States
| | | | - Tommaso Sciarra
- Joint Veteran Center, Scientific Department, Army Medical Center, Rome 00184, Italy
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23
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Chun A, Asselin PK, Knezevic S, Kornfeld S, Bauman WA, Korsten MA, Harel NY, Huang V, Spungen AM. Changes in bowel function following exoskeletal-assisted walking in persons with spinal cord injury: an observational pilot study. Spinal Cord 2020; 58:459-466. [PMID: 31822808 PMCID: PMC7145720 DOI: 10.1038/s41393-019-0392-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/15/2023]
Abstract
STUDY DESIGN Prospective, observational study. OBJECTIVE To explore the effects of exoskeletal-assisted walking (EAW) on bowel function in persons with spinal cord injury (SCI). SETTING Ambulatory research facility located in a tertiary care hospital. METHODS Individuals 18-65 years of age, with thoracic vertebrae one (T1) to T11 motor-complete paraplegia of at least 12 months duration were enrolled. Pre- and post-EAW training, participants were asked to report on various aspects of their bowel function as well as on their overall quality of life (QOL) as related to their bowel function. RESULTS Ten participants completed 25-63 sessions of EAW over a period of 12-14 weeks, one participant was lost to follow up due to early withdrawal after ten sessions. Due to the small sample size, each participant's results were presented descriptively in a case series format. At least 5/10 participants reported improvements with frequency of bowel evacuations, less time spent on bowel management per bowel day, fewer bowel accidents per month, reduced laxative and/or stool softener use, and improved overall satisfaction with their bowel program post-EAW training. Furthermore, 8/10 reported improved stool consistency and 7/10 reported improved bowel function related QOL. One participant reported worsening of bowel function post-EAW. CONCLUSION Between 50 and 80% of the participants studied reported improvements in bowel function and/or management post-EAW training. EAW training appeared to mitigate SCI-related bowel dysfunction and the potential benefits of EAW on bowel function after SCI is worthy or further study.
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Affiliation(s)
- Audrey Chun
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Pierre K Asselin
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Steven Knezevic
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
| | - Stephen Kornfeld
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - William A Bauman
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Mark A Korsten
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Noam Y Harel
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Vincent Huang
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ann M Spungen
- VA Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, 10468, USA.
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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Blanco Belver A, Aach M, Schmiegel W, Schildhauer TA, Meindl R, Brechmann T. Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls. Dig Dis Sci 2020; 65:1197-1205. [PMID: 31468268 DOI: 10.1007/s10620-019-05814-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/20/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality. AIMS The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy. METHODS Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively. RESULTS Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed. CONCLUSION Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.
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Affiliation(s)
- Ana Blanco Belver
- Department of Gastroenterology and Hepatology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Mirko Aach
- Department of General and Trauma Surgery, Spinal Cord Injury Unit, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Wolff Schmiegel
- Department of Gastroenterology and Hepatology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, Spinal Cord Injury Unit, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Renate Meindl
- Department of General and Trauma Surgery, Spinal Cord Injury Unit, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Thorsten Brechmann
- Department of Gastroenterology and Hepatology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
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Leuprolide Acetate, a GnRH Agonist, Improves the Neurogenic Bowel in Ovariectomized Rats with Spinal Cord Injury. Dig Dis Sci 2020; 65:423-430. [PMID: 31471861 DOI: 10.1007/s10620-019-05783-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 08/07/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Electromyographic studies have shown that external anal sphincter activity is modified in response to distension in animals with spinal cord injury. Gonadotropin-releasing hormone and its agonist leuprolide acetate have neurotrophic properties in animals with spinal cord injury. AIM This study was to determine the effects of leuprolide acetate treatment on electromyographic activity of the external anal sphincter and anorectal manometry in ovariectomized rats with spinal cord injury. METHODS Adult ovariectomized rats were divided in three groups: (a) sham of spinal cord injury, (b) spinal cord injury treated with saline solution, and (c) spinal cord injury treated with leuprolide acetate. The spinal cord injury was induced by clamping at level T9. Leuprolide acetate dosage of 10 μg/kg was proctored intramuscular for 5 weeks, commencing the day after the lesion. Electromyography of the external anal sphincter, anorectal manometry, and volume of the cecum were evaluated in all groups. RESULTS The electromyographic study of the external anal sphincter activity showed a significant improvement in injured rats treated with leuprolide acetate. Manometric analysis and cecum volume data obtained in animals with leuprolide acetate were very similar to those found in the sham group. CONCLUSIONS These results demonstrate that leuprolide acetate treatment improves the neurogenic colon in ovariectomized rats with spinal cord injury.
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Putz C, Alt CD, Wagner B, Gantz S, Gerner HJ, Weidner N, Grenacher L, Hensel C. MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury. Spinal Cord 2019; 58:203-210. [PMID: 31506586 DOI: 10.1038/s41393-019-0351-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A prospective single arm study. OBJECTIVES Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. SETTING A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. METHODS Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. RESULTS The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. CONCLUSIONS MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.
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Affiliation(s)
- Cornelia Putz
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,University Duesseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, 40225, Duesseldorf, Germany
| | - Bjoern Wagner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Simone Gantz
- Department of Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Hans J Gerner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Lars Grenacher
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Diagnostic Clinic Munich, Department of Radiology and Nuclear Medicine, Augustenstraße 115, 80798, Muenchen, Germany
| | - Cornelia Hensel
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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Rooney KD, Mckinstry C. Early Autonomic Dysreflexia in Acute Paraplegia following Anterior Spinal Artery Thrombosis. Anaesth Intensive Care 2019; 35:769-70. [DOI: 10.1177/0310057x0703500517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report discusses the diagnosis and management of autonomic dysreflexia. A 19-year-old man presented with an acute quadriplegia secondary to anterior spinal artery thrombosis. He required admission to the intensive care unit for ventilatory support and developed autonomic dysreflexia within 72 hours of his first symptoms, due to paralytic ileus with distension of the bowel. He was successfully treated by sublingual nifedipine and bowel decompression. Awareness of the potential for autonomic dysreflexia to occur in the acute phase of spinal cord injury will assist to direct management appropriately.
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Affiliation(s)
- K. D. Rooney
- Intensive Care Unit, Cheltenham General Hospital, Cheltenham, Gloucestershire, United Kingdom
- Department of Anaesthesia and Intensive Care
| | - C. Mckinstry
- Intensive Care Unit, Cheltenham General Hospital, Cheltenham, Gloucestershire, United Kingdom
- Department of Anaesthesia and Intensive Care
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Hwang JY, Won JS, Nam H, Lee HW, Joo KM. Current advances in combining stem cell and gene therapy for neurodegenerative diseases. PRECISION AND FUTURE MEDICINE 2018. [DOI: 10.23838/pfm.2018.00037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Neural pathways for colorectal control, relevance to spinal cord injury and treatment: a narrative review. Spinal Cord 2017; 56:199-205. [PMID: 29142293 DOI: 10.1038/s41393-017-0026-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
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.
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Cotterill N, Madersbacher H, Wyndaele JJ, Apostolidis A, Drake MJ, Gajewski J, Heesakkers J, Panicker J, Radziszewski P, Sakakibara R, Sievert KD, Hamid R, Kessler TM, Emmanuel A. Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013. Neurourol Urodyn 2017. [PMID: 28640977 DOI: 10.1002/nau.23289] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evidence-based guidelines for the management of neurological disease and lower bowel dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance. AIMS To update clinical management of neurogenic bowel dysfunction from the recommendations of the 4th ICI, 2009. MATERIALS AND METHODS A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and modifications applied to deliver evidence based conclusions and recommendations for the scientific report of the 5th edition of the ICI in 2013. RESULTS The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic bowel dysfunction. The pathophysiology is described in terms of spinal cord injury, multiple sclerosis, and Parkinson's disease. Assessment requires detailed history and clinical assessment, general investigations, and specialized testing, if required. Treatment primarily focuses on optimizing stool consistency and regulating bowel evacuation to improve quality of life. Symptom management covers conservative and interventional measures to promote good habits and assist stool evacuation, along with prevention of incontinence. Education is essential to achieving optimal bowel management. DISCUSSION The review offers a pragmatic approach to management in the context of complex pathophysiology and varied evidence base.
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Affiliation(s)
- Nikki Cotterill
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | | | | | - Marcus J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | - John Heesakkers
- University Medical Center St Radboud, Nijmegen, The Netherlands
| | - Jalesh Panicker
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Putz C, Alt CD, Hensel C, Wagner B, Gantz S, Gerner HJ, Weidner N, Grenacher L. 3T MR-defecography-A feasibility study in sensorimotor complete spinal cord injured patients with neurogenic bowel dysfunction. Eur J Radiol 2017. [PMID: 28629562 DOI: 10.1016/j.ejrad.2017.02.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To investigate whether MR-defecography can be employed in sensorimotor complete spinal cord injury (SCI) subjects as a potential diagnostic tool to detect defecational disorders associated with neurogenic bowel dysfunction (NBD) using standard parameters for obstructed defecation. MATERIAL AND METHODS In a prospective single centre clinical trial, we developed MR-defecography in traumatic sensorimotor complete paraplegic SCI patients with upper motoneuron type injury (neurological level of injury T1 to T10) using a conventional 3T scanner. Defecation was successfully induced by eliciting the defecational reflex after rectal filling with ultrasonic gel, application of two lecicarbon suppositories and digital rectal stimulation. Examination was performed with patients in left lateral decubitus position using T2-weighted turbo spin echo sequence in the sagittal plane at rest (TE 89ms, TR 3220ms, FOV 300mm, matrix 512×512, ST 4mm) and ultrafast-T2-weighted-sequence in the sagittal plane with repeating measurements (TE 1.54ms, TR 3.51ms, FOV 400mm, matrix 256×256, ST 6mm). Changes of anorectal angle (ARA), anorectal descent (ARJ) and pelvic floor weakness were documented and measured data was compared to reference values of asymptomatic non-SCI subjects in the literature to assess feasibility. RESULTS MR-defecography provides evaluable imaging sequences of the induced evacuation phase in SCI patients. Measurement results for ARA, ARJ, hiatal width (H-line) and hiatal descent (M-line) deviate significantly from reference values in the literature in asymptomatic subjects without SCI. The overall mean values in our study for SCI patients were: ARA (rest) 127.3°, ARA (evacuation) 137.6°, ARJ (rest) 2.4cm, ARJ (evacuation) 4.0cm, H-line (rest) 7.6cm, H-line (evacuation) 8.1cm, M-line (rest) 2.6cm, M-line (evacuation) 4.2cm. CONCLUSIONS MR-defecography is feasible in sensorimotor complete SCI patients. Individual MR-defecography findings may help to determine specific therapeutical options for respective patients suffering from severe NBD.
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Affiliation(s)
- Cornelia Putz
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
| | - Cornelia Hensel
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Björn Wagner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Simone Gantz
- Department of Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Hans-Jürgen Gerner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Lars Grenacher
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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Somatic Comorbidity in Chronic Constipation: More Data from the GECCO Study. Gastroenterol Res Pract 2016; 2016:5939238. [PMID: 27822226 PMCID: PMC5086364 DOI: 10.1155/2016/5939238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 09/21/2016] [Indexed: 12/18/2022] Open
Abstract
Background. Comorbidity in chronic constipation has rarely been investigated, despite the fact that constipation can occur as one symptom in a number of neurological, systemic, and other nonintestinal and intestinal disorders. Methods. Of 1037 individuals with constipation identified during a telephone survey, 589 returned a postal questionnaire with valid data, asking for sociographic data, clinical symptoms, comorbid conditions, medication intake, and health care behavior related to constipation. Among them, 245 reported some somatic diagnoses and another 120 regular medication intake. They were compared to individuals without comorbid condition and presumed functional constipation (n = 215). Results. Individuals reporting a somatic comorbid condition and/or regular medication were significantly older than those with functional constipation (63.8 ± 15.8 and 43.7 ± 15.5 years, resp., p < 0.001) and had lower health and social status (both p < 0.001), but similar general life satisfaction (n.s.). Their quality-of-life was lower for the physical (p < 0.001) but not for the mental health domain (n.s.), while among those with functional constipation, the mental health domain distinguished IBS-C individuals from those with functional constipation but without pain (p < 0.001). Conclusion. In an unselected population sample with constipated individuals, those with a somatic comorbid condition outnumber those with functional constipation alone and are distinctly different with respect to age and health status.
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Routine enema before urodynamics has no impact on the quality of abdominal pressure curves: Results of a prospective controlled study. Prog Urol 2016; 26:1200-1205. [PMID: 27776992 DOI: 10.1016/j.purol.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 11/22/2022]
Abstract
AIMS The presence of stools in the rectum might affect the quality of the abdominal pressure curve during filling cystometry, but, to date, no study has evaluated the impact of bowel preparation before urodynamics. We evaluated the influence of a sodium phosphate enema before urodynamics on the quality of the abdominal pressure curve. METHODS A prospective, controlled, single-blind study was conducted in a single center from May to June 2013. The patients were divided into 2 consecutive groups: patients seen in outpatient clinics during the first 6 weeks (group A) who underwent urodynamics without bowel preparation and patients seen in outpatient clinics during the second 6 weeks (group B) who had a prescription of sodium phosphate enema before urodynamics. The primary endpoint was the quality of the abdominal pressure curve evaluated independently by three physicians who were blinded to the study group. The following data were also collected: age, gender, the presence of a neurological disorder, complicated nature of urodynamics and bother related to preparation for it, assessed using a Likert scale (0 to 10), and the equipment used. A per protocol analysis and an intent-to-treat analysis were conducted. RESULTS One hundred and thirty-nine patients were included: 54 in group A and 85 in group B. One-third of patients had neurological conditions. 14 patients in group B did not perform their scheduled enema. Thus, 68 patients performed an enema before urodynamics and 71 did not. There was no difference between groups A and B regarding the complicated nature of urodynamics (Likert scale: 3.12 vs. 3.18; P=0.91) or bother related to preparation for it (Likert scale: 3.46 vs. 2.97; P=0.43). In the per protocol analysis, the abdominal pressure curve was considered perfectly interpretable (PI) in 69% of patients who did not receive an enema before urodynamics and in 65% of patients who did (P=0.61). The between-group difference was not statistically significant in intent-to-treat analysis (P=0.99). In patients who did not receive an enema before urodynamics, the only factors statistically associated with better quality of abdominal pressure curves were age <60years (P=0.001) and the urodynamic equipment used (Dantec®>Laborie®; P=0.01). CONCLUSION In this prospective study, routine enema before urodynamics did not improve the quality of the abdominal pressure curve and did not increase the complicated nature of urodynamics or the bother of preparation for it. LEVEL OF EVIDENCE 3.
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Hwang M, Zebracki K, Vogel LC. Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury. Arch Phys Med Rehabil 2016; 98:241-248. [PMID: 27473299 DOI: 10.1016/j.apmr.2016.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/27/2016] [Accepted: 07/05/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI). DESIGN Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews. SETTING Community. PARTICIPANTS Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time. RESULTS At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05). CONCLUSIONS Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.
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Affiliation(s)
| | - Kathy Zebracki
- Shriners Hospitals for Children, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lawrence C Vogel
- Shriners Hospitals for Children, Chicago, IL; Rush Medical College, Chicago, IL
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Koo BI, Bang TS, Kim SY, Ko SH, Kim W, Ko HY. Anorectal Manometric and Urodynamic Parameters According to the Spinal Cord Injury Lesion. Ann Rehabil Med 2016; 40:528-33. [PMID: 27446791 PMCID: PMC4951373 DOI: 10.5535/arm.2016.40.3.528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/19/2015] [Indexed: 11/21/2022] Open
Abstract
Objective To assess the correlation between the anorectal function and bladder detrusor function in patients with complete spinal cord injury (SCI) according to the type of lesion. Methods Medical records of twenty-eight patients with SCI were included in this study. We compared the anorectal manometric and urodynamic (UD) parameters in total subjects. We analyzed the anorectal manometric and UD parameters between the two groups: upper motor neuron (UMN) lesion and lower motor neuron (LMN) lesion. In addition, we reclassified the total subjects into two groups according to the bladder detrusor function: overactive and non-overactive. Results In the group with LMN lesion, the mean value of maximal anal squeeze pressure (MSP) was slightly higher than that in the group with UMN lesion, and the ratio of MSP to maximal anal resting pressure (MRP) was statistically significant different between the two groups. In addition, although the mean value of MSP was slightly higher in the group with non-overactive detrusor function, there was no statistical correlation of anorectal manometric parameters between the groups with overactive and non-overactive detrusor function. Conclusion The MSP and the ratio of MSP to MRP were higher in the group with LMN lesion. In this study, we could not identify the correlation between bladder and bowel function in total subjects. We conclude that the results of UD study alone cannot predict the outcome of anorectal manometry in patients with SCI. Therefore, it is recommended to perform assessment of anorectal function with anorectal manometry in patients with SCI.
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Affiliation(s)
- Bon Il Koo
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Sik Bang
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo-Yeon Kim
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sung Hwa Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wan Kim
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun-Yoon Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Kim GW, Won YH, Ko MH, Park SH, Seo JH. Ultrasonic measurement of rectal diameter and area in neurogenic bowel with spinal cord injury. J Spinal Cord Med 2016; 39:301-6. [PMID: 25432419 PMCID: PMC5073751 DOI: 10.1179/2045772314y.0000000282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the efficacy of measuring the diameter and area of the rectum using ultrasonography as an additional parameter for the evaluation of neurogenic bowel in patients with spinal cord injury (SCI). PARTICIPANTS In total, 32 patients with SCI (16 patients with upper motor neuron neurogenic bowel (UMNB) and 16 patients with lower motor neuron neurogenic bowel (LMNB)) participated in this study. We divided the patients by the type of neurogenic bowel: UMNB, patients with supraconal lesions and recovery state of spinal shock or LMNB, patients with infraconal/caudal lesions or spinal shock state). INTERVENTION Ultrasound was applied on the abdomen and measured the diameter and area of the rectum were measured twice each before and after defecation, respectively. OUTCOME MEASURE We compared rectal diameter and area before/after defecation between the two groups, and significant differences were found in both rectal diameter and area before/after defecation in each group. RESULTS After defecation, those in the UMNB group had smaller rectal diameters and areas than those in the LMNB group. Significant reduction of rectal diameter and area was observed after defecation as well. The LMNB group showed slightly increased rectal area after defecation, but the increase was not statistically significant. CONCLUSION Using ultrasound to measure rectal diameter and area seems helpful for classifying neurogenic bowel types and for understanding the neurogenic bowel among SCI patients with symptoms of neurogenic bowel.
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Affiliation(s)
| | | | | | | | - Jeong-Hwan Seo
- Correspondence to: Jeong-Hwan Seo, Department of Physical Medicine & Rehabilitation, Chonbuk National University Medical School, San 2–20, Geumam-dong, Deokjin-gu, Jeonju City, Jeonbuk 561–180, Republic of Korea.
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Altered Colorectal Compliance and Anorectal Physiology in Upper and Lower Motor Neurone Spinal Injury May Explain Bowel Symptom Pattern. Am J Gastroenterol 2016; 111:552-60. [PMID: 26881975 DOI: 10.1038/ajg.2016.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Supraconal spinal cord injury (SCI) and lower motor neurone spinal cord injury (LMN-SCI) cause bowel dysfunction; colorectal compliance may further define its pathophysiology. The aim of this study was to investigate rectal (RC) and sigmoid (SC) compliance and anorectal physiology parameters, in these subjects. METHODS Twenty-four SCI subjects with gut symptoms (14 RC, 10 SC) and 13 LMN-SCI subjects (9 RC, 4 SC) were compared with 20 spinal intact controls (10 RC, 10 SC). Staircase distensions were performed using a barostat. Anorectal manometry, including rectoanal inhibitory reflex (RAIR) measurement, was performed in all. Data presented as mean±standard error (SCI/LMN-SCI vs. controls). RESULTS SCI subjects had a higher RC (17.0±1.9 vs. 10.7±0.5 ml/mm Hg, P<0.05) and SC (8.5±0.6 vs. 5.2±0.5 ml/mm Hg, P=0.002). LMN-SCI subjects had a lower RC (7.3±0.7 ml/mm Hg, P=0.0021) while SC was unchanged (8.3±2.2 ml/mm Hg, P>0.05). Anal resting pressure was decreased in SCI (55±5 vs. 79±7 cmH2O, P=0.0102). Anal squeeze pressure was decreased in LMN-SCI (76±13 vs. 154±21 cmH2O, P=0.0158). In SCI and LMN-SCI, the amplitude reduction of the RAIR was greater (62±4% and 70±6% vs. 44±3%, P=0.0007). CONCLUSIONS Colorectal compliance abnormalities may explain gut symptoms: increased RC and SC contributing to constipation in SCI, reduced rectal compliance contributing to fecal incontinence (FI) in LMN-SCI. Reduced resting anal pressure in SCI and reduced anal squeeze pressure in LMN-SCI along with a greater RAIR amplitude reduction may be factors in FI. These co-existing abnormalities may explain symptom overlap, and represent future therapeutic targets to ameliorate neurogenic bowel dysfunction.
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Ozisler Z, Koklu K, Ozel S, Unsal-Delialioglu S. Outcomes of bowel program in spinal cord injury patients with neurogenic bowel dysfunction. Neural Regen Res 2015; 10:1153-8. [PMID: 26330842 PMCID: PMC4541250 DOI: 10.4103/1673-5374.160112] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2015] [Indexed: 11/04/2022] Open
Abstract
In this study, we aimed to determine gastrointestinal problems associated with neurogenic bowel dysfunction in spinal cord injury patients and to assess the efficacy of bowel program on gastrointestinal problems and the severity of neurogenic bowel dysfunction. Fifty-five spinal cord injury patients were included in this study. A bowel program according to the characteristics of neurogenic bowel dysfunction was performed for each patient. Before and after bowel program, gastrointestinal problems (constipation, difficult intestinal evacuation, incontinence, abdominal pain, abdominal distension, loss of appetite, hemorrhoids, rectal bleeding and gastrointestinal induced autonomic dysreflexia) and bowel evacuation methods (digital stimulation, oral medication, suppositories, abdominal massage, Valsalva maneuver and manual evacuation) were determined. Neurogenic bowel dysfunction score was used to assess the severity of neurogenic bowel dysfunction. At least one gastrointestinal problem was identified in 44 (80%) of the 55 patients before bowel program. Constipation (56%, 31/55) and incontinence (42%, 23/55) were the most common gastrointestinal problems. Digital rectal stimulation was the most common method for bowel evacuation, both before (76%, 42/55) and after (73%, 40/55) bowel program. Oral medication, enema and manual evacuation application rates were significantly decreased and constipation, difficult intestinal evacuation, abdominal distention, and abdominal pain rates were significantly reduced after bowel program. In addition, mean neurogenic bowel dysfunction score was decreased after bowel program. An effective bowel program decreases the severity of neurogenic bowel dysfunction and reduces associated gastrointestinal problems in patients with spinal cord injury.
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Affiliation(s)
- Zuhal Ozisler
- Ankara Physical Medicine and Rehabilitation Education and Research Hospital, PMR Clinics, Ministry of Health, Ankara, Turkey
| | - Kurtulus Koklu
- Ankara Physical Medicine and Rehabilitation Education and Research Hospital, PMR Clinics, Ministry of Health, Ankara, Turkey
| | - Sumru Ozel
- Ankara Physical Medicine and Rehabilitation Education and Research Hospital, PMR Clinics, Ministry of Health, Ankara, Turkey
| | - Sibel Unsal-Delialioglu
- Ankara Physical Medicine and Rehabilitation Education and Research Hospital, PMR Clinics, Ministry of Health, Ankara, Turkey
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Brechmann T, Swol J, Knop-Hammad V, Willert J, Aach M, Cruciger O, Schmiegel W, Schildhauer TA, Hamsen U. Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection. World J Gastroenterol 2015; 21:3736-3740. [PMID: 25834343 PMCID: PMC4375600 DOI: 10.3748/wjg.v21.i12.3736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/04/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.
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Antegrade continence enema procedure: impact on quality of life in patients with spinal cord injury. Spinal Cord 2014; 53:213-215. [PMID: 25535156 DOI: 10.1038/sc.2014.223] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/26/2014] [Accepted: 11/10/2014] [Indexed: 01/18/2023]
Abstract
STUDY DESIGN This is a prospective cohort study. OBJECTIVES Patients with spinal cord injury (SCI) often suffer from severe constipation/fecal incontinence. The antegrade continence enema (ACE) procedure is often used to control these distressing symptoms when medical management fails. Improvement in the quality of life (QOL) following the ACE procedure has been demonstrated in patients with fecal incontinence of various etiologies. We assess the impact of the ACE procedure on QOL in patients with fecal incontinence due to SCI. SETTING This study was conducted in the United States. METHODS We measured the impact of fecal incontinence on QOL in patients with SCI undergoing ACE using the validated fecal incontinence quality of life (FIQL) QOL instrument. The FIQL scores QOL in four domains: lifestyle, coping/behavior, depression/self-perception and embarrassment. Surveys were prospectively administered before and after surgery. Preoperative and postoperative survey scores were compared using two-sample T-test. RESULTS Between 2003 and 2010, the ACE procedure was performed on 17 patients with SCI, including 10 paraplegic and seven quadriplegic patients with an average age of 33 years at the time of surgery. Scores in all four QOL realms assessed by the FIQL instrument improved significantly following the ACE procedure. Stomal stenosis requiring channel revision occurred in three patients and was the most common complication. CONCLUSIONS This is the first study to our knowledge that assesses the impact of the ACE procedure on the QOL in patients with SCI. Using a validated questionnaire, we demonstrated significant improvement in QOL related to fecal incontinence following the ACE procedure in these patients who are severely affected by their bowel dysfunction.
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Khan U, Mason JM, Mecci M, Yiannakou Y. A prospective trial of temporary sacral nerve stimulation for constipation associated with neurological disease. Colorectal Dis 2014; 16:1001-9. [PMID: 25251843 DOI: 10.1111/codi.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 02/12/2014] [Indexed: 02/08/2023]
Abstract
AIM This study assessed the effectiveness of temporary sacral nerve stimulation (SNS) in patients with constipation associated with neurological disease using an off-on-off design, and evaluated the long-term response in patients undergoing permanent SNS. METHOD Patients with chronic constipation associated with neurological disease receiving specialist clinic care at the University Hospital North Durham over a 2-year period were recruited to a trial of SNS. Recordings of bowel function were made for 6 weeks (baseline) and a temporary electrode was then inserted and recordings were made for the next 3 weeks (stimulation). The electrodes were then removed and assessment was continued for a further 3 weeks (posttreatment). Patient-completed questionnaires were used to determine the severity of constipation (Global Assessment of Symptoms, Constipation, GA Constipation), symptoms (Patient Assessment of Constipation Symptoms score, PAC-SYM) and quality-of-life (Patient Assessment of Constipation-Quality Of Life score, PAC-QOL; European Quality of Life-Five-Domain score; European Quality of Life-Visual Analogue Score). Information was obtained on bowel function and medication. Physiological data were also available for transit and laser Doppler flow cytometry to measure mucosal blood flow. RESULTS Twenty-two patients were recruited, of whom 18 completed the trial. GA Constipation reduced significantly during temporary SNS: -1.09 (95% CI -1.59 to -0.59; P = 0.0003). PAC-SYM and PAC-QOL scores showed similar improvements. There was also a significant fall in the time spent in the toilet (P = 0.04) and a decrease in laxative use (P = 0.03). Twelve (67%) patients responded to temporary SNS and received a permanent implant with long-term success in 50%. CONCLUSION Sacral nerve stimulation can be effective in treating some patients with refractory severe neuroconstipation. A response to temporary SNS may predict long-term benefit in only half the patients undergoing permanent SNS.
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Affiliation(s)
- U Khan
- Wrexham Maelor Hospital, Wrexham, UK
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Mearin F. [Impact of chronic constipation on quality of life: Much more important than it seems]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:467-72. [PMID: 23769426 DOI: 10.1016/j.gastrohep.2012.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/30/2012] [Indexed: 11/27/2022]
Abstract
Chronic constipation is highly frequent in the general population (a prevalence of 14%). An underlying organic cause is usually absent, this type of constipation being known as chronic idiopathic constipation (CIC). Although usually considered banal, this disorder has a substantial personal, social and healthcare impact. Several studies have associated CIC with high rates of absenteeism in the workplace and disruption of routine activities. All these factors lead to high direct and indirect healthcare expenditure. Physically, the impact on patients with CIC, who require specialized care, is higher than that of ulcerative colitis or stable Crohn's disease. The psychological impact exceeds that caused by rheumatoid arthritis or hemodialysis. Appropriate treatment can improve HRQL in affected individuals. Recently, prucalopride, a highly selective 5-HT4 receptor agonist has been shown to improve the symptoms of CIC and to have a beneficial effect on HRQL.
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Affiliation(s)
- Fermín Mearin
- Servicio de Aparato Digestivo, Instituto de Trastornos Funcionales y Motores Digestivos, Centro Médico Teknon, Barcelona, España.
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Abstract
Intestinal motor and sensory dysfunctions in traumatic complete or incomplete spinal cord injury (SCI) are frequent and result in altered mechanisms of defecation. The aim of this study is to investigate sigmoid compliance and perception in chronic SCI patients. Sigmoid responses to fixed-tension distentions were assessed using a tensostat in six patients (six men, 42 ± 4 years) with chronic complete transection of the spinal cord (high-SCI; five tetraplegic C5-C7 and one paraplegic T4-T6) and impaired evacuation (i.e. constipation). A group of 10 healthy individuals (six men, 25 ± 1 years) served as controls. SCI patients had higher sigmoid compliance at the highest distention level than the controls (10.3 ± 2.4 vs. 5.1 ± 0.8 ml/mmHg; P<0.05). Perception scores at first sensation were higher in SCI patients (2.3 ± 0.7 vs. 1.1 ± 0.1; P<0.05), but were not different at the highest distention levels (3.7 ± 0.8 vs. 3 ± 1; NS). The most commonly reported sensation by patients was distention/bloating and was referred less commonly to the hypogastrium compared with distention/bloating in controls. An increased sigmoid compliance can be detected in constipated SCI patients. The preservation of some degree of visceral sensations, although abnormally referred, could imply the occurrence of sensory input remodeling at the spinal level.
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Vallès M, Mearin F. [Intestinal alterations in patients with a medullary lesion]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:330-6. [PMID: 22296768 DOI: 10.1016/j.gastrohep.2011.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/18/2011] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Margarita Vallès
- Unidad de Rehabilitación Funcional Digestiva, Institut Guttmann, Universidad Autónoma de Barcelona, Barcelona, Spain
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Secondary health conditions in individuals aging with SCI: Terminology, concepts and analytic approaches. Spinal Cord 2011; 50:373-8. [DOI: 10.1038/sc.2011.150] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
BACKGROUND AND OBJECTIVE We previously showed that approximately 10% of patients with intractable constipation have spinal abnormalities without any other physical findings. Given that spinal magnetic resonance imaging is costly and often requires deep sedation in children, it would be useful to find a screening tool to determine who has a higher likelihood of having a spinal abnormality. The aim of the study was to determine whether anorectal manometry is a useful screening test in predicting which patients will have abnormal spinal MRIs. PATIENTS AND METHODS This is a case-control study comparing the anorectal manometries of 10 children with constipation who had abnormal spinal MRIs (cases) to the manometries of 10 age-matched children with normal MRIs (controls). RESULTS The maximum relaxation of the sphincter after balloon distention was achieved with a significantly smaller balloon in the cases as compared with the controls (35 ± 20 vs 60 ± 23 mL; P = 0.02). The dose-response curve of sphincter relaxation at different balloon distention was shifted to the left in patients with spinal lesions. Anal spasms after balloon distention were noted in 60% of the patients with abnormal magnetic resonance images compared with 0% of the controls (P < 0.003). There were no other differences. CONCLUSIONS Patients with spinal cord abnormalities may show changes in anorectal manometry. Anal spasms on anorectal manometry are significant predictors of spinal abnormalities. Also, patients with spinal abnormalities have maximum sphincter relaxations with smaller balloon sizes. Further studies are needed to determine the utility of anorectal manometry as a screening test for spinal abnormalities in patients with constipation.
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Bajwa A, Thiruppathy K, Trivedi P, Boulos P, Emmanuel A. Effect of rectal distension on voluntary external anal sphincter function in healthy subjects. Colorectal Dis 2011; 13:1173-9. [PMID: 20860712 DOI: 10.1111/j.1463-1318.2010.02420.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure. METHOD Fifty-seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50-ml distensions (n=35) or isobaric 4-mmHg distensions (n=22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure. RESULTS The distension-induced squeeze increment was calculated as the maximum percentage increase in maximum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean ± standard deviation (range) increase of 32.8 ± 24.1 (-5.5 to 97.7)%. The mean ± standard deviation (range) distension-induced squeeze increment in male subjects was 36.1 ± 25.7 (-5.5 to 97.7)% and in female subjects was 28.1 ± 20.1 (-3.8 to 70.2)%. There was no significant difference between the sexes (P=0.194). CONCLUSION Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.
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Affiliation(s)
- A Bajwa
- Physiology Unit, University College Hospital, London, UK
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Treatment and prevention of bacterial translocation and endotoxemia with stimulation of the sacral nerve root in a rabbit model of spinal cord injury. Spine (Phila Pa 1976) 2011; 36:363-71. [PMID: 20531069 DOI: 10.1097/brs.0b013e3181d25495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Yang DH, Myung SJ, Jung KW, Yoon IJ, Seo SY, Koh JE, Yoon SM, Kim KJ, Ye BD, Byeon JS, Jung HY, Yang SK, Kim JH. Anorectal function and the effect of biofeedback therapy in ambulatory spinal cord disease patients having constipation. Scand J Gastroenterol 2010; 45:1281-8. [PMID: 20602567 DOI: 10.3109/00365521.2010.483741] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Constipation in patients with mild spinal cord disease is not well investigated yet. We aimed to investigate anorectal function and the effect of biofeedback therapy in constipated patients with mild spinal cord diseases. MATERIAL AND METHODS A total of 14 constipated patients with myelopathy and 32 with radiculopathy were enrolled retrospectively. All patients were able to walk independently. The control group comprised of 100 constipated patients without any neurologic problem. Colonic transit time and the presence of dyssynergia were assessed before biofeedback therapy. All patients answered structured questionnaires on constipation, before and after biofeedback therapy. RESULTS The mean rectosigmoid colonic transit time of the myelopathy group was significantly delayed (myelopathy, 18.6 ± 14.6 h; radiculopathy, 12.8 ± 11.9 h; control, 9.6 ± 11.2 h; p = 0.032). Delay in total colonic transit time was more frequent in the myelopathy group (myelopathy, 57.1%; radiculopathy, 23.3%; control, 18.5%; p = 0.004). On anorectal manometry, the squeezing pressure of the anal sphincter was decreased in the myelopathy group (myelopathy, 132.3 ± 73.3 mmHg; radiculopathy, 179.9 ± 86.1 mmHg; control 200.4 ± 82.4 mmHg; p < 0.05). The success rate of biofeedback therapy was lower in the myelopathy group (28.6% for myelopathy vs. 62.0% for control group; p = 0.034). The response rate to biofeedback therapy was similar between radiculopathy and control group (62.5% for radiculopathy vs. 62.0% for control group; p = 1.000). CONCLUSIONS In constipation associated with mild myelopathy, delayed colonic transit and dyssynergic defecation were major pathophysiologic abnormalities and biofeedback was less effective compared with control group. However, in the radiculopathy group, biofeedback was as effective as in the control group.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Mohammed SD, Lunniss PJ, Zarate N, Farmer AD, Grahame R, Aziz Q, Scott SM. Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue? Neurogastroenterol Motil 2010; 22:1085-e283. [PMID: 20618831 DOI: 10.1111/j.1365-2982.2010.01562.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous studies report an association between joint hypermobility (JHM), as a clinical feature of underlying connective tissue (CT) disorder, and pelvic organ prolapse. However, its association with rectal evacuatory dysfunction (RED) has not been evaluated. To investigate the prevalence of JHM in the general population and in patients with symptoms of RED referred for anorectal physiological investigation. METHODS Bowel symptom and Rome III questionnaires to detect irritable bowel syndrome were sent to 273 patients with RED. Patients then underwent full investigation, including evacuation proctography. A validated 5-point self-reported questionnaire was used to assess JHM in both the patient group and 100 age- and sex-matched controls [87 female, median age 55 (range 28-87)]. KEY RESULTS Seventy-three patients were excluded from analysis (incomplete questionnaire or investigation). Of 200, 65 patients [32%: 63 female, median age 52 (range 15-80)] and 14% of controls (P = 0.0005 vs patients) had features satisfying criteria for JHM. Overall constipation score (P < 0.0001), abdominal pain (P = 0.003), need for manual assistance (P = 0.009), and use of laxatives (P = 0.03) were greater in the JHM group than the non-JHM group. On proctography, 56 of JHM patients (86%) were found to have significant morphological abnormalities (e.g. functional rectocoele), compared with 64% of the non-JHM group (P = 0.001). CONCLUSIONS & INFERENCES The greater prevalence of JHM in patients with symptoms of RED, and the demonstration of significantly higher frequencies of morphological abnormalities than those without JHM, raises the possibility of an important pathoaetiology residing in either an enteric or supporting pelvic floor abnormality of CT.
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Affiliation(s)
- S D Mohammed
- GI Physiology Unit (Academic Surgical Unit) and Neurogastroenterology Group, Centre for Digestive Diseases, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, UK.
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