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A systematic review of the effectiveness of bowel management strategies for constipation in adults with stroke
International Journal of Nursing Studies 50 (2013) 1004–1010
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Review
A systematic review of the effectiveness of bowel management strategies for constipation in adults with stroke Su Fee Lim a,b,*, Charmaine Childs b a b
Rehabilitation Medicine, Block 6, Level 9, Singapore General Hospital, Outram Road, Singapore 169608, Singapore Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 August 2012 Received in revised form 3 December 2012 Accepted 3 December 2012
Objective: Constipation is one of the most common medical complications of acute stroke. Currently, management strategies to guide clinical practice are limited. This review aimed to examine the effectiveness of bowel management strategies for constipation in adults with stroke. Design: A systematic review of randomised controlled trials or other quantitative research designs in the absence of randomised controlled trials was undertaken. Data sources: A comprehensive search of major electronic databases and all reference lists of relevant articles in the English language were performed from January 1990 up to March 2011. Review methods: Data were extracted and assessed by two independent reviewers. Due to differences in the study designs, the findings are presented in narrative form. Results: There were a total of three studies (two randomised controlled trials and one quasi-experimental study). One of the randomised controlled trials examined a single (once-only) structured nurse-led intervention and the other randomised controlled trial evaluated four bowel management programmes. Both studies yield improvements respectively in symptoms of bowel dysfunction and bowel training efficiency when the programme corresponded with the subjects’ bowel patterns before the stroke onset. The quasi-experimental study compared the effectiveness of daily digital stimulation versus every other day and found higher bowel regularity with daily digital stimulation. Conclusion: Constipation management strategies are limited. This review suggests that structured bowel programmes and nurse-led intervention in bowel care have a significant effect in improving bowel evacuations. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Bowel Constipation Nurse-led intervention Stroke Systematic review
What is already known about this topic? Treatment strategies which include non-pharmacological approaches (diet modification, fluid intake, bowel training, abdominal massage and increased mobility) and pharmacological therapies (fibre supplements and laxatives) are based on expert opinion and targeted at older adults with chronic constipation. The clinical
* Corresponding author. Tel.: +65 63265700; fax: +65 62225391. E-mail addresses: [email protected] (S.F. Lim), [email protected] (C. Childs). 0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.12.002
evidence supporting the use in stroke patients is yet to be demonstrated. No systematic review of the types of constipation management strategies currently exists in the stroke population.
What this paper adds This review provides evidence to support the finding that structured bowel management programmes and nurseled intervention in bowel care are effective in managing constipation in the stroke population.
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1. Introduction Constipation is one of the most common complications of acute stroke. The prevalence is 55% at acute stage within 1 month after first stroke (Su et al., 2009) and 30% after a period of median 36 weeks after stroke onset (Bracci et al., 2007). Constipation not only causes discomfort, but it can also affect a person’s physical and psychological wellbeing in addition to the ability to participate in social and family life. This consequence can have a great impact on a person’s quality of life and contribute to a poorer outcome (Su et al., 2009). Management of constipation is typically based on experience and anecdotal evidence. There are range of treatment modalities: diet modification, fluid intake, bowel training, abdominal massage and increased mobility, for managing chronic constipation in older adults (Ernst, 1999; Frizelle and Barclay, 2007; Hsieh, 2005). However the clinical evidence of efficacy in supporting their use in stroke patients has yet to be demonstrated. The clinical benefits of traditional pharmacologic agents such as fibre supplements and laxatives (bulk forming, stool softeners, stool lubricants, stimulants and hyperosmotics) remain unclear (Johanson, 2007; Ramkumar and Rao, 2005; Rao, 2003). The available systematic reviews on management of constipation are focused on older adults (Joanna Briggs Institute, 2008) and adults with central neurological diseases (Coggrave et al., 2006). Whether results are transferrable to the stroke population remains unclear. There is no systematic review on management of constipation in the stroke population to guide clinical practice. This paper is based on a detailed review published online in the Joanna Briggs Institute Library of Systematic Reviews (JBI000463 2011 9(64) 2875–2914). 1.1. Objectives This review aimed to identify the effectiveness of bowel management strategies for managing constipation in adults with stroke. This review would be beneficial to healthcare providers in their clinical management of constipation in people with stroke. The review question was What is the effectiveness of contemporary bowel management strategies for constipation in stroke patients for promoting bowel evacuation? 2. Methods 2.1. Search strategies A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was undertaken across all included electronic databases. Databases searched were CINAHL, Medline, SCOPUS, ScienceDirect, Web of Science, Mosby’s Nursing Consult, Expanded Academic ASAP, Dissertation Abstracts International and Mednar. Thirdly, the reference lists of all
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identified reports and articles were searched for additional studies. Initial keywords used were: stroke, cerebrovascular accident, CVA, constipation, fec* impaction, bowel management, bowel care, bowel training and bowel program*. An initial review involved screening the titles and abstracts of studies identified from the literature search. Subsequently, reviewers examined full-text articles to determine the methodological quality. 2.2. Inclusion criteria This review included studies in English, conducted from January 1990 up to March 2011, that utilised a randomised controlled trial (RCT). Other research designs were included in the absence of available RCTs evaluated any type of bowel management strategies included adults of 18 years of age or older with a clinical diagnosis of stroke with symptoms of constipation reported bowel evacuation as the outcome measure. 2.3. Data collection and analyses The reviewers (SL and CC) assessed eligibility and methodological quality of the full text articles before inclusion in the review using a standardised critical appraisal instrument (Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument, JBIMAStARI). Any disagreements arising between the reviewers were resolved through discussion. Data were extracted from the included studies using a standardised data extraction tool (JBI-MAStARI). Data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. As there were differences in the types of intervention and outcome measures, statistical pooling of the findings was not appropriate. The findings were therefore presented in narrative form. 3. Results Two thousand five hundred and thirty-three articles were identified and reviewed according to the preset inclusion and exclusion criteria. Two thousand five hundred and twenty-five articles were deemed not relevant at this screening stage based on the title and abstract. Five articles were in languages other than English: Chinese (Huang and Li, 2002; Wang et al., 2008), Korean (Jeon and Jung, 2005; Lee and Shon, 2006) and Japanese (Ikari et al., 1993). Three studies met the eligibility criteria and full-text articles were retrieved and assessed for methodological quality. Due to the small number of studies, all three studies (Table 1) were included in this review. Fig. 1 provides a summary of the literature search. 3.1. Description of studies The three studies included in the review were conducted in London (Harari et al., 2004) and
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Table 1 Description of Studies included in the review. Authors and year Study design and setting
Participants
Intervention
Venn et al. (1992)
58 patients admitted to the rehabilitation unit with stroke and no GI disease
Group 1 – morning bowel training and mandatory suppository Group 2 – morning bowel training and optional suppository Group 3 – evening bowel training and mandatory suppository Group 4 – evening bowel training and optional suppository
Randomised controlled trial 4 comparison arms Single centre: rehabilitation unit in a community hospital at Midwest
Harari et al. (2004)
Randomised controlled trial 2 comparison arms Multi-centred: 3 rehabilitation units and local communities in London
25 stroke patients received daily digital stimulation
73 stroke patients 146 patients who received intervention had experienced a consisted of stroke beyond 1 month and within 4 1. a single (once only) assessment by a nurse years with bowel 2. provision of booklet and dysfunction 3. diagnostic summary and treatment recommendations sent to patient’s general practitioner, and ward physician if in hospital
Methods of testing outcomes Outcome measure Efficiency rating was determined by number of days needed to achieve effectiveness (e.g., five consecutive daily bowel movements were given an efficiency rating of 16. Rating dropped by one point for each additional 2 days required to establish effectiveness)
Bowel regularity 23 stroke patients programme received every other day digital stimulation establishment was determined by bowel movement (spontaneous or assisted) occurring within a series of 4 consecutive successful timed defecations
73 stroke patients who received routine care with no study nurse assessment
Postal prospective selfreported 1-week stool diary at 1, 3, 6 and 12 months
Outcomes
Efficiency rating
Morning bowel training group established a more effective bowel movement pattern than those assigned to evening schedules (13.3 versus 7.37; p 0.01). No differences between mandatory or optional suppository uses. Efficiency was highest for those assigned to a bowel training group that matched their premorbid bowel habit and lowest for those assigned to a group that conflicted their premorbid bowel habit (p 0.01). 1. Number of patients who More subjects in the experimental group established a bowel established regularity regularity programme (x2 = 6.02, p < 0.05); 2. Mean number of days in establishing a however, the subjects bowel regularity in the control group programme who did achieve regularity took less time to do it. Subjects with right-side hemiplegia (t = 2.21, p < 0.05) and less mobility (r = 0.31, p < 0.05) required more time to establish their bowel regularity. Percentage of bowel 1. Number of bowel movements (BMs) movements per week per week gradedas 2. Percentage of bowel ‘‘normal’’ by patients movement graded in a prospective as normal. 1-week stool diary was significantly higher in intervention versus control group at 6 months (72% versus 55%; p = 0.027), as was mean number of BMs per week.
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48 patients with Munchiando and Quasi-experimental newly diagnosed Kendall (1993) 2 comparison arms Single centre: 26-bedded stroke Rehabilitation unit in a hospital at Midwest
Control
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3.2. Effectiveness of interventions
References located following searches 2533
Articles assessed in detail against eligibility criteria 8
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Excluded after review of abstract and title 2525 -
Not for stroke patients Not on constipation Not an intervention study
Articles excluded 5 -
Not in English
Studies meeting eligibility criteria and assessed for methodological quality 3
Studies included for review 3
Controlled Trials 2 RCTs 1 Non-RCT Fig. 1. Summary of literature search.
Midwestern United States (Munchiando and Kendall, 1993; Venn et al., 1992). Two studies were carried out in a single centre [rehabilitation unit in either a general hospital (Munchiando and Kendall, 1993) or a community hospital (Venn et al., 1992)] and one carried out in multi-centres (three rehabilitation units and local communities) (Harari et al., 2004). The studies were published in 1992 (Venn et al., 1992), 1993 (Munchiando and Kendall, 1993) and 2004 (Harari et al., 2004). Two of the studies were RCTs (Harari et al., 2004; Venn et al., 1992) and one was non-randomised trial (Munchiando and Kendall, 1993). Sample sizes ranged from 48 (Munchiando and Kendall, 1993), 58 (Venn et al., 1992) and 146 (Harari et al., 2004) participants. Power analysis was reported to calculate sample sizes in one study only (Harari et al., 2004). All participants had a diagnosis of stroke. Their mean age ranged from 69.5 years (Munchiando and Kendall, 1993) to 72 years (Harari et al., 2004; Venn et al., 1992). Two studies recruited patients who were admitted with newly diagnosed stroke (Munchiando and Kendall, 1993; Venn et al., 1992) and one study recruited patients with stroke onset beyond 1 month and within 4 years (mean time of 21–25 months post stroke) (Harari et al., 2004). One study included subjects of Caucasian and African-Caribbean with the additional inclusion criteria of a defined bowel dysfunction (Harari et al., 2004). The remaining studies did not provide description of the subjects’ race (Munchiando and Kendall, 1993; Venn et al., 1992).
3.2.1. Nurse-led intervention versus routine care Harari et al. (2004) compared the outcomes of a nurseled intervention versus routine care in a group of 146 stroke subjects presenting with bowel dysfunction. The intervention consisted of a one-time assessment (history and rectal examination) undertaken by a nurse followed by targeted patient and carer education with provision of a booklet. A diagnostic summary using an established protocol was sent to the subject’s general practitioner or ward physician if the subject was in hospital. The percentage of bowel movements (BMs) per week, graded as ‘‘normal’’ by subjects, in a prospective 1-week stool diary was significantly higher in the nurse-led intervention group versus the routine care group at 1 month (75% versus 55%; p = 0.03) and 6 months (72% versus 55%; p = 0.027), as was mean number of BMs per week (at 1 month: 5.5 versus 4.1; p = 0.01; at 6 months: 5.2 versus 3.6; p = 0.005). 3.2.2. Daily digital stimulation versus every other day Munchiando and Kendall (1993) compared the effectiveness of daily versus alternate day bowel care with digital stimulation to establish a regulated bowel evacuation for a group of 48 stroke subjects. The bowel programmes required both groups of subjects to be placed on the toilet or commode at the same time each day. Interventions progressed from digital stimulation, insertion of suppository followed by fleet enema and finally use of a soapsuds enema, if necessary, in addition to the standard care of diet modification (prune juice) and medications (fibre supplements, pericolace and senokot). Subjects assigned to receive daily digital stimulation achieved higher rates of bowel regularity (a series of four consecutive timed defecations, whether spontaneous or assisted, that occur at least every other day) than subjects who received alternate day digital stimulation (96% versus 69.6%; x2 = 6.02 p < 0.05); however, subjects in the alternate day group who did achieve bowel regularity took less time to do it as compared to the subjects in the daily group (7.7 days versus 13 days). Subjects with rightside hemiplegia (t = 2.21, p < 0.05) and less mobility (r = 0.31, p < 0.05) required more time to establish their bowel regularity. 3.2.3. Morning versus evening schedule of bowel evacuation Venn et al. (1992) compared four bowel programmes based on the timing of bowel evacuations and suppository use: (1) morning bowel training with a mandatory suppository; (2) morning bowel training with an optional suppository if the subject had a bowel movement within the previous 4 h; (3) evening bowel training with a mandatory suppository; (4) evening bowel training with an optional suppository if the subject had a bowel movement within the previous 4 h. Outcome measure was an efficiency rating determined by number of days needed to achieve bowel training effectiveness (e.g., five consecutive daily bowel movements was given an efficiency rating of 16. Rating dropped by one point for each additional 2 days). 80% of the stroke subjects (n = 39) achieved effective bowel training within 1 month. Subjects
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assigned to morning bowel schedule were more efficient than those assigned to evening schedule (13.3 versus 7.37; p 0.01). No differences were found between mandatory or optional suppository uses. Efficiency was highest for those assigned to a bowel training group whose time coincided with their previous bowel pattern and lowest for those assigned to a group whose time conflicted with their previous bowel pattern (p 0.01).
based on several staff members’ clinical observations which could affect the reliability of the measurements. The efficiency rating used to assess the subjects’ bowel function was devised by the researchers and not validated. Lastly, there was no description of the numbers and types of suppository used by the mandatory suppository group and whether the groups assigned to the optional suppository have received any suppositories.
3.3. Methodological quality of included studies
4. Discussion
Although the three studies met the inclusion criteria, only one published study met the criteria of a high quality paper (Harari et al., 2004). The remaining studies failed to report baseline characteristics of the subjects, the inclusion criteria, the interventions used and also used unvalidated methods to measure outcomes (Munchiando and Kendall, 1993; Venn et al., 1992). The study by Harari et al. (2004) has good methodological qualities of randomisation (computer generated numbers), allocation concealment (closed envelopes) and intention to treat analysis. In addition, power analysis was used to calculate the sample size in the study. Baseline comparison between groups was clearly presented. The study described clearly the inclusion criteria of a defined term of constipation. Risk of bias in this study included: (1) the treatment recommendations were based on an unvalidated protocol and the targeted education programme was not fully described; (2) the subjects’ adherence to treatment recommendations was not assessed therefore it was difficult to determine that the positive effects were due to the treatment recommendations; (3) the outcome measure of using a grading system of bowel movement rated as normal by the subjects was not described; and (4) this nurse-led intervention has a multicomponent intervention whereby it was difficult to define which single action had most effect on the positive outcomes. The digital stimulation study by Munchiando and Kendall (1993) has several risk of bias. Firstly, loss of subjects was acknowledged as one of the study’s limitations but the drop-out rates were not reported. Although there was some baseline comparability between the groups which found no statistical significance, there was no description of the study subjects’ race and stroke characteristics or severity. There was no description of the statistical analysis method used. Another variable which could have an influence on the study outcome was the subjects’ pre-existing bowel dysfunctions, which were not determined prior to the interventions. Lastly, the criteria of the established bowel programme were devised by the researchers and not validated thus making the results difficult to be interpreted. The risk of bias in the RCT of comparing four bowel programmes by Venn et al. (1992) included firstly, the nondescription of its randomisation process. The study also did not indicate details of the subjects’ characteristics (sex, onset and severity of stroke, concomitant treatments, etc.) and did not report baseline comparison of the study groups to determine that the effect difference was truly due to the intervention alone. The study outcomes were recorded
The objective of this review was to assess the effectiveness of bowel management strategies for constipation in adults with stroke. The number of studies meeting the inclusion criteria for this review was small, and the studies varied in the aspects of inclusion criteria, types of intervention used and outcome measures. Despite the high prevalence of constipation in the stroke population, there is still a lack of coordinated high quality studies. There are various challenges in the research of constipation. Firstly, there is a lack of interest by the clinical researchers as constipation is often viewed as a non-life threatening condition. Many studies focusing on medical complications do not include constipation as a complication. Although bowel care is the fundamental area of patient care, constipation is still a neglected study subject. Secondly, there is a lack of a consensus definition of constipation. There are various definitions of constipation. Most are based on reported symptoms. In this review, only one study (Harari et al., 2004) defined bowel dysfunction based on Rome III diagnostic criteria for functional constipation (Rome Foundation, 2010). The remaining two studies used other criteria to measure effective bowel function. As a result, it is difficult to compare and interpret the effectiveness of the interventions used. Importantly, there are differences in the prevalence of constipation in various studies. For example, Bracci et al. (2007) report high prevalence but included only small number of patients and outcomes were measured at different time point after stroke onset: 90 patients assessed at median 36 weeks after stroke onset (prevalence 30%). In a slightly larger population of 154 patients who were assessed at 1 month after stroke onset, prevalence was 55% (Su et al., 2009). However, in a larger cohort of patients (11,757) with stroke, 7% only had constipation (Ingeman et al., 2011). The articles included in the review are primarily of small populations: 48 (Munchiando and Kendall, 1993), 58 (Venn et al., 1992) and 146 (Harari et al., 2004). These differences highlight that the prevalence is unclear and raises the question of whether the differences, in constipation prevalence, are related to the size of the study group, the inclusion criteria, variations in definition of constipation and also in which phase of health care and time point the patients were included and assessed. It will be of interest to study the prevalence of constipation among larger number of stroke patients in an epidemiological group with a ‘first-ever’ stroke because that would give a clear indication of the percentage of people having problems with constipation after stroke. In recent years, we have seen an emerging trend of nurses advancing their clinical role to address the growing
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burden of caring for patients with multiple chronic diseases. These nurses are taking the lead in managing patients in collaboration with the medical physicians. They are able to assess (perform history taking and physical examinations), diagnose and treat common ailments. Studies have shown that patients under these nurse-led care initiatives have improved health outcomes in various settings: nursing home, hospital and community care (Blozik et al., 2010; Mac Lellan, 2004; Sindhu et al., 2010). The nurse-led intervention by Harari et al. (2004), which is the only high quality study in this review, has further highlighted that active involvement of nurses in the management and prevention of health conditions such as constipation merits further investigation with respect to patient assessment, planning and implementing structured bowel management interventions and individualised education programmes. One of the studies advocated the use of daily bowel care with digital stimulation to achieve higher rates of bowel regularity (Munchiando and Kendall, 1993). Although there have been major advances and rigorous effort in the scientific field of acute stroke management, research in the field of managing stroke complications such as bowel dysfunctions is comparably slow. Digital stimulation has been commonly utilised to facilitate defecation in patients with spinal cord injury (Faaborg et al., 2008; Haas et al., 2005; Valles et al., 2007), and has remained essentially unchanged in the past decades. It could evoke an anorectal colonic reflex resulting in enhanced contractions of the descending colon and rectum (Korsten et al., 2007; Shafik et al., 2000). The effect of digital stimulation should be further evaluated with considerations in a subset of stroke population who do not respond to other interventions as the stroke subjects in the study by Munchiando and Kendall (1993) were already on an every other day digital stimulation programme at baseline in addition to the standard care of diet modification and medications. In recent reviews there have been some new promising ideas of using assistive devices such as irrigation techniques and electrical stimulation to manage neurogenic bowel in patients with spinal cord injuries (Krassioukov et al., 2010), conditions which affect the central nervous system and the pathway of reflexes involved in the defecation process (gastro colic and spinal reflex). These new techniques could be further evaluated in this subset of stroke population. Management of constipation should also focus on factors that could influence normal bowel functioning other than the latest innovations alone. The findings of association between right hemiplegic (possibly expressive dysphasia) and reduced mobility with prolonged time required for bowel regularity by Munchiando and Kendall (1993), suggests that mobility and speech impairment may be an important risk factor for constipation. Constipation is often associated with prolonged bed rest and immobility in the elderly (Hsieh, 2005). Failure to respond to defecation urges can also lead to suppression of rectal sensation and subsequently, faecal retention and constipation (Talley et al., 1996). Future studies should therefore evaluate the influence of impaired physical mobility and communication deficits in establishing bowel regularity. The timing of
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defecation also affects normal bowel functioning. Regular timing influences reflex activity which promotes normal defecation. People with regular bowel patterns have been shown to empty their bowel at approximately the same time every day (Heaton et al., 1994). This supports Venn et al.’s (1992) study whereby bowel efficiency was highest when subjects were assigned to a bowel training group that coincide with their previous bowel habits. The importance of assessing previous bowel habits in detail as part of the history taking and incorporating it into patient management plan should therefore be emphasised. This again, explores the essential role that nurses can play, which can have a dramatic impact on patient care. Colonic activity has been found to be greatest at waking and after breakfast (Heaton et al., 1994; Rao et al., 2001) and the most common time for call to defecation is immediately on rising or after breakfast (Heaton et al., 1994). Therefore, the optimal time for attempting defecation should be in the morning and after breakfast for those whose previous bowel habits are in the morning, as indicated by the outcome of Venn et al.’s (1992) study. The findings of mandatory or optional use of suppositories which had no significant differences in achieving bowel efficiency is difficult to interpret as the types and numbers of suppositories used for both groups of subjects were not reported. Nevertheless, the use of pharmacological agents as part of a treatment in bowel management programmes should be further explored in terms of necessity, types and frequency in the stroke population. 5. Limitations of the review All three studies have small sample sizes where generalisation has to be taken with caution. The restriction of this review to English language may have resulted in language bias with potentially relevant studies published in other languages being missed. This review also did not include unpublished abstracts from relevant Gastroenterology or Geriatric conferences. Low level methodological quality studies were included due to limited number of studies available and utilised a narrative approach to provide a broad overview of the subject, hence the conclusions drawn are no conclusive. In addition, the latest study identified was published in 2004, highlighting a lack of primary research on this subject. 6. Conclusion The bowel management strategies for constipation in adults with stroke are limited. The available evidence suggests that structured bowel programmes and nurse-led interventions in bowel care have a significant effect in improving bowel evacuations, which merits further evaluation. Moving forward, large randomised controlled studies are needed to explore all aspects of care that could improve bowel dysfunction which include pharmacological and non-pharmacological interventions. The development of future studies should adopt an agreed definition of bowel dysfunction and validated intervention protocols and education programmes. The outcome measures should include measures of social factors such of quality of life and
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caregivers’ burden of care to add further value to the established bowel programme. Acknowledgement The authors would like to acknowledge the Joanna Briggs Institute staff for their review of full manuscript upon which this manuscript is based. Conflicts of interest There is no conflict of interest associated with this systematic review. Funding: None. Ethical approval: None. References Blozik, E., Born, A.M., Stuck, A.E., Benninger, U., Gillmann, G., Clough-Gorr, K.M., 2010. Reduction of inappropriate medications among older nursing-home residents: a nurse-led, pre/post-design intervention study. Drugs & Aging 27 (12), 1009–1017. Bracci, F., Badiali, D., Pezzotti, P., Scivoletto, G., Fuoco, U., Di Lucente, L., Corazziari, E., 2007. Chronic constipation in hemiplegic patients. World Journal of Gastroenterology 13 (29), 3967–3972. Coggrave, M., Wiesel, P.H., Norton, C., 2006. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Review (2), CD002115, http:// dx.doi.org/10.1002/14651858.CD002115.pub3. Ernst, E., 1999. Abdominal massage therapy for chronic constipation: a systematic review of controlled clinical trials. Research in Complementary Medicine (Forschende Komplementa¨rmedizin).6 (3), 149–151. Faaborg, P.M., Christensen, P., Finnerup, N., Laurberg, S., Krogh, K., 2008. The pattern of colorectal dysfunction changes with time since spinal cord injury. Spinal Cord 46 (3), 234–238, http://dx.doi.org/10.1038/ sj.sc.3102121. Frizelle, F., Barclay, M., 2007. Constipation in adults. Clinical Evidence (Online) 2007 http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2943807/ (accessed 07.07.11). Haas, U., Geng, V., Evers, G.C., Knecht, H., 2005. Bowel management in patients with spinal cord injury – a multicentre study of the German speaking society of paraplegia (DMGP). Spinal Cord 43 (12), 724–730, http://dx.doi.org/10.1038/sj.sc.3101795. Harari, D., Norton, C., Lockwood, L., Swift, C., 2004. Treatment of constipation and fecal incontinence in stroke patients: randomized controlled trial. Stroke 35 (11), 2549–2555, http://dx.doi.org/10.1161/ 01.str.0000144684.46826.62. Heaton, K.W., Wood, N., Cripps, H.A., Philipp, R., 1994. The call to stool and its relationship to constipation: a community study. European Journal of Gastroenterology & Hepatology 6 (2), 145–150. Hsieh, C., 2005. Treatment of constipation in older adults. American Family Physician 72 (11), 2277–2284. Huang, X.B., Li, Z.X., 2002. Clinical observation on effect of qirong runchang oral liquid in treating constipation after stroke. Zhongguo Zhong Xi Yi Jie He Za Zhi 22 (8), 622–623. Ikari, H., Miura, S., Ando, F., Ito, I., Kono, K., Goto, T., et al., 1993. The effect of soluble fiber dietary supplement on constipation in 3 patients with dysphagia who suffered from cerebral infarction with special reference to serum diamine oxidase activity. Nippon Ronen Igakkai Zasshi 30 (5), 397–402.
Ingeman, A., Andersen, G., et al., 2011. Processes of care and medical complications in patients with stroke. Stroke 42 (1), 167–172. Jeon, S.Y., Jung, H.M., 2005. The effects of abdominal meridian massage on constipation among CVA patients. Taehan Kanho Hakhoe Chi 35 (1), 135–142. Joanna Briggs Institute, 2008. Management of constipation in older adults. Best Practice 12 (7), 1–4. Johanson, J.F., 2007. Review of the treatment options for chronic constipation. Medscape General Medicine 9 (2), 25. Korsten, M.A., Singal, A.K., Monga, A., Chaparala, G., Khan, A.M., Palmon, R., Bauman, W.A., 2007. Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury. Journal of Spinal Cord Medicine 30 (1), 31–35. Krassioukov, A., Eng, J.J., Claxton, G., Sakakibara, B.M., Shum, S., 2010. Neurogenic bowel management after spinal cord injury: a systematic review of the evidence. Spinal Cord 48 (10), 718–733, http:// dx.doi.org/10.1038/sc.2010.14. Lee, G.N., Shon, K.H., 2006. The effects of meridian acupressure on decreasing constipation for stroke patients. Journal of Korean Academy Adult Nursing 18 (5), 760–770. Mac Lellan, K., 2004. Postoperative pain: strategy for improving patient experiences. Journal of Advanced Nursing 46 (2), 179–193. Munchiando, J.F., Kendall, K., 1993. Comparison of the effectiveness of two bowel programs for CVA patients. Rehabilitation Nursing 18 (3), 168–172. Ramkumar, D., Rao, S.S., 2005. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. American Journal of Gastroenterology 100 (4), 936–971, http://dx.doi.org/ 10.1111/j.1572-0241.2005.40925.x. Rao, S.S., 2003. Constipation: evaluation and treatment. Gastroenterology Clinics of North America 32 (2), 659–683. Rao, S.S.C., Sadeghi, P., Beaty, J., Kavlock, R., Ackerson, K., 2001. Ambulatory 24-h colonic manometry in healthy humans. American Journal of Physiology: Gastrointestinal and Liver Physiology 280 (4), G629– G639. Rome Foundation, 2010. Rome III diagnostic criteria for functional gastrointestinal disorders. http://www.romecriteria.org/assets/pdf/ 19_RomeIII_apA_885-898.pdf (accessed 01.04.11). Shafik, A., El-Sibai, O., Shafik, I.A., 2000. Physiologic basis of digital-rectal stimulation for bowel evacuation in patients with spinal cord injury: identification of an anorectal excitatory reflex. Journal of Spinal Cord Medicine 23 (4), 270–275. Sindhu, S., Pholpet, C., Puttapitukpol, S., 2010. Meeting the challenges of chronic illness: a nurse-led collaborative community care program in Thailand. Collegian 17 (2), 93–99, http://dx.doi.org/10.1016/ j.colegn.2010.05.003. Su, Y., Zhang, X., Zeng, J., Pei, Z., Cheung, R.T., Zhou, Q.P., Zhang, Z., 2009. New-onset constipation at acute stage after first stroke: incidence, risk factors, and impact on the stroke outcome. Stroke 40 (4), 1304– 1309, http://dx.doi.org/10.1161/strokeaha.108.534776. Talley, N.J., Fleming, K.C., Evans, J.M., O’Keefe, E.A., Weaver, A.L., Zinsmeister, A.R., Melton 3rd., L.J., 1996. Constipation in an elderly community: a study of prevalence and potential risk factors. American Journal of Gastroenterology 91 (1), 19–25. Valles, M., Terre, R., Guevara, D., Portell, E., Vidal, J., Mearin, F., 2007. Bowel dysfunction in patients with spinal cord injury: relation with neurological patterns. Medicina Clinica (Barc) 129 (5), 171–173. Venn, M.R., Taft, L., Carpentier, B., Applebaugh, G., 1992. The influence of timing and suppository use on efficiency and effectiveness of bowel training after a stroke. Rehabilitation Nursing 17 (3), 116–121. Wang, D.S., Wang, S., Kong, L.L., Wang, W.Y., Cui, X.M., 2008. Clinical observation on abdominal electroacupuncture for treatment of poststroke constipation. Zhongguo Zhen Jiu 28 (1), 7–9.
Contents lists available at SciVerse ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Review
A systematic review of the effectiveness of bowel management strategies for constipation in adults with stroke Su Fee Lim a,b,*, Charmaine Childs b a b
Rehabilitation Medicine, Block 6, Level 9, Singapore General Hospital, Outram Road, Singapore 169608, Singapore Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 August 2012 Received in revised form 3 December 2012 Accepted 3 December 2012
Objective: Constipation is one of the most common medical complications of acute stroke. Currently, management strategies to guide clinical practice are limited. This review aimed to examine the effectiveness of bowel management strategies for constipation in adults with stroke. Design: A systematic review of randomised controlled trials or other quantitative research designs in the absence of randomised controlled trials was undertaken. Data sources: A comprehensive search of major electronic databases and all reference lists of relevant articles in the English language were performed from January 1990 up to March 2011. Review methods: Data were extracted and assessed by two independent reviewers. Due to differences in the study designs, the findings are presented in narrative form. Results: There were a total of three studies (two randomised controlled trials and one quasi-experimental study). One of the randomised controlled trials examined a single (once-only) structured nurse-led intervention and the other randomised controlled trial evaluated four bowel management programmes. Both studies yield improvements respectively in symptoms of bowel dysfunction and bowel training efficiency when the programme corresponded with the subjects’ bowel patterns before the stroke onset. The quasi-experimental study compared the effectiveness of daily digital stimulation versus every other day and found higher bowel regularity with daily digital stimulation. Conclusion: Constipation management strategies are limited. This review suggests that structured bowel programmes and nurse-led intervention in bowel care have a significant effect in improving bowel evacuations. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Bowel Constipation Nurse-led intervention Stroke Systematic review
What is already known about this topic? Treatment strategies which include non-pharmacological approaches (diet modification, fluid intake, bowel training, abdominal massage and increased mobility) and pharmacological therapies (fibre supplements and laxatives) are based on expert opinion and targeted at older adults with chronic constipation. The clinical
* Corresponding author. Tel.: +65 63265700; fax: +65 62225391. E-mail addresses: [email protected] (S.F. Lim), [email protected] (C. Childs). 0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.12.002
evidence supporting the use in stroke patients is yet to be demonstrated. No systematic review of the types of constipation management strategies currently exists in the stroke population.
What this paper adds This review provides evidence to support the finding that structured bowel management programmes and nurseled intervention in bowel care are effective in managing constipation in the stroke population.
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1. Introduction Constipation is one of the most common complications of acute stroke. The prevalence is 55% at acute stage within 1 month after first stroke (Su et al., 2009) and 30% after a period of median 36 weeks after stroke onset (Bracci et al., 2007). Constipation not only causes discomfort, but it can also affect a person’s physical and psychological wellbeing in addition to the ability to participate in social and family life. This consequence can have a great impact on a person’s quality of life and contribute to a poorer outcome (Su et al., 2009). Management of constipation is typically based on experience and anecdotal evidence. There are range of treatment modalities: diet modification, fluid intake, bowel training, abdominal massage and increased mobility, for managing chronic constipation in older adults (Ernst, 1999; Frizelle and Barclay, 2007; Hsieh, 2005). However the clinical evidence of efficacy in supporting their use in stroke patients has yet to be demonstrated. The clinical benefits of traditional pharmacologic agents such as fibre supplements and laxatives (bulk forming, stool softeners, stool lubricants, stimulants and hyperosmotics) remain unclear (Johanson, 2007; Ramkumar and Rao, 2005; Rao, 2003). The available systematic reviews on management of constipation are focused on older adults (Joanna Briggs Institute, 2008) and adults with central neurological diseases (Coggrave et al., 2006). Whether results are transferrable to the stroke population remains unclear. There is no systematic review on management of constipation in the stroke population to guide clinical practice. This paper is based on a detailed review published online in the Joanna Briggs Institute Library of Systematic Reviews (JBI000463 2011 9(64) 2875–2914). 1.1. Objectives This review aimed to identify the effectiveness of bowel management strategies for managing constipation in adults with stroke. This review would be beneficial to healthcare providers in their clinical management of constipation in people with stroke. The review question was What is the effectiveness of contemporary bowel management strategies for constipation in stroke patients for promoting bowel evacuation? 2. Methods 2.1. Search strategies A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was undertaken across all included electronic databases. Databases searched were CINAHL, Medline, SCOPUS, ScienceDirect, Web of Science, Mosby’s Nursing Consult, Expanded Academic ASAP, Dissertation Abstracts International and Mednar. Thirdly, the reference lists of all
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identified reports and articles were searched for additional studies. Initial keywords used were: stroke, cerebrovascular accident, CVA, constipation, fec* impaction, bowel management, bowel care, bowel training and bowel program*. An initial review involved screening the titles and abstracts of studies identified from the literature search. Subsequently, reviewers examined full-text articles to determine the methodological quality. 2.2. Inclusion criteria This review included studies in English, conducted from January 1990 up to March 2011, that utilised a randomised controlled trial (RCT). Other research designs were included in the absence of available RCTs evaluated any type of bowel management strategies included adults of 18 years of age or older with a clinical diagnosis of stroke with symptoms of constipation reported bowel evacuation as the outcome measure. 2.3. Data collection and analyses The reviewers (SL and CC) assessed eligibility and methodological quality of the full text articles before inclusion in the review using a standardised critical appraisal instrument (Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument, JBIMAStARI). Any disagreements arising between the reviewers were resolved through discussion. Data were extracted from the included studies using a standardised data extraction tool (JBI-MAStARI). Data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. As there were differences in the types of intervention and outcome measures, statistical pooling of the findings was not appropriate. The findings were therefore presented in narrative form. 3. Results Two thousand five hundred and thirty-three articles were identified and reviewed according to the preset inclusion and exclusion criteria. Two thousand five hundred and twenty-five articles were deemed not relevant at this screening stage based on the title and abstract. Five articles were in languages other than English: Chinese (Huang and Li, 2002; Wang et al., 2008), Korean (Jeon and Jung, 2005; Lee and Shon, 2006) and Japanese (Ikari et al., 1993). Three studies met the eligibility criteria and full-text articles were retrieved and assessed for methodological quality. Due to the small number of studies, all three studies (Table 1) were included in this review. Fig. 1 provides a summary of the literature search. 3.1. Description of studies The three studies included in the review were conducted in London (Harari et al., 2004) and
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Table 1 Description of Studies included in the review. Authors and year Study design and setting
Participants
Intervention
Venn et al. (1992)
58 patients admitted to the rehabilitation unit with stroke and no GI disease
Group 1 – morning bowel training and mandatory suppository Group 2 – morning bowel training and optional suppository Group 3 – evening bowel training and mandatory suppository Group 4 – evening bowel training and optional suppository
Randomised controlled trial 4 comparison arms Single centre: rehabilitation unit in a community hospital at Midwest
Harari et al. (2004)
Randomised controlled trial 2 comparison arms Multi-centred: 3 rehabilitation units and local communities in London
25 stroke patients received daily digital stimulation
73 stroke patients 146 patients who received intervention had experienced a consisted of stroke beyond 1 month and within 4 1. a single (once only) assessment by a nurse years with bowel 2. provision of booklet and dysfunction 3. diagnostic summary and treatment recommendations sent to patient’s general practitioner, and ward physician if in hospital
Methods of testing outcomes Outcome measure Efficiency rating was determined by number of days needed to achieve effectiveness (e.g., five consecutive daily bowel movements were given an efficiency rating of 16. Rating dropped by one point for each additional 2 days required to establish effectiveness)
Bowel regularity 23 stroke patients programme received every other day digital stimulation establishment was determined by bowel movement (spontaneous or assisted) occurring within a series of 4 consecutive successful timed defecations
73 stroke patients who received routine care with no study nurse assessment
Postal prospective selfreported 1-week stool diary at 1, 3, 6 and 12 months
Outcomes
Efficiency rating
Morning bowel training group established a more effective bowel movement pattern than those assigned to evening schedules (13.3 versus 7.37; p 0.01). No differences between mandatory or optional suppository uses. Efficiency was highest for those assigned to a bowel training group that matched their premorbid bowel habit and lowest for those assigned to a group that conflicted their premorbid bowel habit (p 0.01). 1. Number of patients who More subjects in the experimental group established a bowel established regularity regularity programme (x2 = 6.02, p < 0.05); 2. Mean number of days in establishing a however, the subjects bowel regularity in the control group programme who did achieve regularity took less time to do it. Subjects with right-side hemiplegia (t = 2.21, p < 0.05) and less mobility (r = 0.31, p < 0.05) required more time to establish their bowel regularity. Percentage of bowel 1. Number of bowel movements (BMs) movements per week per week gradedas 2. Percentage of bowel ‘‘normal’’ by patients movement graded in a prospective as normal. 1-week stool diary was significantly higher in intervention versus control group at 6 months (72% versus 55%; p = 0.027), as was mean number of BMs per week.
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48 patients with Munchiando and Quasi-experimental newly diagnosed Kendall (1993) 2 comparison arms Single centre: 26-bedded stroke Rehabilitation unit in a hospital at Midwest
Control
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3.2. Effectiveness of interventions
References located following searches 2533
Articles assessed in detail against eligibility criteria 8
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Excluded after review of abstract and title 2525 -
Not for stroke patients Not on constipation Not an intervention study
Articles excluded 5 -
Not in English
Studies meeting eligibility criteria and assessed for methodological quality 3
Studies included for review 3
Controlled Trials 2 RCTs 1 Non-RCT Fig. 1. Summary of literature search.
Midwestern United States (Munchiando and Kendall, 1993; Venn et al., 1992). Two studies were carried out in a single centre [rehabilitation unit in either a general hospital (Munchiando and Kendall, 1993) or a community hospital (Venn et al., 1992)] and one carried out in multi-centres (three rehabilitation units and local communities) (Harari et al., 2004). The studies were published in 1992 (Venn et al., 1992), 1993 (Munchiando and Kendall, 1993) and 2004 (Harari et al., 2004). Two of the studies were RCTs (Harari et al., 2004; Venn et al., 1992) and one was non-randomised trial (Munchiando and Kendall, 1993). Sample sizes ranged from 48 (Munchiando and Kendall, 1993), 58 (Venn et al., 1992) and 146 (Harari et al., 2004) participants. Power analysis was reported to calculate sample sizes in one study only (Harari et al., 2004). All participants had a diagnosis of stroke. Their mean age ranged from 69.5 years (Munchiando and Kendall, 1993) to 72 years (Harari et al., 2004; Venn et al., 1992). Two studies recruited patients who were admitted with newly diagnosed stroke (Munchiando and Kendall, 1993; Venn et al., 1992) and one study recruited patients with stroke onset beyond 1 month and within 4 years (mean time of 21–25 months post stroke) (Harari et al., 2004). One study included subjects of Caucasian and African-Caribbean with the additional inclusion criteria of a defined bowel dysfunction (Harari et al., 2004). The remaining studies did not provide description of the subjects’ race (Munchiando and Kendall, 1993; Venn et al., 1992).
3.2.1. Nurse-led intervention versus routine care Harari et al. (2004) compared the outcomes of a nurseled intervention versus routine care in a group of 146 stroke subjects presenting with bowel dysfunction. The intervention consisted of a one-time assessment (history and rectal examination) undertaken by a nurse followed by targeted patient and carer education with provision of a booklet. A diagnostic summary using an established protocol was sent to the subject’s general practitioner or ward physician if the subject was in hospital. The percentage of bowel movements (BMs) per week, graded as ‘‘normal’’ by subjects, in a prospective 1-week stool diary was significantly higher in the nurse-led intervention group versus the routine care group at 1 month (75% versus 55%; p = 0.03) and 6 months (72% versus 55%; p = 0.027), as was mean number of BMs per week (at 1 month: 5.5 versus 4.1; p = 0.01; at 6 months: 5.2 versus 3.6; p = 0.005). 3.2.2. Daily digital stimulation versus every other day Munchiando and Kendall (1993) compared the effectiveness of daily versus alternate day bowel care with digital stimulation to establish a regulated bowel evacuation for a group of 48 stroke subjects. The bowel programmes required both groups of subjects to be placed on the toilet or commode at the same time each day. Interventions progressed from digital stimulation, insertion of suppository followed by fleet enema and finally use of a soapsuds enema, if necessary, in addition to the standard care of diet modification (prune juice) and medications (fibre supplements, pericolace and senokot). Subjects assigned to receive daily digital stimulation achieved higher rates of bowel regularity (a series of four consecutive timed defecations, whether spontaneous or assisted, that occur at least every other day) than subjects who received alternate day digital stimulation (96% versus 69.6%; x2 = 6.02 p < 0.05); however, subjects in the alternate day group who did achieve bowel regularity took less time to do it as compared to the subjects in the daily group (7.7 days versus 13 days). Subjects with rightside hemiplegia (t = 2.21, p < 0.05) and less mobility (r = 0.31, p < 0.05) required more time to establish their bowel regularity. 3.2.3. Morning versus evening schedule of bowel evacuation Venn et al. (1992) compared four bowel programmes based on the timing of bowel evacuations and suppository use: (1) morning bowel training with a mandatory suppository; (2) morning bowel training with an optional suppository if the subject had a bowel movement within the previous 4 h; (3) evening bowel training with a mandatory suppository; (4) evening bowel training with an optional suppository if the subject had a bowel movement within the previous 4 h. Outcome measure was an efficiency rating determined by number of days needed to achieve bowel training effectiveness (e.g., five consecutive daily bowel movements was given an efficiency rating of 16. Rating dropped by one point for each additional 2 days). 80% of the stroke subjects (n = 39) achieved effective bowel training within 1 month. Subjects
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assigned to morning bowel schedule were more efficient than those assigned to evening schedule (13.3 versus 7.37; p 0.01). No differences were found between mandatory or optional suppository uses. Efficiency was highest for those assigned to a bowel training group whose time coincided with their previous bowel pattern and lowest for those assigned to a group whose time conflicted with their previous bowel pattern (p 0.01).
based on several staff members’ clinical observations which could affect the reliability of the measurements. The efficiency rating used to assess the subjects’ bowel function was devised by the researchers and not validated. Lastly, there was no description of the numbers and types of suppository used by the mandatory suppository group and whether the groups assigned to the optional suppository have received any suppositories.
3.3. Methodological quality of included studies
4. Discussion
Although the three studies met the inclusion criteria, only one published study met the criteria of a high quality paper (Harari et al., 2004). The remaining studies failed to report baseline characteristics of the subjects, the inclusion criteria, the interventions used and also used unvalidated methods to measure outcomes (Munchiando and Kendall, 1993; Venn et al., 1992). The study by Harari et al. (2004) has good methodological qualities of randomisation (computer generated numbers), allocation concealment (closed envelopes) and intention to treat analysis. In addition, power analysis was used to calculate the sample size in the study. Baseline comparison between groups was clearly presented. The study described clearly the inclusion criteria of a defined term of constipation. Risk of bias in this study included: (1) the treatment recommendations were based on an unvalidated protocol and the targeted education programme was not fully described; (2) the subjects’ adherence to treatment recommendations was not assessed therefore it was difficult to determine that the positive effects were due to the treatment recommendations; (3) the outcome measure of using a grading system of bowel movement rated as normal by the subjects was not described; and (4) this nurse-led intervention has a multicomponent intervention whereby it was difficult to define which single action had most effect on the positive outcomes. The digital stimulation study by Munchiando and Kendall (1993) has several risk of bias. Firstly, loss of subjects was acknowledged as one of the study’s limitations but the drop-out rates were not reported. Although there was some baseline comparability between the groups which found no statistical significance, there was no description of the study subjects’ race and stroke characteristics or severity. There was no description of the statistical analysis method used. Another variable which could have an influence on the study outcome was the subjects’ pre-existing bowel dysfunctions, which were not determined prior to the interventions. Lastly, the criteria of the established bowel programme were devised by the researchers and not validated thus making the results difficult to be interpreted. The risk of bias in the RCT of comparing four bowel programmes by Venn et al. (1992) included firstly, the nondescription of its randomisation process. The study also did not indicate details of the subjects’ characteristics (sex, onset and severity of stroke, concomitant treatments, etc.) and did not report baseline comparison of the study groups to determine that the effect difference was truly due to the intervention alone. The study outcomes were recorded
The objective of this review was to assess the effectiveness of bowel management strategies for constipation in adults with stroke. The number of studies meeting the inclusion criteria for this review was small, and the studies varied in the aspects of inclusion criteria, types of intervention used and outcome measures. Despite the high prevalence of constipation in the stroke population, there is still a lack of coordinated high quality studies. There are various challenges in the research of constipation. Firstly, there is a lack of interest by the clinical researchers as constipation is often viewed as a non-life threatening condition. Many studies focusing on medical complications do not include constipation as a complication. Although bowel care is the fundamental area of patient care, constipation is still a neglected study subject. Secondly, there is a lack of a consensus definition of constipation. There are various definitions of constipation. Most are based on reported symptoms. In this review, only one study (Harari et al., 2004) defined bowel dysfunction based on Rome III diagnostic criteria for functional constipation (Rome Foundation, 2010). The remaining two studies used other criteria to measure effective bowel function. As a result, it is difficult to compare and interpret the effectiveness of the interventions used. Importantly, there are differences in the prevalence of constipation in various studies. For example, Bracci et al. (2007) report high prevalence but included only small number of patients and outcomes were measured at different time point after stroke onset: 90 patients assessed at median 36 weeks after stroke onset (prevalence 30%). In a slightly larger population of 154 patients who were assessed at 1 month after stroke onset, prevalence was 55% (Su et al., 2009). However, in a larger cohort of patients (11,757) with stroke, 7% only had constipation (Ingeman et al., 2011). The articles included in the review are primarily of small populations: 48 (Munchiando and Kendall, 1993), 58 (Venn et al., 1992) and 146 (Harari et al., 2004). These differences highlight that the prevalence is unclear and raises the question of whether the differences, in constipation prevalence, are related to the size of the study group, the inclusion criteria, variations in definition of constipation and also in which phase of health care and time point the patients were included and assessed. It will be of interest to study the prevalence of constipation among larger number of stroke patients in an epidemiological group with a ‘first-ever’ stroke because that would give a clear indication of the percentage of people having problems with constipation after stroke. In recent years, we have seen an emerging trend of nurses advancing their clinical role to address the growing
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burden of caring for patients with multiple chronic diseases. These nurses are taking the lead in managing patients in collaboration with the medical physicians. They are able to assess (perform history taking and physical examinations), diagnose and treat common ailments. Studies have shown that patients under these nurse-led care initiatives have improved health outcomes in various settings: nursing home, hospital and community care (Blozik et al., 2010; Mac Lellan, 2004; Sindhu et al., 2010). The nurse-led intervention by Harari et al. (2004), which is the only high quality study in this review, has further highlighted that active involvement of nurses in the management and prevention of health conditions such as constipation merits further investigation with respect to patient assessment, planning and implementing structured bowel management interventions and individualised education programmes. One of the studies advocated the use of daily bowel care with digital stimulation to achieve higher rates of bowel regularity (Munchiando and Kendall, 1993). Although there have been major advances and rigorous effort in the scientific field of acute stroke management, research in the field of managing stroke complications such as bowel dysfunctions is comparably slow. Digital stimulation has been commonly utilised to facilitate defecation in patients with spinal cord injury (Faaborg et al., 2008; Haas et al., 2005; Valles et al., 2007), and has remained essentially unchanged in the past decades. It could evoke an anorectal colonic reflex resulting in enhanced contractions of the descending colon and rectum (Korsten et al., 2007; Shafik et al., 2000). The effect of digital stimulation should be further evaluated with considerations in a subset of stroke population who do not respond to other interventions as the stroke subjects in the study by Munchiando and Kendall (1993) were already on an every other day digital stimulation programme at baseline in addition to the standard care of diet modification and medications. In recent reviews there have been some new promising ideas of using assistive devices such as irrigation techniques and electrical stimulation to manage neurogenic bowel in patients with spinal cord injuries (Krassioukov et al., 2010), conditions which affect the central nervous system and the pathway of reflexes involved in the defecation process (gastro colic and spinal reflex). These new techniques could be further evaluated in this subset of stroke population. Management of constipation should also focus on factors that could influence normal bowel functioning other than the latest innovations alone. The findings of association between right hemiplegic (possibly expressive dysphasia) and reduced mobility with prolonged time required for bowel regularity by Munchiando and Kendall (1993), suggests that mobility and speech impairment may be an important risk factor for constipation. Constipation is often associated with prolonged bed rest and immobility in the elderly (Hsieh, 2005). Failure to respond to defecation urges can also lead to suppression of rectal sensation and subsequently, faecal retention and constipation (Talley et al., 1996). Future studies should therefore evaluate the influence of impaired physical mobility and communication deficits in establishing bowel regularity. The timing of
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defecation also affects normal bowel functioning. Regular timing influences reflex activity which promotes normal defecation. People with regular bowel patterns have been shown to empty their bowel at approximately the same time every day (Heaton et al., 1994). This supports Venn et al.’s (1992) study whereby bowel efficiency was highest when subjects were assigned to a bowel training group that coincide with their previous bowel habits. The importance of assessing previous bowel habits in detail as part of the history taking and incorporating it into patient management plan should therefore be emphasised. This again, explores the essential role that nurses can play, which can have a dramatic impact on patient care. Colonic activity has been found to be greatest at waking and after breakfast (Heaton et al., 1994; Rao et al., 2001) and the most common time for call to defecation is immediately on rising or after breakfast (Heaton et al., 1994). Therefore, the optimal time for attempting defecation should be in the morning and after breakfast for those whose previous bowel habits are in the morning, as indicated by the outcome of Venn et al.’s (1992) study. The findings of mandatory or optional use of suppositories which had no significant differences in achieving bowel efficiency is difficult to interpret as the types and numbers of suppositories used for both groups of subjects were not reported. Nevertheless, the use of pharmacological agents as part of a treatment in bowel management programmes should be further explored in terms of necessity, types and frequency in the stroke population. 5. Limitations of the review All three studies have small sample sizes where generalisation has to be taken with caution. The restriction of this review to English language may have resulted in language bias with potentially relevant studies published in other languages being missed. This review also did not include unpublished abstracts from relevant Gastroenterology or Geriatric conferences. Low level methodological quality studies were included due to limited number of studies available and utilised a narrative approach to provide a broad overview of the subject, hence the conclusions drawn are no conclusive. In addition, the latest study identified was published in 2004, highlighting a lack of primary research on this subject. 6. Conclusion The bowel management strategies for constipation in adults with stroke are limited. The available evidence suggests that structured bowel programmes and nurse-led interventions in bowel care have a significant effect in improving bowel evacuations, which merits further evaluation. Moving forward, large randomised controlled studies are needed to explore all aspects of care that could improve bowel dysfunction which include pharmacological and non-pharmacological interventions. The development of future studies should adopt an agreed definition of bowel dysfunction and validated intervention protocols and education programmes. The outcome measures should include measures of social factors such of quality of life and
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