231Incidence, Risk Factors, and Outcomes of Fecal IncontinenceAfter Acute Brain Injury: Findings from the Traumatic BrainI...
232                                        FECAL INCONTINENCE AFTER TBI, Foxx-OrensteinBrain Injury Model Systems (TBIMS) ...
FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein                                               233  Table 1: Demographic Chara...
234                                        FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein                    Table 3: Demogr...
FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein                                             235 Table 5: Categoric Injury Cha...
236                                              FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein                             ...
FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein                                                  237tent evidence of concomit...
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Fecal incontinence after acute brain injury


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Fecal Incontinence after acute brain injury, 68% to 2% afdt

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Fecal incontinence after acute brain injury

  1. 1. 231Incidence, Risk Factors, and Outcomes of Fecal IncontinenceAfter Acute Brain Injury: Findings from the Traumatic BrainInjury Model Systems National DatabaseAmy Foxx-Orenstein, DO, Stephanie Kolakowsky-Hayner, MA, Jennifer H. Marwitz, MA, David X. Cifu, MD,Ann Dunbar, PT, MS, Jeffrey Englander, MD, Gerard Francisco, MD ABSTRACT. Foxx-Orenstein A, Kolakowsky-Hayner S, rent 1-year disposition, admission GCS score, length of coma,Marwitz JH, Cifu DX, Dunbar A, Englander J, Francisco G. LOS, FIM scores, and incidence of UTI (P .05). AlthoughIncidence, risk factors, and outcomes of fecal incontinence logistic regression analyses were significant (P .001), andafter acute brain injury: findings from the Traumatic Brain predicted continence with 100% accuracy, demographics, in-Injury Model Systems national database. Arch Phys Med jury characteristics, medical complications, and functional out-Rehabil 2003;84:231-7. comes did not predict incontinence at discharge and at 1-year Objective: To investigate the incidence, risk factors, and follow-up.outcome in patients with fecal incontinence after acute brain Conclusions: Fecal incontinence is a significant probleminjury. after brain injury. Certain factors may increase its likelihood. Design: A retrospective study of the incidence of and risk Further studies evaluating mechanisms of fecal incontinencefactors contributing to fecal incontinence, and outcomes at and treatment or control interventions would be useful.admission to and discharge from inpatient rehabilitation and at Key Words: Brain injuries; Fecal incontinence; Incidence;1-year follow-up. Rehabilitation; Risk factors; Treatment outcome. Setting: Medical centers in the federally sponsored Trau- © 2003 by the American Congress of Rehabilitation Medi-matic Brain Injury Model Systems (TBIMS). cine and the American Academy of Physical Medicine and Participants: A total of 1013 consecutively enrolled reha- Rehabilitationbilitation inpatients from 17 TBIMS centers who were admittedto acute care within 24 hours of traumatic brain injury and seenat 1-year postinjury between 1990 and 2000. Interventions: Not applicable. F ECALstigmata thatquietly IS athis condition leaves sufferers social INCONTINENCE and caretakers to cope surround silent disorder. The negative with their feelings of embarrass- Main Outcome Measures: Incidence of fecal incontinence, ment, humiliation, and social isolation.1-3 The prevalence of thelength of coma, length of posttraumatic amnesia (PTA), ad- disorder is unknown because those affected are often unwillingmission Glasgow Coma Scale (GCS) score, length of stay or unable to speak of the problem, and physicians are unlikely(LOS), FIM™ instrument scores, disposition at discharge and to ask.4,5 Fecal incontinence is socially devastating, becausefollow-up, and incidences of pelvic fracture, frontal contusion, when it happens, it is impossible to disguise. It is easier andand urinary tract infection (UTI). more comfortable to avoid the potential incident. Incontinence Results: The incidence of fecal incontinence was 68% at is often overlooked or misinterpreted6 when, in fact, it may beadmission to inpatient rehabilitation, 12.4% at rehabilitation associated with loose stool, normal stool consistency, or evendischarge, and 5.2% at 1-year follow-up. Analysis of variance constipation. This inadvertent loss of stool occurs because theand chi-square analyses revealed statistically significant asso- normal continence mechanisms are overwhelmed and the abil-ciations between the incidence of fecal incontinence at reha- ity to store material and selectively release gas or solid materialbilitation admission and admission GCS score, length of coma is lost. Additionally, fecal incontinence has several medicaland PTA, LOS, and incidence of UTI and frontal contusion. consequences, including skin irritation, pressure ulcers, andFecal incontinence at rehabilitation discharge was significantly skin infections.associated with several variables, including age, discharge dis- Limited literature exists on the incidence and risk factors forposition, admission GCS score, length of coma, PTA, LOS, fecal incontinence in patients with brain injury. It is recognizedFIM scores, and incidence of pelvic fracture and frontal con- early during hospitalization and is addressed by placing pa-tusion. Significant associations were also found between fecal tients on bowel-management regimens that often include bulk-incontinence at 1-year follow-up and age, discharge and cur- ing and/or motility agents and timed elimination programs. Impaired cognition and neural control of evacuation contribute to fecal incontinence in the brain-injured patient. Its specific cause is not generally determined diagnostically, perhaps be- From the Virginia Commonwealth University, Richmond, VA (Foxx-Orenstein, cause bowel consistency is regimented soon after initial brainKolakowsky-Hayner, Marwitz, Cifu, Dunbar); Santa Clara Valley Medical Center,San Jose, CA (Englander); and TIRR, Houston, TX (Francisco). trauma, and factors contributing to incontinence may become Supported in part by the National Institute on Disability and Rehabilitation Re- less apparent. Incontinence in these patients may be exacer-search, US Department of Education (grant no. H133B80029) and the Irving I. and bated by various factors such as medications, diet, lack ofFelicia F. Rubin Family Brain Injury Research Fund. Data were contributed from the access to bathroom facilities, lack of awareness of the need toTraumatic Brain Injury Model Systems. No commercial party having a direct financial interest in the results of the research defecate, and weak pelvic floor muscles. Incontinence maysupporting this article has or will confer a benefit upon the author(s) or upon any delay a patient’s discharge from an acute care facility and canorganization with which the author(s) is/are associated. substantially hinder a return to the home environment and a Reprint requests to Jennifer H. Marwitz, MA, Dept of Physical Medicine and resumption of preinjury activities.Rehabilitation, Virginia Commonwealth University, Box 980542, Richmond, VA23298-0542. To enhance representativeness, multicenter, longitudinal 0003-9993/03/8402-7125$35.00/0 data collection methods were used7 at the National Institute on doi:10.1053/apmr.2003.50095 Disability and Rehabilitation Research (NIDRR) Traumatic Arch Phys Med Rehabil Vol 84, February 2003
  2. 2. 232 FECAL INCONTINENCE AFTER TBI, Foxx-OrensteinBrain Injury Model Systems (TBIMS) centers to address 3 the time elapsed between onset of injury and the time eachprimary objectives: (1) to identify the incidence of fecal incon- patient was able consistently to follow commands (GCS motortinence after traumatic brain injury (TBI), (2) to identify the score 6).risk factors associated with fecal incontinence, and (3) to Duration of PTA. The Galveston Orientation and Amne-determine at 1-year postinjury the outcome in patients who sia Test (GOAT) was used to assess orientation and PTA.have fecal incontinence. Duration of PTA was measured by calculating the number of days that elapsed between the onset of injury and the date that METHOD the first of 2 consecutive GOAT scores was greater than 75. Disposition. This is a dichotomous classification that in-Participants and Data Source dicates whether patients were living at home or in institutional In 1987, NIDRR provided funding to establish the TBIMS, settings.whose focus is on developing and showing a model system ofcare for persons with TBI and on maintaining a standardized Procedurenational database for analyses of treatment and outcomes. For A comprehensive program of inpatient rehabilitation wasthe purpose of the database, TBI is defined as injury to brain provided to patients, tailored to meet their needs and abilities.tissue caused by an external mechanical force, as evidenced by Within each center the following services were provided: nurs-loss of consciousness from brain trauma, posttraumatic amne- ing, occupational therapy, physiatry and related medical ser-sia (PTA), skull fracture, or objective neurologic findings that vices, physical therapy, psychology and neuropsychology, rec-can be reasonably attributed to TBI on physical or mental status reation therapy, social services, and speech and languageexamination. Criteria for inclusion in the database include (1) therapy. Admission decisions were based on the rehabilitationbeing at least 16 years old, (2) presentation to the emergency team’s perceptions of the patients’ rehabilitation needs, withdepartment of a TBIMS trauma center within 24 hours of approval from third-party payment sources.injury, (3) receipt of acute care and inpatient rehabilitation at a Information about medical aspects of the patients’ injuriesparticipating center, and (4) consent to participate. Data were was obtained from hospital records. Admission and dischargecollected prospectively. FIM scores were obtained within 24 hours of admission and 72 The TBIMS database contains information on 1013 individ- hours of discharge, respectively. Scores were determined byuals who were consecutively enrolled in any of the 17 medical certified interdisciplinary team members by using the standardcenters in the system. These centers represent geographically protocols established by the Uniform Data Set for Medicaldiverse regions of the United States, and each includes emer- Rehabilitation.8gency medical services, intensive and acute medical care, in- An annual follow-up interview is attempted with every per-patient rehabilitation, and a spectrum of community rehabili- son who entered data into the database. An in-person follow-uptation services. To improve sample representativeness, interview with the subject is the method of first choice. If thisstandardized protocols are used to provide for the inclusion of is not possible, a telephone interview is attempted; if this isindividuals with a previous brain injury, a preexisting neuro- unsuccessful, data are collected through a mail questionnairelogic condition, or a history of substance abuse. and/or interview with a significant other or family member. Demographic features of patients in the database are de-scribed elsewhere.7 Selected descriptive information about the Data Analysispresent sample is reported in our Results section. Descriptive statistics were computed for all relevant vari-Measures ables. Data were examined based on incidence of fecal incon- tinence. Relationships between fecal incontinence and other Measurement categories and evaluation protocols are de- variables were examined by using analyses of variance (ANO-scribed below. VAs). Where data were categoric, chi-square analyses were FIM™ instrument. The FIM™ instrument8 is an 18-item, performed.7-point scale on which higher values indicate greater levels of Three forward-conditional stepwise multiple logistic regres-independence. The 18 items describe levels of self-care, con- sion analyses were conducted to predict patients’ continence-tinence, mobility, communication, and cognition.9-11 The fol- incontinence status: (1) admission variables predicting dis-lowing scores were calculated from the FIM: (1) FIM change: charge incontinence, (2) admission variables predicting 1-yearto determine absolute change, admission scores were sub- follow-up incontinence, and (3) discharge variables predictingtracted from discharge scores, and admission and discharge 1-year follow-up incontinence. Variables were entered andscores were subtracted from 1-year follow-up scores, and (2) removed from the model based on .05-entry and 1.0-removalFIM efficiency: to control for variation in length of stay (LOS), criteria. Repeated execution of the estimation algorithms wereFIM change was divided by LOS. terminated at iteration 9 for admission predicting discharge, 10 Fecal incontinence. Fecal incontinence was defined as a for admission predicting 1-year follow-up, and 8 for dischargescore of less than 5 on the bowel-management subscale of the predicting 1-year follow-up because the 2Log likelihoodFIM instrument; this subscale indicates total, maximum, mod- values decreased by less than .01%. Significance was deter-erate, or minimum assistance needed. Bowel management in- mined by using the Wald statistic. All categoric data werecludes intentional control of bowel movements and, if neces- automatically recoded during the analyses by using the Helmertsary, use of equipment or agents for bowel control.8 coding method. Glasgow Coma Scale. Glasgow Coma Scale (GCS) ad-mission score (as recorded by a physician when the patient is RESULTSadmitted to the emergency department) was used as a measureof injury severity. To determine an accurate GCS score for Incidence and Risk Factors of Fecal Incontinence atsubjects who were intubated, we used the conversion formulaestablished by Choi et al.12 Rehabilitation Admission Duration of coma. Coma was defined as a GCS motor On admission to inpatient rehabilitation, 68.3% of the sam-score of less than 6. Duration of coma was calculated based on ple presented with fecal incontinence. To determine the riskArch Phys Med Rehabil Vol 84, February 2003
  3. 3. FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein 233 Table 1: Demographic Characteristics and Fecal Incontinence their relation to incidence of fecal incontinence at rehabilitation at Admission discharge. Information about demographic characteristics for Variable Incontinent Continent each rehabilitation discharge incontinence group is provided in table 3. Significant between-group differences were found in Mean age SD (y) 35.8 16.3 35.1 14.6 Gender, n (%) age (F1,973 5.42, P .05) and residence at discharge Male 498 (74.7) 240 (77.4) ( 2 92.92, P .001), but not in gender, ethnicity, or residence Female 169 (25.3) 70 (22.6) preinjury. Persons with fecal incontinence at discharge were, Ethnicity, n (%) on average, 3.5 years older than persons who were continent at Minority 289 (43.3) 140 (45.2) discharge. Further, persons who were continent were more Nonminority 978 (56.7) 170 (54.8) likely to be discharged to a private residence than were persons Preinjury residence, n (%) who were incontinent. Private 643 (96.8) 303 (97.7) With regard to injury characteristics, ANOVAs revealed Institution 8 (1.2) 1 (0.3) significant between-group differences for all variables analyzed Homeless/hotel 13 (2.0) 6 (1.9) (table 4), including admission GCS (F1,874 32.17, P .001), duration of unconsciousness (F1,925 84.64, P .001), durationNOTE. No significant differences were noted between groups.Abbreviation: SD, standard deviation. of PTA (F1,662 28.89, P .001), discharge FIM score (F1,947 1025.63, P .001), FIM change from admission to discharge (F1,897 82.97, P .001), and FIM efficiency (F1,897 139.39, P .001). The incontinent group showedfactors of fecal incontinence on admission, demographics, in- greater injury severity across all measures, as well as lowerjury characteristics, and medical complications were analyzed functional gains, and less efficiency. Also shown in table 4,by incontinence group. Information about demographic char- acute care LOS (F1,973 206.74, P .001) and rehabilitationacteristics for each incontinence group is provided in table 1. LOS (F1,973 223.80, P .001) differed significantly betweenThere were no significant differences between the 2 groups for the 2 groups. On average, persons with fecal incontinence atage, gender, ethnicity, or preinjury residence. discharge stayed 24 more days in acute care, and 53 more days With regard to injury characteristics, ANOVAs revealed in inpatient rehabilitation than persons who were continent.significant between-group differences for all variables analyzed The relation between incidence of medical complications(table 2), including admission GCS (F1,877 71.60, P .001), and fecal incontinence at rehabilitation discharge was alsoduration of unconsciousness (F1,928 73.02, P .001), duration examined (table 5). Incidence of pelvic fracture, frontal con-of PTA (F1,660 71.64, P .001), and admission FIM score tusions to the brain, and UTIs were included in the analyses.(F1,923 998.75, P .001). The incontinent group showed With regard to discharge fecal incontinence, chi-square analy-greater injury severity across all measures. Acute care LOS ses were statistically significant for pelvic fractures ( 2 5.13,also differed significantly between the 2 groups (F1,976 77.26, P .05) and UTIs ( 2 40.38, P .001). Individuals who wereP .001) (table 2). On average, persons with fecal incontinence incontinent at rehabilitation discharge were more likely to havestayed 11 days longer in acute care than persons who were sustained a pelvic fracture or developed a UTI some timecontinent. during their acute or rehabilitation LOS. Data were further examined to determine if relationshipsexisted between incidence of comorbidities and conditions andfecal incontinence at rehabilitation admission. Incidence of Incidence and Risk Factors of Fecal Incontinencepelvic fracture, frontal contusions to the brain, and urinary tract at 1-Year Follow-Upinfections (UTIs) were included in analyses. With regard to Incidence of fecal incontinence declined further at 1-yearadmission fecal incontinence, chi-square analyses were statis- follow-up, to 5.2%. Demographics, injury characteristics, andtically significant for frontal contusions ( 2 5.96, P .05) and medical complications were examined to determine their rela-UTI ( 2 40.88, P .001). Individuals who were incontinent at tion to incidence of fecal incontinence at 1-year follow-up.admission were more likely to have complications from frontal Table 6 lists the demographic characteristics for each inconti-contusions (47% vs 36%) and UTI (33% vs 14%). The per- nence group. Significant differences were found between the 2centages of pelvic fractures were similar for persons who were groups in age (F1,877 71.60, P .001), residence at dischargecontinent (8%) or incontinent (10%) at admission. ( 2 5.96, P .05), and residence at follow-up ( 2 40.88, P .001). However, no significant differences were identifiedIncidence and Risk Factors of Fecal Incontinence at for gender, ethnicity, or residence preinjury. Persons with fecalRehabilitation Discharge incontinence at 1-year follow-up were, on average, 9 years At discharge, the percentage of patients with fecal inconti- older than persons who were continent. Persons who werenence decreased to 12.4%. Demographics, injury characteris- continent at 1-year follow-up were more likely to have beentics, and medical complications were examined to determine discharged to a private residence rather than to an institution Table 2: Injury Characteristics and Fecal Incontinence at Admission Incontinent Continent Variable (mean SD) (mean SD) Significance Admission GCS 8.0 4.0 10.4 3.8 F1,877 71.60, P .001 Duration of unconsciousness (d) 13.8 25.1 3.8 5.9 F1,928 73.02, P .001 Duration of PTA (d) 39.9 28.3 20.3 29.0 F1,660 71.64, P .001 Admission FIM 40.5 18.4 80.4 16.7 F1,923 998.75, P .001 Acute LOS (d) 26.2 21.1 15.1 10.3 F1,976 77.26, P .001 Arch Phys Med Rehabil Vol 84, February 2003
  4. 4. 234 FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein Table 3: Demographics, Discharge Disposition, and Fecal Incontinence at Rehabilitation Discharge Variable Incontinent Continent Significance Mean age SD (y) 38.6 17.5 35.1 15.4 F1,973 5.42, P .05 Gender, n (%) NS Male 85 (70.2) 652 (76.4) Female 36 (29.8) 201 (23.6) Ethnicity, n (%) NS Minority 47 (38.8) 387 (45.4) Nonminority 74 (61.2) 466 (54.6) Residence preinjury, n (%) NS Private 119 (98.4) 825 (97.1) Institution 1 (0.8) 8 (0.9) Homeless/hotel 1 (0.8) 17 (2.0) 2 Residence at discharge, n (%) 92.92, P .001 Private 67 (55.4) 749 (88.6) Institution 54 (44.6) 93 (11.0) Homeless/hotel 0 (0.0) 3 (0.4)Abbreviation: NS, not significant.than were persons who were incontinent, and were more likely Predicting Fecal Incontinence at Discharge and 1-Yearto live currently in a private residence. Follow-Up Concerning injury characteristics, ANOVAs revealed signif- Incontinence at discharge can be predicted by using theicant between-group differences for all variables analyzed (ta- multivariate model that included acute LOS, rehabilitationble 7), including admission GCS (F1,854 5.03, P .05), dura- LOS, admission GCS score, highest GCS score, lowest GCStion of unconsciousness (F1,904 16.63, P .001), follow-up score, length of coma, length of PTA, and Rancho Los AmigosFIM score (F1,904 1668.78, P .001), FIM change from dis- Levels of Cognitive Functioning (RLA), whether a patient hadcharge to follow-up (F1,855 62.57, P .001), and FIM change frontal contusions, and whether a patient had a UTI (Waldfrom admission to follow-up (F1,826 134.46, P .001). A trend statistic 145.01, P .001). Overall, the percentage of personswas also noted for duration of PTA (F1,650 3.70, P .055). who were correctly classified by the multivariate model wasThe incontinent group showed greater injury severity across all 92.8%. However, even though the correct prediction rate formeasures, as well as lower functional gains for both time continence was 100%, the prediction rate for incontinenceperiods. Acute care LOS (F1,952 112.04, P .001) and reha- was 0%.bilitation LOS (F1,951 123.14, P .001) differed significantly Similarly, the regression analysis predicting incontinence atbetween the 2 groups (table 7). On average, persons with fecal 1-year follow-up from admission variables was significant us-incontinence at 1-year follow-up stayed 28 more days in acute ing the same model described in the previous paragraph (Waldcare and 63 more days in inpatient rehabilitation than persons statistic 110.82, P .001). Overall, the percentage of personswho were continent. who were correctly classified by the multivariate model was Data were further examined to determine if relationships 97.2%. Again, however, although the correct prediction rate forexisted between incidence of medical complications and fecal continence was 100%, the prediction rate for incontinenceincontinence at 1-year follow-up (table 8). Incidence of pelvic was 0%.fracture, frontal contusions to the brain, and UTIs were in- The regression model predicting fecal incontinence fromcluded in the analyses. With regard to fecal incontinence, discharge variables at 1-year follow-up differed slightly in thatchi-square analyses were statistically significant only for UTI it included age at injury and discharge residence. The results( 2 29.41, P .001). Individuals who were incontinent at fol- again indicate that the model (Wald statistic 109.99, P .001)low-up were more likely to have contracted a UTI during their predicts the presence of incontinence at 1-year follow-up.initial hospital stay. Overall, the percentage of persons who were correctly classi- Table 4: Injury Characteristics and Incontinence at Rehabilitation Discharge Incontinent Continent Variables (mean SD) (mean SD) Significance Admission GCS 6.8 4.0 9.1 4.0 F1,874 32.17, P .001 Duration of unconsciousness 22.1 29.5 8.1 11.5 F1,925 84.64, P .001 Duration of PTA 56.9 34.3 31.0 28.8 F1,662 28.89, P .001 Discharge FIM 53.5 24.6 103.1 14.2 F1,947 1025.63, P .001 FIM change (discharge FIM admission FIM) 27.2 19.1 45.9 20.8 F1,897 82.97, P .001 FIM efficiency (FIM change/rehabilitation LOS) 0.4 0.4 1.1 0.6 F1,897 139.39, P .001 Acute LOS 43.4 30.1 19.4 14.4 F1,973 206.74, P .001 Rehabilitation LOS 105.2 58.4 52.0 32.4 F1,973 223.80, P .001Arch Phys Med Rehabil Vol 84, February 2003
  5. 5. FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein 235 Table 5: Categoric Injury Characteristics and Fecal Incontinence and motor improvements noted after TBI, this study validates at Discharge these assumptions. Incontinent, Continent, Not surprisingly, the only demographic feature associated Variable n (%) n (%) Significance with bowel incontinence was increased age. The associations Pelvic fractures 2 5.13, P .05 noted between it and an increased incidence of bowel inconti- Yes 18 (15.0) 73 (8.6) nence at rehabilitation discharge and 1-year follow-up may No 102 (85.0) 779 (91.4) relate to several factors. Although physiologic changes from Frontal contusions NS aging may influence gastrointestinal motility and continence, it Yes 34 (41.0) 255 (43.7) is unlikely that the less than 10-year differences would have No 49 (59.0) 329 (56.3) resulted in a clinically significant increase in incontinence. UTIs 2 40.38, P .001 More likely, the greater cognitive and physical limitations in Yes 60 (49.6) 651 (76.9) older adults after TBI would have contributed more directly to No 61 (50.4) 196 (23.1) this finding. Other research13 has shown a greater degree of functional dependency in older adults after TBI associated with (1) the greater sensitivity of the older brain to injury, (2) the dimin- ished functional reserve in the older adult, (3) an increase infied by the multivariate model was again 97.2%. However, as concomitant illness with aging (eg, peripheral neuropathy), andwith the 2 previous analyses, although the correct prediction (4) the predilection to greater medical complications (eg, UTIs)rate for continence was 100%, the prediction rate for inconti- with increased age. Any or all of these factors may havenence was 0%. Although statistically significant, none of the 3 influenced bowel incontinence. Additionally, an age bias mayregression analyses were clinically significant. have existed, wherein it was more accepted that older adults would be bowel incontinent after TBI, therefore less intensive DISCUSSION behavioral and functional interventions were carried out by In our study, more than two thirds of all individuals admitted care providers for older adults.to inpatient rehabilitation after TBI were bowel incontinent. As expected, indicators of increased severity of injury afterThis high incidence is not surprising given the significant TBI were associated with an increased incidence of bowelcognitive and motor deficits that often result after moderate to incontinence. Although there may be no direct relation betweensevere TBI. In fact, the typical individual with TBI who is actual injury severity and continence, bowel continence isadmitted to the TBIMS programs is functioning at an RLA likely a functional deficit that reflects impaired cognitive andlevel of between IV (agitated and confused) and V (confused motor deficits. The association between injury severity andand inappropriate), and requires assistance with even basic cognitive and motor functional deficits has been well de-mobility skills, an indication of profound cognitive limita- fined.14,15 Thus, the increase in motor and cognitive deficits,tions.8 Fortunately, more than 82% of those incontinent at seen with an increased injury severity, may explain persistentrehabilitation admission were able to regain continence by the incontinence. Similarly, associations among acute and rehabil-time of rehabilitation discharge. Achievement of this goal is a itation LOSs, functional deficits, functional improvement,basic foundation of any rehabilitation program. Similarly, by functional improvement efficiency, and bowel incontinence1-year postinjury, an additional 60% of those incontinent at may reflect injury severity and cognitive deficits. In short,discharge progressed to continence. Although these dramatic bowel incontinence may be more of a marker of a significantimprovements would be expected, considering the cognitive brain injury. Table 6: Demographics, Discharge Disposition, and Fecal Incontinence at 1-Year Follow-Up Variable Incontinent Continent Significance Mean age SD (y) 44.0 19.0 35.0 15.3 F1,877 71.60, P .001 Gender, n (%) n% n% NS Male 37 (74.0) 683 (75.6) Female 13 (26.0) 220 (24.4) Ethnicity, n (%) NS Minority 22 (44.0) 339 (44.2) Nonminority 28 (56.0) 504 (55.8) Residence preinjury, n (%) NS Private 49 (98.0) 875 (97.1) Institution 1 (2.0) 8 (0.9) Homeless/hotel 0 (0.0) 18 (2.0) 2 Residence at discharge, n (%) 5.96, P .05 Private 26 (52.0) 771 (86.4) Institution 24 (48.0) 119 (13.3) Homeless/hotel 0 (0.0) 2 (0.1) 2 Residence at follow-up, n (%) 40.88, P .001 Private 28 (56.0) 834 (93.2) Institution 22 (44.0) 58 (6.5) Homeless/hotel 0 (0.0) 3 (0.3) Arch Phys Med Rehabil Vol 84, February 2003
  6. 6. 236 FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein Table 7: Injury Characteristics and Incontinence at 1-Year Follow-Up Incontinent Continent Variables (mean SD) (mean SD) Significance Admission GCS 7.5 4.2 8.9 4.0 F1,854 5.03, P .05 Duration of unconsciousness (d) 19.3 30.7 9.5 14.4 F1,904 16.63, P .001 Duration of PTA (d) 49.5 28.4 32.6 30.2 F1,650 3.70, P .055* Follow-up FIM 41.4 24.3 117.7 10.9 F1,904 1668.78, P .001 FIM change from discharge 3.8 26.2 17.8 16.5 F1,855 62.57, P .001 (follow-up FIM discharge FIM) FIM change from admission 16.1 23.4 63.1 24.4 F1,826 134.46, P .001 (follow-up FIM admission FIM) Acute LOS (d) 49.3 38.0 21.4 16.4 F1,952 112.04, P .001 Rehabilitation LOS (d) 118.6 71.9 56.1 36.1 F1,951 123.14, P .001* Nonsignificant trend. Although bowel incontinence after TBI may reflect global bowel incontinent, whether because of the gastrointestinal ef-impairments associated with increased injury severity, rather fects of the antibiotics used, or the increased perineal irritationthan be directly caused by it, damage to the frontal lobes associated with infection. Likewise, the pain associated withspecifically could cause both increased injury severity and pelvic fractures and the effects of the pain medications used toincontinence. Frontal lobe injuries, a common occurrence in treat the fractures (both the initial sedating effects and theTBI because of the relation between the skull and the predom- long-term constipating effects) may result in bowel inconti-inance of frontward-occurring motor vehicle crashes, could nence. Pelvic fractures can also result in lumbosacral plexusresult in a direct increase in the social control of bowel conti- injuries that effect motor and sensory input to the pelvic floornence. The so-called “frontal defecation center” is believed to muscles, which help to maintain continence.allow for voluntary (or social) control of defecation, providing Bowel incontinence associated with an increased likelihoodan overriding pathway to monitor and control the need to that patients will be placed in nursing homes.16,17 This studydefecate. Typically lacking in the infantile (poorly myelinated) confirms a similar likelihood for TBI, both at rehabilitationand senile (demented) brain, this frontal lobe locus of conti- discharge and 1-year postinjury. Again this relationship maynence is likely to be injured in many individuals with moderate reflect the notion that bowel incontinence is a marker foror severe TBI, causing the noted high incidence of initial greater injury severity, but there may also be a direct causalincontinence. It is not surprising, therefore, to find a significant relation. Bowel incontinence results in significant physicalassociation between increased frontal-lobe contusions and requirements of patients and caretakers, often necessitatingbowel incontinence. The improvement in almost all incontinent full-time care and preventing involvement in community ac-individuals attests to the extent and rapidity of recovery of this tivities. This heavy family burden, plus the patient’s difficultyportion of frontal lobe functioning. in resuming preinjury lifestyle, may necessitate placement in The relationships noted among UTIs, pelvic fractures, and an institution. Given this type of burden, persistent inconti-bowel incontinence may be related to overall injury severity or nence may be among the consequences of injury severity thatfocal peripheral nerve injuries. Increased injury severity alone lead to increased acute rehabilitation LOS. Moreover, if bowelmay result in all 3 conditions independently. Individuals with incontinence is not resolved sufficiently, it may be a maingreater injury severity would be more likely to require indwell- factor in discharging a patient to an institution, as opposed to aing Foley catheters, require longer intensive and acute care home. In fact, landmark research by Granger et al17 foundhospitalization stays, and receive antibiotics, all of which bowel incontinence to be the strongest predictor of nursingwould increase their risk for UTIs. Similarly, fractures are home placement after stroke.more likely to occur in high speed and result in impact injuriesof greater severity. Although these factors could occur inde- CONCLUSIONpendently, there may be direct associations. UTIs (and the Bowel incontinence after TBI is a significant functionalfactors that cause them) may predispose individuals to be deficit, affecting both day-to-day care needs and the ability of an individual to return home. No published research exists that clearly identifies the incidence and degree of bowel inconti-Table 8: Categoric Injury Characteristics and Fecal Incontinence at 1-Year Follow-Up nence in the TBI population. Despite the obvious importance of this information and the relative ease with which it can be Incontinent, Continent, acquired, the limited research into this critical function may Variable n (%) n (%) Significance reflect the discomfort felt by patients, families, clinicians, and Pelvic fractures NS researchers with an open discussion of bowel care and regula- Yes 6 (12.0) 81 (9.0) tion. This study is the first comprehensive analysis of the No 44 (88.0) 820 (91.0) incidence of bowel incontinence and associated factors in a Frontal contusions NS large multicenter population after TBI. Yes 14 (43.8) 270 (43.5) The inability of retrograde analyses to differentiate between No 18 (56.2) 350 (56.5) individuals who would eventually be bowel incontinent versus UTIs 2 29.41, P .001 continent necessitates early and aggressive management of Yes 30 (60.0) 225 (25.1) bowel regulation after TBI. Although several factors in this No 20 (40.0) 673 (74.9) study are associated with a greater likelihood of incontinence in the first year after injury, it is clear that none provides consis-Arch Phys Med Rehabil Vol 84, February 2003
  7. 7. FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein 237tent evidence of concomitant bowel incontinence. This may 8. Guide for the Uniform Data Set for Medical Rehabilitation, ver-reflect the multifactorial nature of continence, as well as the sion 5.0. Buffalo (NY): State Univ New York; 1996.interrelationship of the numerous demographic, injury severity, 9. Forer S. Functional assessment instruments in medical rehabilita-and functional outcome factors after TBI. Further analysis, tion. J Organization Rehabil Evaluators 1982;2:29-41. 10. Granger CV, Hamilton BB, Keith RA, Zielesny M, Sherwin FS.using well-controlled, prospective methodology with specific Advances in functional assessment for medical rehabilitation. Topfocus on standardizing bowel-management protocols and reg- Geriatr Rehabil 1986;1:59-74.ulating secondary factors that may influence incontinence, is 11. Hall KM, Johnston MV. Outcomes evaluation in traumatic brainencouraged. injury rehabilitation. Part II: Measurement tools for a nationwide data system. Arch Phys Med Rehabil 1994;75:SC10-8. References 12. Choi SC, Ward JD, Becker DP. Chart for outcome prediction in 1. Toglia MR. Pathophysiology of anorectal dysfunction. Obstet severe head injury. J Neurosurg 1983;59:294-7. Gynecol Clin North Am 1998;25:771-81. 13. Cifu DX, Kreutzer JS, Marwitz JH, Rosenthal M, Englander 2. Haugen V, Moore A. “I will manage”: promoting continence J. Medical and functional characteristics of older adults with through community education. J Wound Ostomy Continence Nurs traumatic brain injury: a multicenter analysis. Arch Phys Med 1995;22:291-5. Rehabil 1996;77:883-8. 3. Gibson E. An exhibition to eradicate ignorance. Setting up a 14. Hagen C. Language cognitive disorganization following closed continence resource center. Prof Nurse 1990;6:38-41. head injury: a conceptualization. In: Trexler LE, editor. Cognitive 4. Francombe J, Carter PS, Hershman MJ. The aetiology and epide- rehabilitation: conceptualization and intervention. New York: Ple- miology of fecal incontinence. Hosp Med 2001;62:529-32. num Pr; 1982. p 131-51. 5. Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence 15. Malkmus D. Cognitive assessment and goal setting. In: Rehabil- of anal incontinence and other anorectal symptoms in women. Int itation of the head injured adult: comprehensive management. Urogynecol J Pelvic Floor Dysfunct 2001;12:117-20. Downey (CA): Rancho Los Amigos Hospital; 1979. 6. Jacquot JM, Finiels H, Fardjad S, Belhassen S, Leroux JL, Pelis- 16. Cifu DX, Lorish T. Stroke rehabilitation: outcome. Arch Phys sier J. Neurological complications in insufficiency of the sacrum. Med Rehabil 1994;75:S56-7. Three case reports. Rev Rhum Engl Ed 1999;66:109-14. 17. Granger CV, Hamilton BB, Gresham GE, Kramer AA. The stroke 7. Harrison-Felix C, Newton N, Hall K, Kreutzer J. Descriptive outcome study. Part 2. Relative merits of the total Barthel Index findings from the Traumatic Brain Injury Model Systems National score and a four-item subscore in predicting patient outcomes. Database. J Head Trauma Rehabil 1996;11(5):1-14. Arch Phys Med Rehabil 1989;70:100-3. Arch Phys Med Rehabil Vol 84, February 2003