Effectiveness of Non-Surgical Management Strategies for Constipation in Adults with Stroke: A Systematic Review.
BACKGROUND: Constipation is one of the most common medical complications of acute stroke. Identifying evidence-based management strategies are essential to ensure an optimum stroke rehabilitation outcome. Currently, there are limited management strategies of constipation in stroke.

OBJECTIVE: The objective of this review was to determine the effectiveness of non-surgical management strategies for constipation in adults with stroke.

SELECTION CRITERIA: This review included studies of people of 18 years of age or more with a clinical diagnosis of stroke and symptoms of constipation defined by Rome Foundation. This review included studies that evaluate any types of non-surgical management of constipation in an adult person with stroke. The following comparisons were made where possible: This review considered studies that included bowel evacuation as the outcome measure.

TYPES OF STUDIES: All randomised controlled trials or other quantitative research designs were considered in the absence of RCTs.

SEARCH STRATEGY: A comprehensive search of eight major databases and all reference lists of relevant articles in English was performed from January 1990 up to March 2011.

DATA COLLECTION & ANALYSIS: 
Two reviewers independently assessed methodological quality using a standardised critical appraisal tool. Data was extracted from included studies using a standardised data extraction tool. There was heterogeneity in the types of intervention and outcome measures and statistical pooling of the findings was not appropriate. As such, the studies were grouped according to types of intervention where possible and the findings were presented in narrative form.

MAIN FINDINGS: The review included two randomised controlled trials and one quasi-experimental study. All studies were small and most were of poor quality. A one-off structured nurse assessment and intervention can be effective in improving symptoms of bowel dysfunction in stroke subjects. Targeted educational approach with written materials can result in long term lifestyle changes such as modifying diet and fluid intake to control bowel (one trial). Daily bowel care with digital stimulation may assist in achieving regular bowel evacuation but not within a shorter time frame (one trial). Time-scheduled bowel evacuation which follows premorbid bowel habit is considered to contribute to the efficacy of a bowel management program. Morning bowel program schedules are more effective than evening schedules in establishing effective bowel movement pattern (one trial).

CONCLUSION: The management strategies are limited due to insufficient evidence. The available evidence to support these treatments is only modest and not without methodological flaws.

IMPLICATIONS FOR PRACTICE: It is recommended that bowel management programs should incorporate a nursing component (assessment and education interventions) to improve symptoms of bowel dysfunction. The recommended optimal time for bowel evacuation schedule is in the morning, after breakfast for those whose premorbid bowel habits are in the morning.

IMPLICATIONS FOR RESEARCH: Future longitudinal and larger studies are needed to explore pharmacological and non-pharmacological aspects of care that could improve bowel dysfunction in patients with stroke. This review supports the integration of nursing intervention in the development of bowel care programs which merits further evaluation.
1. PhD Student at Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore (NUS). Contact: (65) 81275584; Email: lim.su.fee@sgh.com.sg 2. Associate Professor at Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore (NUS). Contact: (65) 6516 3116; Email: nurcc@nus.edu.sg.
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