Bowel burdens: a systematic review and meta-analysis examining the relationships between bowel dysfunction and quality of life after spinal cord injury

Abstract

Study design: Systematic review and meta-analysis.

Objectives: Many individuals with spinal cord injury (SCI) experience autonomic dysfunction, including profound impairments to bowel and cardiovascular function. Neurogenic bowel dysfunction (NBD) is emerging as a potential determinant of quality of life (QoL) after SCI. For individuals with high-level lesions ( > T6), bowel care-related autonomic dysreflexia (B-AD; profound episodic hypertension) further complicates bowel care. We aimed to evaluate the extent of bowel dysfunction after SCI, and the impact of bowel dysfunction on QoL after SCI.

Methods: We searched five databases to identify research assessing the influence of NBD or B-AD on QoL after SCI. Metrics of bowel dysfunction (fecal incontinence [FI], constipation, time to complete, and B-AD) and QoL data were extracted and synthesised. Where possible, meta-analyses were performed.

Results: Our search identified 2042 titles, of which 39 met our inclusion criteria. Individuals with SCI identified problems with NBD (74.7%), FI (56.9%), and constipation (54.6%), and 49.3% of individuals with SCI > T6 experienced B-AD. Additionally, 40.3% of individuals experienced prolonged defecation ( > 30 min). Moderate/severe deterioration in QoL due to NBD was reported by 55.5% of individuals with SCI, with negative impacts on physical, emotional, and social health-related QoL associated with inflexibility of bowel routines, fear of accidents, and loss of independence.

Conclusion: Bowel dysfunction and bowel care challenges are prevalent and disabling for individuals with SCI, with a profoundly negative impact on QoL. Improving bowel management is a key target to improve QoL for those living with SCI.

Fig. 1. PRISMA diagram summarising the study selection process [26].

The search identified 2,042 articles. After screening and eligibility review, 39 articles met our inclusion criteria.

Fig. 2. Severity of neurogenic bowel dysfunction, frequency of fecal incontinence, and time to complete bowel care in individuals with SCI.

A Across the seven studies (n = 901) that used the Neurogenic Bowel Dysfunction (NBD) score unmodified, NBD was problematic for most individuals living with SCI (52.6%). B A weighted average of 56.9% of individuals in 14 studies (n = 4111) experienced fecal incontinence (FI). Seven studies (n = 2010) reported the frequency with which individuals with SCI experienced FI: 4.6% experienced FI daily; 9.4% weekly; 18.5% monthly; and 60.5% less than monthly. C In the self-reported average time to complete bowel care from 6 studies, a weighted average of 70.2% of participants required 30 minutes or less, 25.7% required 31–60 min, and 14.7% required over 60 min. Grey percentages indicate the range of responses in different studies. Red percentages indicate the weighted average. * Indicates data from references [3, 38, 45, 46, 52]; ** indicates data from references [3, 6, 29, 30, 38, 45, 46, 52, 59, 60].

Fig. 3. Impact of bowel dysfunction on quality of life.

Numerical rating scales evaluating (A) the impact of bowel problems on QoL and (B) satisfaction with current bowel management. Data are shown as mean ± standard deviation on a 0–10 scale. Bubble size indicates sample size (log transformed). * Denotes mean and standard deviation calculated from median and range; $†$ indicates the scale direction has been reversed for compatibility; $‡$ indicates the scale range was from 1-10.

Fig. 4. Meta-analysis of Neurogenic Bowel Dysfunction (NBD) score and SF-36 component summary scores.

Data for each study are shown as mean ± standard deviation, with the size of the datapoint proportional to the sample size [40, 42, 44]. A The physical component score (PCS) was negatively correlated (r = −0.637; p = 0.024) with the NBD score. B The mental component score (MCS) was not correlated (r = 0.047; p = 0.885) with the NBD score. The vertical lines denote the range of scores for NBD severity subgroups (very minor, minor, moderate, severe). The horizontal line and red shading denote the mean and standard deviation of American normative SF-36 component summary scores (n = 2474) [32]; a score below this norm indicates reduced QoL. Data from each of the three studies are indicated with different colours and symbols.