Treatment of Constipation and Fecal Incontinence in
Stroke Patients
Randomized Controlled Trial
Danielle Harari, FRCP; Christine Norton, PhD, RN; Linda Lockwood, RN; Cameron Swift, PhD, FRCP
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Background and Purpose—Despite its high prevalence in stroke survivors, there is little clinical research on bowel
dysfunction in this population. This is the first randomized controlled trial to evaluate treatment of constipation and fecal
incontinence in stroke survivors.
Methods—Stroke patients with constipation or fecal incontinence were identified by screening questionnaire (122
community, 24 stroke rehabilitation inpatients) and randomized to intervention or routine care (73 per group). The
intervention consisted of a 1-off structured nurse assessment (history and rectal examination), leading to targeted
patient/carer education with booklet and provision of diagnostic summary and treatment recommendations (after
consultation with geriatrician) to patient’s general practitioner (GP)⫾ward physician.
Results—Percentage of bowel movements (BMs) per week graded as “normal” by participants in a prospective 1-week
stool diary was significantly higher in intervention versus control patients at 6 months (72% versus 55%; P⫽0.027), as
was mean number of BMs per week (5.2 versus 3.6; P⫽0.005). There was no significant reduction in fecal incontinence,
although numbers were small. At 12 months, intervention patients were more likely to be modifying their diets (odds
ratio [OR], 3.1 [1.2 to 8.0]) and fluid intake (OR, 4.2 [1.4 to 12.2]) to control their bowels and to have visited their GP
for their bowel problem (OR, 5.0 [1.4 to 17.5]). GP prescribing of laxatives and suppositories was significantly
influenced at 12 months.
Conclusions—A single clinical/educational nurse intervention in stroke patients effectively improved symptoms of bowel
dysfunction up to 6 months later, changed bowel-modifying lifestyle behaviors up to 12 months later, and influenced
patient–GP interaction and physician prescribing patterns. (Stroke. 2004;35:2549-2555.)
Key Words: constipation 䡲 fecal incontinence 䡲 randomized controlled trial 䡲 stroke
B
owel dysfunction is a common and distressing condition
after stroke, but there are virtually no intervention
studies in this important clinical area.1 Fecal incontinence
(FI) affects ⱕ56% of individuals acutely after stroke, 11% at
3 months, and ⱕ22% at 12 months.2– 4 Constipation is
recognized as a serious problem in clinical practice, affecting
60% of those in stroke rehabilitation wards.5 FI may develop
months after acute stroke and can be transient, consistent with
constipation overflow as a possible cause.2,6 We identified
only 2 published clinical studies of constipation in stroke.
Munchiando found that daily versus alternate day bowel care
with digital stimulation achieved regular evacuation sooner
after acute stroke in an uncontrolled trial,7 whereas Venn
found no difference in efficacy between morning versus
evening inpatient bowel care, with or without a suppository.8
There are no published trials examining treatment of FI in
stroke patients. However, epidemiological data suggest FI is
associated more with modifiable disability-related factors (eg,
toilet access and anticholinergic medications) than stroke-related
factors (eg, severity and lesion location).2,3 Similarly, constipation in older people is related more to modifiable lifestyle factors
such as diet,9 –11 fluid intake,9,10,12,13 physical activity,14 and
toileting habits15,16 than to aging gut pathophysiology. Therefore, we hypothesized that an educational intervention targeting
lifestyle factors combined with structured clinical assessment
and treatment would significantly improve bowel function in
stroke patients with constipation or FI compared with “usual
care.” Our secondary hypothesis was that intervention patients
would benefit regarding quality of life and self-management of
their bowel problem through lifestyle changes.
Materials and Methods
We recruited participants from 3 stroke rehabilitation units and local
communities in London who had experienced a stroke beyond 1 month
Received May 5, 2004; final revision received July 13, 2004; accepted August 9, 2004.
From the Department of Aging and Health (D.H., L.L.), Guys and St Thomas’ Hospital, London, UK; the Department of Healthcare of the Elderly
(D.H., C.S.), Kings College, London, UK; and the St. Marks Hospital and Florence Nightingale School of Nursing and Midwifery (C.N.), Kings College,
London, UK.
Correspondence to Dr Danielle Harari, Consultant Physician/Senior Lecturer, Department of Aging and Health, St. Thomas’ Hospital, 9th Floor, North
Wing, Lambeth Palace Rd, London SE1 7EH. E-mail [email protected]
© 2004 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000144684.46826.62
2549
2550
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November 2004
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Figure 1. Participant flowchart.
and within 4 years. Patients were screened by questionnaire to identify
bowel dysfunction according to standardized definitions:9,16,17
●
●
●
Constipation (ⱕ2 bowel movements [BMs] per week or ⱖ2 of the
following on more than 1 in 4 occasions: straining, hard stools,
feeling of incomplete evacuation);
Rectal outlet delay (need for self-digitation or feeling of anal
blockage or prolonged defecation [⬎10 minutes] on ⬎1 in 4
occasions);
FI (any degree of bowel leakage).
Patients with ⱖ1 of the above met the inclusion criteria. People
reporting acute diarrhea or colonic disease other than diverticular
disease were excluded (Figure 1). Of the 1715 people screened, 521
(30%) responded, 189 had no bowel dysfunction, and 146 gave
written consent (24 stroke rehabilitation inpatients, 122 community).
Randomization was by external process using computer-generated
numbers and closed envelopes. Baseline data included Barthel Index
(physical function),18 SF-12,19 Geriatric Depression Scale,20 abbreviated mental test score (AMTS),21 and clinical data and stroke
characteristics.
Intervention
Patients were seen in the outpatient or ward setting or at home.
Figure 2 outlines the evidence-based assessment and treatment
protocol.1,9,16,22–26 The intervention consisted of a 1-off assessment
by a nurse22 leading to (1) targeted patient and carer education; (2)
provision of booklet; and (3) diagnostic summary and treatment
recommendations sent to the patient’s general practitioner (GP), and
ward physician if in hospital. The nonspecialist study nurse received
simple practice-based training in bowel management. History taking
focused on medications, bowel symptoms, and toilet access. Examination consisted of abdominal palpation, perineal inspection (fecal
soiling, pelvic floor descent, rectal prolapse), and rectal examination.
Internal sphincter tone was evaluated by ease of entry into the anal
canal and external sphincter tone by asking the patient to “squeeze
and pull up” around the examining finger.27 Patients with FI but
without rectal impaction had an abdominal x-ray to look for
obstructive colonic impaction.
This assessment identified the often multifactorial causes for
bowel symptoms, and after discussion with the geriatrician (D.H.),
the nurse communicated treatment recommendations with the patient, carer, and provider. Providers were alerted when medications
(eg, opiates) were possibly causing bowel problems. Generic education was provided by the study booklet28 (contents listed in Figure 2),
with instructions on regular toilet habits,15,16 pelvic floor and
sphincter-strengthening exercises, suppository insertion, and laxative
and loperamide dose titration. Control subjects received routine care
with no study nurse assessment, but their providers were notified of
their enrollment, thus identifying them as having bowel problems.
Harari et al
Treatment of Bowel Problems After Stroke
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Figure 2. Assessment and treatment protocol.
Outcome Measures
The primary outcome was BMs per week on the basis of published
data enabling the power calculation and demonstrating clinical
importance.26 Secondary outcomes were percentage of BM graded as
normal by the patient and number of FI episodes, all measured by
postal prospective 7-day stool diary at 1, 3, 6, and 12 months.26,29
Other outcomes included bowel-related symptoms,30 visual analogue
scores for severity rating, quality of life (bowel-related and SF-12),19
and self-reported treatment and resource use.
Statistical Analysis
Studies of bran supplementation versus placebo show an increase of
1.3 BMs per week,10 representing a 54% increment from baseline
mean of 2.4 BMs per week (SD⫽2.0) derived from laxative trials in
older people.26 Assuming 90% power (␣0.05) and a 20% drop out
rate, we aimed to randomize 120 patients. Continuous outcome data
were compared using t tests if normally distributed, Mann–Whitney
U test if skewed, and ␹ 2 if dichotomous. All outcomes were adjusted
for baseline AMTS (Table 1) and time since stroke (linear regression
for continuous data, multiple logistic regression for categorical data).
Resource use was additionally adjusted for baseline Barthel score.
Individual bowel characteristics were adjusted for baseline level in
view of some baseline discrepancy between randomized groups. The
data were analyzed on an intention-to-treat basis using SPSS
software.
Results
Drop-Outs
Drop-out rates were 17% at 1 month, 19% at 3 months, 24%
at 6 months, and 27% at 12 months (Figure 1). Comparison of
baseline data (including bowel function) showed that nonrespondents at 12 months (n⫽40) compared with respondents
(n⫽106) had worse physical function (Barthel Index ⬍16 of
20, 33% versus 18%; P⫽0.007) but no other differences.
Furthermore, no baseline differences were found between
drop-outs in intervention versus control group.
Baseline Characteristics
Table 1 shows baseline comparisons between randomized
groups. Prestroke rates of self-reported constipation and FI
were comparable to those in similarly aged populations.9,17,18
Assessment Findings in Intervention
Group (nⴝ73)
Most participants had ⬎1 finding on assessment. Forty-eight
(66%) had constipation, 41 (56%) rectal outlet delay, and 16
(22%) rectal impaction. Twenty-two (30%) reported FI, of
whom 12 had constipation with overflow. Thirty (41%) had
reduced internal sphincter tone, 40 (55%) weak external
sphincter tone, and 27 (37%) excessive pelvic floor descent.
Thirty-four (47%) had difficulties with toilet access.
Effect of Intervention
The intervention group were significantly more likely to be
modifying their dietary and fluid intake to control their bowel
problem, even at 12 months after intervention (Table 2). Prescribing and use of suppositories and ⱖ2 types of laxatives was
2552
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November 2004
TABLE 1.
Intervention
No. (%)
n⫽73
Control
No. (%)
n⫽73
OR
(95% CI)
P value
72.2⫾10.2
72.9⫾9.6
P⫽0.66
34 (46.6)
25 (33.5)
1.67 (0.9–3.3) P⫽0.129
White
52 (71.2)
59 (80.8)
P⫽0.435
Black African-Caribbean
14 (19.2)
9 (12.3)
Lives alone
16 (21.9)
26 (35.6)
P⫽0.207
Professional/technical qualification
27 (37.0)
29 (39.7)
1.16 (0.6–2.4) P⫽0.554
Community
62 (84.9)
60 (82.2)
overall P⫽0.662
Hospital
11 (15.1)
13 (17.8)
Baseline Characteristics
Demographics
Age
Sex (% female)
Race
Recruited in
Clinical factors
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AMTS ⬍10*
34 (46.6)
17 (23.3)
3.10 (1.4–6.9) P⫽0.002
Geriatric Depression Scale ⬎5 of 15
36 (49.3)
26 (35.6)
1.72 (0.8–3.6) P⫽0.118
1.27 (0.5–3.0) P⫽0.548
Moderate-severe functional impairment (Barthel ⬍15)
18 (24.7)
15 (20.6)
Difficulty using toilet because of physical function
17 (23.3)
17 (23.3)
0.98 (0.4–2.3) P⫽0.962
General health perception: fair or poor
34 (46.6)
26 (35.6)
1.60 (0.8–3.3) P⫽0.172
Diabetes mellitus
13 (17.8)
17 (23.3)
0.66 (0.3–1.6) P⫽0.310
Urinary incontinence
23 (31.5)
25 (34.2)
0.90 (0.4–1.9) P⫽0.767
5 (6.9)
5 (6.9)
0.93 (0.2–4.0) P⫽0.918
17 (23.3)
17 (23.3)
1.02 (0.5–2.4) P⫽0.961
21.7⫾20.1
25.1⫾26.7
P⫽0.391
39 (53.4)
26 (35.6)
overall P⫽0.213
Lacunar infarct
5 (6.9)
11 (15.1)
Brain stem stroke
2 (2.7)
2 (2.7)
Cerebral haemorrhage
9 (12.3)
6 (8.2)
Prestroke FI
Prestroke constipation
Stroke characteristics
Time since stroke (months)
Hemispheric infarct
Acute stroke presentation
Impaired conscious level
9 (12.3)
6 (8.2)
1.50 (0.4–5.3) P⫽0.476
Dysphagia
9 (12.3)
11 (15.1)
0.76 (0.3–2.3) P⫽0.578
Dysarthria
30 (41.1)
35 (48.0)
0.63 (0.3–1.3) P⫽0.185
Neglect or visual field defect
26 (35.6)
19 (26.0)
1.94 (0.5–7.4) P⫽0.260
*Difference in baseline characteristic significant at P⬎0.05 level.
higher in intervention patients throughout the 12 months, although overall laxative use was higher initially only (Table 2).
Enema and antidiarrhoeal use did not differ significantly, although numbers were small. Percentage of self-rated normal
BMs per week was significantly higher in intervention patients
at 1 and 6 months, as was mean number of BMs per week with
a persisting trend at 12 months (Table 3). The number of
uncomfortable BMs per week was significantly reduced in the
intervention group at 1 month. There was a trend in reduction in
FI episodes at 1 month, but numbers were small. At baseline, the
intervention group rated the severity of their bowel problem and
loss of bowel control as being worse than the control group
(Table 4). However, at 1 month follow-up, this finding was
reversed, with the intervention group having a significantly
lower severity rating. There was a significant intervention effect
on straining at 1 month and prolonged evacuation at 12 months.
Intervention patients showed no benefit in specific (“bowel
problems affect physical or emotional health”) or SF-12 quality
of life measures.
During the last 6 months of follow-up, intervention subjects
were more likely to have visited their GP (15 [20.6%] versus 5
[6.9%], odds ratio, 4.96 [1.4 to 17.5]), or hospital (13 [17.8%]
versus 0) for their bowel problem. There were no differences in
number of barium enemas or colonoscopies performed or
number of district nurse and personal carer visits.
Discussion
In this first randomized controlled trial of constipation and FI
management in stroke patients, we found that 1 year after intervention, active subjects were more likely to be altering their diet and
fluid intake to control their bowel problem and were receiving
different GP-prescribed patterns of bowel agents. Intervention
Harari et al
Treatment of Bowel Problems After Stroke
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TABLE 2.
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Self-Reported Treatment and Health Care
Resource Use
Alters diet to control bowel problem
1 month
6 months*
12 months*
Alters amount or type of fluids to control bowel problem
1 month*
6 months*
12 months*
Laxative taken over previous week
1 month*
6 months
12 months
Taking ⱖ2 types of laxatives
1 month
6 months
12 months*
Suppository use over previous week
1 month*
6 months
12 months
Intervention
No. (%)
n⫽73
Control
No. (%)
n⫽73
OR
(95% CI)
P value
28 (38.4)
27 (37.0)
24 (32.9)
19 (26.0)
15 (20.6)
13 (17.8)
1.80 (0.8–4.0) P⫽0.158
2.31 (1.0–5.4) P⫽0.052
3.13 (1.2–8.0) P⫽0.017
27 (37.0)
24 (32.9)
18 (24.7)
11 (15.1)
10 (13.7)
8 (11.0)
3.57 (1.5–8.6) P⫽0.005
3.76 (1.4–9.8) P⫽0.007
4.15 (1.4–12.2) P⫽0.010
44 (60.3)
28 (38.4)
29 (39.7)
19 (26.0)
18 (24.7)
20 (27.4)
4.19 (1.5–11.8) P⫽0.007
1.62 (0.6–2.6) P⫽0.323
1.21 (0.5–3.2) P⫽0.692
16 (21.9)
13 (17.8)
15 (20.6)
5 (6.9)
4 (5.5)
4 (9.6)
3.32 (1.0–11.5) P⫽0.059
2.00 (0.6–6.8) P⫽0.270
6.57 (1.3–33.1) P⫽0.023
13 (17.8)
6 (8.2)
8 (11.0)
4 (5.5)
2 (2.8)
0
3.82 (1.1–15.0) P⫽0.020
*Favorable intervention effect at a significance level of P⬍0.05 (OR ⬎1).
All analyzed outcomes adjusted for baseline laxative use, baseline AMTS, and time since stroke.
subjects reported an improvement in bowel function at 6 months in
terms of number and normality of weekly BMs, although the effect
was no longer significant at 12 months. Although 32% of intervention and 26% of control subjects reported FI at baseline, the small
number of documented episodes during follow-up made underestimation of treatment effect a possibility.
The study assessment findings demonstrated that bowel problems in stroke patients are often multifactorial, thereby needing
structured broad-based management. Therefore, this is a multicomponent intervention (per Medical Research Council guidelines),31 but this study design cannot define which single action
had most effect.31 However, more important, it does test a
TABLE 3.
Bowel Function (Prospective 7-Day
Stool Diary)
No. of BMs per week
1 month*
6 months*
12 months
Percentage of normal BMs per week
1 month*
6 months*
12 months
No. of uncomfortable BMs per week
1 month*
6 months
12 months
One or more episodes of FI per week
1 month
6 months
12 months
Intervention
(n⫽73)
Control
(n⫽73)
Mean⫾SD
5.55⫾3.4
5.22⫾3.0
5.57⫾3.2
Mean⫾SD
75.1⫾35.9
72.1⫾32.3
74.9⫾28.9
Median (25–75%)
1.0 (0.0–2.25)
1.0 (0.0–3.0)
1.0 (0.0–3.0)
n (%)
5 (6.9)
5 (6.9)
3 (4.1)
Mean⫹SD
4.10⫾4.0
3.56⫾3.3
4.81⫾2.3
Mean⫾SD
55.3⫾40.9
55.0⫾39.0
67.7⫾33.6
Median (25–75%)
1.0 (0.0–3.75)
2.0 (0.0–4.0)
1.0 (0.0–3.0)
n (%)
12 (16.4)
6 (8.2)
3 (4.1)
P Value
P⫽0.011
P⫽0.005
P⫽0.209
P⫽0.030
P⫽0.027
P⫽0.277
P⫽0.031
P⫽0.185
P⫽0.934
OR (95% CI)
0.36 (0.1–1.2) P⫽0.065
0.85 (0.2–3.7) P⫽0.806
1.13 (0.1–8.9) P⫽0.887
*Favorable intervention effect at significance level P⬍0.05.
Normally distributed data presented as mean⫹SD, adjusted for AMTS and time since stroke.
Skewed data presented as median (percentiles).
Dichotomous data presented as n (%) with ORs (95% CI).
Exact confidence limits used for small numbers.
2554
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TABLE 4.
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Self-Reported Bowel-Related Symptoms
Severity of bowel problem
Visual analog scale (0 “no problem at all” to
100 mm “terrible problem”)
Baseline
1 month*
6 months
12 months
Bowel control
Visual analogue scale (0 “no control”
to 100 mm “perfect control”)
Baseline
1 month
6 months
12 months
Straining on ⬎1 in 4 BMs
Baseline
1 month*
6 months
12 months
Hard stool on ⬎1 in 4 BMs
Baseline
1 month
6 months
12 months
Takes ⬎10 minutes to complete BM
Baseline
1 month
6 months
12 months*
Uses manual assistance to have BM
Baseline
1 month
6 months
12 months
Intervention
No. (%)
n⫽73
Control
No. (%)
n⫽73
mean⫾SD
mean⫾SD
57.8⫾26.4
36.7⫾33.5
32.7⫾34.2
33.6⫾30.9
47.2⫾27.6
43.5⫾29.7
37.1⫾31.0
32.0⫾27.6
P⫽0.021
P⫽0.029
P⫽0.456
P⫽0.877
76.7⫾30.5
75.4⫾26.5
76.1⫾27.7
77.9⫾24.7
86.7⫾23.2
75.7⫾22.9
75.5⫾26.7
73.9⫾28.3
P⫽0.031
P⫽0.230
P⫽0.418
P⫽0.154
44 (60.3)
15 (20.6)
14 (19.2)
13 (17.8)
36 (49.3)
19 (26.0)
17 (23.3)
6 (8.2)
P⫽0.145
0.33 (0.1–1.0) P⫽0.041
0.40 (0.1–1.2) P⫽0.094
1.51 (0.5–4.9) P⫽0.485
39 (53.4)
15 (20.6)
13 (17.8)
10 (13.7)
32 (43.8)
18 (24.7)
15 (20.6)
14 (19.2)
P⫽0.237
0.42 (0.1–1.2) P⫽0.109
0.52 (0.2–1.4) P⫽0.205
0.41 (0.1–1.2) P⫽0.098
34 (46.6)
10 (13.7)
8 (11.0)
4 (5.5)
28 (38.4)
11 (15.1)
8 (11.0)
7 (9.6)
P⫽0.275
0.29 (0.1–1.1) P⫽0.064
0.85 (0.3–2.8) P⫽0.794
0.14 (0.02–0.9) P⫽0.038
35 (48.0)
17 (23.3)
21 (28.8)
15 (20.6)
27 (37.0)
21 (28.8)
21 (28.8)
15 (20.6)
P⫽0.152
0.37 (0.1–1.2) P⫽0.103
1.22 (0.4–3.4) P⫽0.701
1.11 (0.4–3.2) P⫽0.855
OR (95% CI)
P value
*Favorable intervention effect at a significance level of P⬍0.05 (OR, ⬍1).
All outcomes adjusted for AMTS, time since stroke, baseline score for individual bowel characteristic, and baseline
laxative use.
structured practical approach that nonspecialist doctors and
nurses may feasibly apply in various settings. Further applied
research would aid in assessing effective ways of delivering this
type of intervention within health services.
Although there are no comparable intervention trials, there are
epidemiological data in older people with constipation and FI to
support our lifestyle measures intervention.11–13,16,23,32 Although our
study does not specifically demonstrate the effectiveness of nonpharmacological measures in stroke patients, we have shown that a
simple targeted educational approach including written materials
can result in long-term lifestyle changes in this population.
Our intervention design was of a simple but structured
nurse-led assessment leading to targeted treatment of bowel
dysfunction. For instance, where rectal outlet delay (a common
constipation subtype associated with rectal impaction with overflow)9,17 was identified, suppositories rather than increased
doses of laxatives were recommended,1,9 and suppository use
was demonstrably higher in the intervention group. Our overall
treatment approach moved away from empirical laxative prescribing (common in neurologically disabled people)1,16,26 toward individualized recommendations (eg, patients with constipation plus weak anal sphincters were advised to use a bulking
agent rather than stool softener to avoid anal leakage).
Our findings show that although dietary and prescribing
pattern changes persisted, the benefits on bowel symptoms were
not maintained beyond 6 months. Health care visits for bowel
problems among the active group increased in the last 6 months,
which may imply that they were empowered through education
to talk to their GPs about their condition; qualitative evaluation
may have clarified this. Older patients often do not report FI to
providers,16 and structured assessment in stroke patients would
make it less of a “hidden problem.” One practical implication is
Harari et al
that this intervention should be repeated periodically and long
term in stroke patients with bowel dysfunction.
Quality of life scores were unchanged in the context of
improved bowel function in intervention patients. Similar to
these findings, studies of secondary prevention through education in stroke patients show that although knowledge and
adherence to lifestyle changes improves, perceived health status
and quality of life measures remain unaltered.33
Limitations
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The drop-out rate was high, reflecting the frailty of this
population, but comparative analysis showed that randomization was uncompromised. The study had sufficient power to
demonstrate intervention effect on bowel pattern, but a larger
sample would have permitted evaluation of impact on FI and
constipation subgroups (eg, rectal outlet delay). Baseline
stool diary data were not collected, although statistical
adjustment for other baseline bowel symptom measures
(Table 4) showed that significant treatment effects remained
significant. The study was nonblinded by nature of the
intervention. The study nurse was involved in collecting
outcome data, but potential bias was minimized through use
of postal self-completed questionnaires. By recruiting mainly
community patients, the possible Hawthorne effect of having
control and intervention patients on the same ward was
reduced. The intervention effect may have been weakened
through ethical requirement to notify GPs and ward physicians of control group enrollment; there was a trend toward
improved bowel symptoms in controls over 12 months.
Conclusions
A single encounter nurse-led intervention in stroke patients
significantly improved measures of bowel dysfunction ⱕ6
months later and changed bowel-modifying lifestyle behavior
and GP-prescribing patterns throughout the ensuing 12
months. Although further trials are needed, these findings
may promote structured management of bowel problems in
stroke patients and encourage targeted health education (including provision of booklets) to this population.
Acknowledgments
Funding support for this study was provided by Action Research
(grant AP0763). We would to thank all those participating in the
project and all of the stroke physicians and nurses who supported the
project. These study findings were presented to the Spring 2004
Scientific Meeting of the British Geriatric Society
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Treatment of Constipation and Fecal Incontinence in Stroke Patients: Randomized
Controlled Trial
Danielle Harari, Christine Norton, Linda Lockwood and Cameron Swift
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Stroke. 2004;35:2549-2555; originally published online October 14, 2004;
doi: 10.1161/01.STR.0000144684.46826.62
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