A Community Perspective on Bowel Management and Quality of Life after Spinal Cord Injury: The Influence of Autonomic Dysreflexia

Abstract

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p < 0.001) and more severe AD (p = 0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Keywords: autonomic dysreflexia; bowel management; cardiac arrhythmia; orthostatic hypotension; quality of life; spinal cord injury.

FIG. 1.

Severity of symptoms of autonomic dysreflexia during bowel care in individuals with SCI considered at risk for cardiovascular dysfunction. Individuals were considered to be at risk for cardiovascular abnormalities if they had a self-reported lesion level at or above T7. Each symptom was classified according to its perceived severity. SCI, spinal cord injury.

FIG. 2.

Influence of AD outside of bowel care. (A) Prevalence of autonomic dysreflexia interfering with common activities. (B) Additional stimuli that trigger autonomic dysreflexia symptoms in those with symptoms of autonomic dysreflexia during bowel care. AD, autonomic dysreflexia.

FIG. 3.

Frequency of symptoms of orthostatic hypotension in individuals with SCI considered at risk for cardiovascular dysfunction. Individuals were considered to be at risk for cardiovascular abnormalities if they had a self-reported lesion level at or above T7. Each symptom was classified according to its perceived frequency. SCI, spinal cord injury.

FIG. 4.

Impact of different aspects of living with spinal cord injury on quality of life. Respondents were asked to rate each aspect of living with spinal cord injury from 1 (Least effect) to 10 (Worst effect). Solid red line indicates group median; dotted gray line indicates group mode. Asterisk indicates significant difference between indicated aspects (p < 0.05).

FIG. 5.

Impact of bowel management on respondents' life and activities.

FIG. 6.

Primary and secondary factors influencing quality of life. Relationships are expressed as ß (standard error). Primary predictors are shown in red boxes and secondary predictors in gray boxes. AD, autonomic dysreflexia.