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SCI: Fiber and Neurogenic Bowel (2007)

Citation:

Consortium for Spinal Cord Medicine. Neurogenic Bowel Management in Adults with Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America, 1998.

PubMed ID: 9863937
 
Study Design:
Meta-analysis or Systematic Review
Class:
M - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
  • Critically review and synthesize the scientific literature on neurogenic bowel assessment and management, short- and long-term outcomes, and effects on gastrointestinal function.
  • Improve the management of neurogenic bowel.
Inclusion Criteria:
  • Pathophysiology, management, prophylaxis, treatment of complications, epidemiology, and economic issues
  • Adults
  • Experimental and observational studies and review articles
  • English language.
Exclusion Criteria:
  • Progressive and congenital spinal cord disorders and animal studies
  • Studies of children.
Description of Study Protocol:

Recruitment

The Consortium’s systematic method of search, selection, extraction, review, and synthesis, modeled after the Agency for Health Care Policy and Research.  Studies from 1966 - 1997 were included.

Design

Evidence-Based Clinical Practice Guideline—Systematic Review.

Blinding Used (if applicable):  not applicable.

Intervention (if applicable):  Includes strength of panel opinion as well as strength of evidence.

Statistical Analysis

Statistical analysis not completed.

Data Collection Summary:

Timing of Measurements:  not applicable

Dependent Variables

  • Neurogenic bowel

Independent Variables

  • Spinal cord injury

Control Variables

Description of Actual Data Sample:

Initial N:  5 studies related to fiber.  No research articles were available on fluid needs.

Attrition (final N):  5 

Age:  Not mentioned

Ethnicity:  not mentioned

Other relevant demographics:

Anthropometrics

Location:  Worldwide studies

Summary of Results:

Other Findings

  • High fiber diets (20-30 gm/d) are frequently recommended for persons w/ SCI on the premise that they will respond similar to those without SCI (decrease in transit time and increase in stool weight and volume). However, evidence indicates the neurogenic bowel responds differently.
  • Menardo, (1987) reported left colonic transit delay with 16.4 gm/d. Cameron (1996) found increase of 6 gm of wheat bran (aver baseline of 25 gm/d) resulted in increases in mean colonic transit time (CTT) in inpatients with recent SCI. Levine (1992) found SCI subjects consumed an average of 12-14 gm/d and Kirk (1997) reported fiber intake of 7 gm/day.  Daily fiber intake of person with SCI is well below the frequently cited goal of 20-30 gm/day to reduce risk of cardiac disease and cancer.  Muller-Lissner (1988) in meta analysis on effect of wheat bran in adults with constipation.  He found inconsistent effect on CTT.
Author Conclusion:
  • Fiber: Individuals with SCI should not be placed uniformly on high fiber diets. A diet history should be taken to determine the individual’s usual fiber intake. The effects of current fiber intake on consistency of stool and frequency of evacuation should be evaluated. A diet containing no less than 15 gm fiber/day is needed initially. Increases should be done gradually, from a variety of sources. Symptoms of intolerance should be monitored and fiber reduced it they occur.
  • Fluid: The amount of fluid needed to promote optimal stood consistency must be balanced with the amount needed for bladder management In general, fluid intake should be approximately 500ml/day greater than the standard guidelines for the general public (NRC, 1989), which can be estimated by:
    • 1 ml fluid/Kcal energy needs +500 ml/d or
    • 40 ml/kg body weight + 500 ml/d.
Funding Source:
Not-for-profit
0
Foundation associated with industry:
Reviewer Comments:

Exemplary methodology for evidence based guidelines. Unfortunately, little scientific evidence exists.

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? Yes
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? Yes
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? Yes
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? Yes
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? Yes
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes