dr. karen smith - Litigation Student

with THOMSON, ROGERS
and Canadian Paraplegic Association Ontario
DR. KAREN SMITH
Dr. Karen M. Smith, Associate Professor at Queen’s University in the Faculty of Health Sciences
from l994 to the present. She is affiliated with Providence Care, St. Mary’s of the Lake Site,
Kingston General, Hotel Dieu and Brockville Hospitals. She is the Clinical Director of the Acquired
Brain Injury and Spinal Cord Injury Rehabilitation Services from 1994 to present. She was Associate
Professor at McMaster University until 1994.
Dr Smith completed her Physical Medicine and Rehabilitation residency training at McMaster
University. She is a Fellow of the Royal College of Physicians and Surgeons of Canada, Diplomat
of the American Board of Electrodiagnostic Medicine and the American Board of Physical Medicine
and Rehabilitation with subspecialty certification in Spinal Cord Injury Medicine attained in 2003.
Her clinical interests and expertise are in ABI, SCI and pediatric rehabilitation. Her research interests
are in clinical trials with current trials in the areas of primary care for persons with disabilities,
quality of life, exercise, and neurogenic bowel management.
CONTACT INFO:
Providence Care | St. Mary’s of the Lake Hospital
Dept. of Physical Medicine and Rehabilitation
340 Union Street, Box 3600, Kingston, ON K7L 5A2
Phone: 613-544-1894
[email protected]
Neurogenic Bowel Update
Dr. Karen M. Smith
Associate Professor
Queen’s University
Disclosure

Have received an honorarium from
Coloplast for speaking on one occasion

Expenses paid to attend a training session
on the use of transanal irrigation

Provided with free supplies to trial TAI with
first 10 patients
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Objectives

Present a treatment paradigm for neurogenic
bowel dysfunction to include transanal
irrigation

Begin a discussion of the opportunities for
research including quality improvement in
neurogenic bowel management
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Compare and contrast the two main
types of neurogenic bowel
dysfunction

Areflexia or LMN bowel
 Damage to the parasympathetic nerves, no spinal cord
mediated reflex defecation nor reflex peristalsis.
Levator ani and EAS are denervated and lax.

Reflexic or UMN bowel
 No volitional control of defecation. Spinal mediated
reflexes intact. Colon and EAS are spastic. Decreased
number of propogating waves after food intake.
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Standard neurogenic bowel care

Standard neurogenic bowel management
according to CPG from the Consortium for
Spinal Cord Medicine by PVA

Bowel program addressing fluids,diet,meds
and regular bowel care addressing position,
digital stimulation and other techniques
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Nonsurgical adjunctive measures

Transanal irrigation Level 1 evidence of
reduced UTI and constipation, and
improved fecal continence

Colonic irrigation Level 4 removing stool

Electrical stimulation of the abdominal wall
Level 1

Functional magnetic stimulation Level 4
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Transanal Irrigation
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Transanal irrigation

Long-term results show improvement in 41-75%
of patients with fecal incontinence and 40-65%
with constipation

Scintigraphic studies show emptying of the
rectosigmoid and descending colon (nonSCI)

Cost-effectiveness analysis shows higher product
related costs but reduced attendant costs,
clothes/garments and UTI costs

Christensen et al Gastro 2006; Spinal Cord 2009
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Colonic scintigraphy
Before defecation
After ”normal” defecation
Non injured
person
SCI
patient
Christensen P et al. Dis Colon Rectum 2003; 46: 68-76. Figures 2 & 3 pages 70-71: Reproduced
with kind permission of Springer Science and Business Media.
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Scintigraphy – pre and post irrigation with
Peristeen in SCI individual
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Colonic Irrigation
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Colonic Irrigation
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Colonic irrigation

Level 4 evidence shown in 31 patients with SCI that this
was effective in removing stool

Long-term safety shown in four patients using the
procedure an average of 3.5 times weekly for av 6.7 years

Published results in nonSCI subjects show safety and
efficacy in short and long term use





Puet et al Spinal Cord 1997;35:694-699
Gramlich et al Dig Dis Sci 1998;43:1831-1834
Kososka et al Dis Colon Rectum 1994;37:161-164
Gilger et al J Ped 1994;18:92-95
Chang et al Gastro Endosc 1991;37:444-448
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Surgical strategies

Based on systematic reviews (including 29
original articles), utilities catalogues and
life table analysis Furlan et al ranked 4
surgical strategies for neurogenic bowel
management

Primary outcome quality-adjusted life
expectancy

Furlan et al Br J Surgery 2007;94:1139-1150
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Ranking based on primary outcome

MACE

SARS implantation

Colostomy

Ileostomy
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MACE Malone Antegrade
Continence Enema

picture
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Clinical Assessment Tools

Bowel Function Basic and Extended Data Sets;
contain data allows computation of the St Marks
and Wexner score for fecal incontinence,
Cleveland Constipation Score and Neurogenic
Bowel Dysfn Score

Total gastrointestinal or colonic transit time, right
colonic or left colonic transit

Anorectal manometry
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Optimal conservative neurogenic
bowel care

Targeted implementation strategies improve
provider adherence to Clinical Practice Guidelines

Overall Level 4 evidence of reduced GI transit
time, incidence of difficult evacuations and
duration of time required

Level 1 evidence preferring polyethylene glycolbased suppositories
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Neurogenic Bowel Care

Optimize conservative neurogenic bowel care and don’t
forget education/implementation strategies

Nonsurgical adjunctive measures




Transanal irrigation
Colonic irrigation
Functional electrical and magnetic stimulation of skeletal muscles
Surgical measures (in order of suggested preference)




MACE
SARS
Colostomy
Ileostomy
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Research opportunities

Biologic issues
 Pathology and physiologic changes
 Effects of level, time since injury and autonomic
dysfunction on NBD

Outcome measurement
 Testing

Policy issues
 Funding of supplies, attendant care
 Scope of practice for attendants
 Primary Care
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