Treatment of constipation and fecal incontinence in stroke patients: randomized controlled trial. A randomized trial of behavioral management for continence with older rural women. A phase II exploratory cluster randomized controlled trial of a group mobility training and staff education intervention to promote urinary continence in UK care homes. Promoting urinary continence in women after delivery: randomised controlled trial. Expanding the role of the stroke nurse: a pragmatic clinical trial. Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group. Effectiveness of prompted voiding in treating urinary incontinence in cognitively impaired homebound older adults. An evaluation of multidisciplinary intervention governed by functional independence measure (FIMSM) in incontinent stroke patients. A clinical trial of a behavioral therapy to reduce urinary incontinence in nursing homes. Outcome and implications.
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.
                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.
                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.
                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. Urinary incontinence (UI) is a commonly underreported and underdiagnosed condition. The purpose of this trial was to implement and evaluate behavioral management for continence (BMC), an intervention to manage symptoms of UI with older rural women in their homes. Participants were randomized into BMC or a control group, and 178 were followed for between 6 and 24 months. The intervention involved self-monitoring, bladder training, and pelvic muscle exercise with biofeedback. The primary outcome variable-severity of urine loss-was evaluated by pad test. Secondary variables were episodes of urine loss, micturition frequency, voiding interval, quality of life, and subjective report of severity. Urine loss severity at baseline evaluation was not significantly different in the two groups. But using the generalized linear mixed model analysis, at the four follow-ups, severity of urine loss, episodes of urine loss, quality of life, and subjective report of severity were significantly different. At 2 years the BMC group UI severity decreased by 61%; the control group severity increased by 184%. Self-monitoring and bladder training accounted for most of the improvement. The results support the use of simple strategies based on bladder diaries before implementing more complex treatments.
                Copyright 2002 John Wiley & Sons, To assess feasibility, acceptability and potential efficacy of group exercise and staff education intervention to promote continence in older people residing in care homes. To establish measures and information to inform a larger trial.
                Phase II pilot exploratory cluster randomized controlled trial.
                Six purposely selected care homes in the West Midlands, UK.
                Thirty-four care home residents (mean age 86, 29 female), 23 with cognitive impairments.
                Physiotherapy-led group exercise and staff continence and mobility facilitation training.
                Reported continence status, Rivermead Mobility Index. Feasibility was assessed by uptake and compliance, and acceptability by verbal feedback. A staff knowledge questionnaire was used.
                Thirty-three residents, cluster sizes from 3 to 7. The number of residents agreeing with the statement 'Do you ever leak any urine when you don't mean to?' in the intervention group decreased from 12/17 at baseline to 7/17 at six weeks in the intervention group and increased from 9/16 at baseline to 9/15 at six weeks. The Rivermead Mobility Index scores were better in the intervention group (n=17; baseline: 6.1, six weeks: 6.2) compared with controls (n=16; baseline: 5.9, six weeks: 4.75). The intervention was feasible, well received and had good compliance.
                Group mobility training and staff education to promote continence is feasible and acceptable for use with care home residents, including those with cognitive impairment. To test the effectiveness of a physiotherapist delivered intervention designed to prevent urinary incontinence among women three months after giving birth.
                Prospective randomised controlled trial with women randomised to receive the intervention (which entailed training in pelvic floor exercises and incorporated strategies to improve adherence) or usual postpartum care.
                Postpartum wards of three tertiary teaching hospitals in the Hunter region, New South Wales, Australia.
                Women who had forceps or ventouse deliveries or whose babies had a high birth weight (> or =4000 g), or both-676 (348 in the intervention group and 328 in the usual care group) provided endpoint data at three months.
                Urinary incontinence at three months measured as a dichotomous variable. The severity of incontinence was also measured. Self report of the frequency of performance of pelvic floor exercises was recorded.
                At three months after delivery, the prevalence of incontinence in the intervention group was 31.0% (108 women) and in the usual care group 38.4% (125 women); difference 7.4% (95% confidence interval 0.2% to 14.6%, P=0.044). At follow up significantly fewer women with incontinence were classified as severe in the intervention group (10.1%) v (17.0%), difference 7.0%, 1.6% to 11.8%). The proportions of women reporting doing pelvic floor exercises at adequate levels was 84% (80% to 88%) for the intervention group and 58% (52% to 63%) for the usual care group (P=0.001).
                The intervention promoting urinary continence reduced the prevalence of urinary incontinence after giving birth, particularly its severity, and promoted the performance of pelvic floor exercises at adequate levels; both continence and adherence to the programme were measured at three months after delivery in women who had forceps or ventouse deliveries or babies weighing 4000 g or more. This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery.
                Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization.
                A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke.
                The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049).
                The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers. We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.
                A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.
                The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.
                Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact. The objective of this study was to examine the short-term effectiveness of prompted voiding (PV) in cognitively impaired homebound older adults.
                This was a prospective, controlled exploratory study with a cross-over design where usual care controls crossed-over to the intervention following an 8-week observation period.
                Adults aged 60 years and older with urinary incontinence and who met Center for Medicare and Medicaid Services criteria for being homebound were referred to the study by home care nurses from 2 large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania. Nineteen cognitively impaired older adults were randomly assigned to either the PV intervention or a usual care attention control group.
                Measures used included structured continence and medical histories. Older American Research and Service Physical and Instrumental Activities of Daily Living scales, Folstein Mini Mental State Examination, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination.
                Nineteen subjects were randomly assigned to a PV (n = 9) or delayed attention-control group (n = 10). Treatment subjects with complete pretreatment and posttreatment data (n = 6) experienced a mean 60% reduction in daytime incontinent episodes compared with a mean 37% reduction among control subjects (n = 10). Following the control phase, subjects crossed over to the treatment protocol. A total of 15 subjects completed the PV protocol. Among all subjects completing the treatment protocol, there was a 22% reduction in daytime incontinent episodes compared with true baseline (immediately following the control phase for those crossing over from the control group).
                The PV intervention resulted in clinically significant reductions in urinary incontinence for many of the participants, which may be achievable for many cognitively impaired homebound older adults. Patients with acute hemispheric stroke and ensuring urinary incontinence were randomly allocated to a ward using conventional methods of rehabilitation (n = 13) or to a ward practicing rehabilitation governed by Functional Independence Measure (FIM) (n = 21). All patients were assessed on admission and on discharge using the Katz activities of daily living (ADL) index, the psychological general well-being index, item G of the FIM index (FIM-G), and a mobility score. Patients admitted to the ward utilizing FIM were additionally evaluated using the total FIM on admission, repeatedly during the rehabilitation period and on discharge. An individual rehabilitation programme based on the latest FIM score was used throughout rehabilitation. There were no differences on admission between groups regarding clinical and demographic characteristics, ADL, mobility and mood. Twenty patients in the intervention group regained continence before discharge compared to 3 (p < 0.01) in the control group. There was also a greater improvement in well-being in the intervention group compared to the control group (p < 0.01). This study has indicated that rehabilitation governed by the use of FIM reduced urinary incontinence and enhanced well-being better than conventional methods of rehabilitation. The results warrant a larger study to further investigate rehabilitation of incontinent stroke patients using FIM. One hundred thirty-three incontinent women in seven nursing homes were assigned randomly to a 13-week behavior therapy program for urinary incontinence or to a control group that received usual incontinence-related care. The therapy became effective after 6 weeks of training. By the final month of training, the treatment women's wet episodes had been reduced by 0.6 episodes per day, a 26% reduction over baseline. This reduction in the number of wet episodes was statistically significant, both with respect to this group's baseline levels of incontinence and in comparison with the performance of the control women. The number of wet episodes in the control group remained about the same throughout training and the 22-week follow-up period. The treatment women improved partly because they learned to request help, a response prompted and reinforced by the program. Trainees with a high frequency of incontinence during baseline, the more cognitively intact residents, and residents with normal bladder capacity responded better to this behavior therapy program.
Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.