Bowel Continence Research Articles

Achieving Social Bowel Continence in Children With Hypermotility After Repair of Anorectal Malformations and Hirschsprung

Children presenting to the Pediatric Colorectal Bowel Management clinic with soiling after surgical repair of anorectal malformations or Hirschsprung can be categorized into two groups: Most are constipated and managed with laxatives and/or enemas, whereas the second subset has frequent loose stools. This second group, children with multiple loose stools, presents a unique challenge for the achievement of social bowel continence. We present three case studies illustrating various clinical presentations of incontinence with loose stools, along with dietary and pharmacologic management strategies and a treatment algorithm. Children who soil with loose stools can achieve social continence using a combination approach using toileting supports, diet manipulation, fiber supplementation, medications, and small-volume enemas.

Achieving Social Bowel Continence in Children With Hypermotility After Repair of Anorectal Malformations and Hirschsprung

Achieving Social Bowel Continence in Children With Hypermotility After Repair of Anorectal Malformations and Hirschsprung

Simultaneous Robotic-Assisted Laparoscopy for Bladder and Bowel Reconstruction

Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients. We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program. Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes. Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

Anal and Perineal Injuries.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

Bowel management and continence in adults with spina bifida: Results from the National Spina Bifida Patient Registry 2009-15.

Advances in care have allowed most children with spina bifida (SB) to live to adulthood. The majority have neuropathic bowel dysfunction (NBD), resulting in constipation, incontinence, and diminished quality of life. We sought to 1)describe contemporary NBD management and continence outcomes of adults with SB; 2) describe differences from younger patients; and 3) assess for association with socio-economic factors. We analyzed data on NBD management and continence from the National Spina Bifida Patient Registry (NSBPR). Patients were segregated into young children (5-11 years), adolescents (12-19 years), and adults (20 years and older). A strict definition of continence was utilized. Statistical analysis compared cohorts by gender, ethnicity, SB type, lesion level, insurance status, educational attainment, employment status, and continence. A total of 5209 SB patients were included, of whom 1370 (26.3%) were adults. Management and continence varied by age and SB type. Oral medication use did not differ between groups (5.2-6.6%). Suppositories and rectal enemas were used only by 11.5% of adults, which was significantly less than among school-aged children. Antegrade enemas were used by 17.7% of adults which was significantly less than among adolescents (27.2%). Adults were more likely to use digital stimulation or disimpaction or have undergone a colostomy. Bowel continence was reported by 58.3% of overall adult cohort: 55.6% of adults with myelomeningocele and 74.9% with non-myelomeningocele. Bowel continence was significantly associated with employment (p= 0.0002), private insurance (p= 0.0098), non-myelomeningocele type of SB (p= 0.0216) and educational attainment (p= 0.0324) on univariate analysis but only with employment on multivariable logistic regression (p= 0.0027). Bowel management techniques differed between adults and younger patients with SB. Bowel continence was reported by over half of SB adults and was associated with socio-economic factors.

Variation in bowel and bladder continence across US spina bifida programs: A descriptive study.

Continence is low in individuals with spina bifida, but published prevalence varies markedly across studies. The objective of this study was to examine bladder and bowel continence among patients served by multidisciplinary clinics participating in the National Spina Bifida Patient Registry and to examine whether variation in prevalence exists across clinics. Data were obtained from patients 5 years and older from March 2009 to December 2012. Data were gathered at clinic visits using standardized definitions. Data from 3252 individuals were included. Only 40.8% of participants were continent of urine; 43% were continent of stool. Bladder and bowel continence differed by spina bifida type, with those with myelomeningocele having significantly lower reported prevalence of continence than those with other forms of spina bifida. Bladder and bowel continence varied across registry sites. Adjustment based on demographic and condition-specific variables did not make substantive differences in prevalence observed. Less than half of spina bifida patients served in multidisciplinary clinics report bladder or bowel continence. Variability in prevalence was observed across clinics. Further research is needed to examine if clinic-specific variables (e.g., types of providers, types of interventions used) account for the observed variation.

Understanding Experiences of Youth Growing Up with Anorectal Malformation or Hirschsprung's Disease to Inform Transition Care: A Qualitative In-Depth Interview Study.

The impact of anorectal malformation (ARM) or Hirschsprung's disease (HD) in children continues into adulthood despite early surgical correction. We aimed to explore the physical, social, and emotional impacts of these conditions on youth to inform best transition care strategies. Eligible participants were those aged between 14 and 21 years who had undergone surgery for ARM/HD in our institution. We conducted one-on-one in-depth interviews to saturation using a question guide developed from literature review and clinician expertise. Deidentified transcripts were coded by four coders (two pediatric surgeons, one psychiatrist, and one qualitative expert) for major themes using a constant comparison approach. A theoretical model for understanding the transition experience was developed using grounded theory. Out of 120 patients identified as eligible, 11 youth (6 males) participated in the study. Interviews lasted from 50 to 60 minutes. Four major themes emerged: (1) social support (subthemes: family as core, friends as outer support), (2) cognitive and emotional change (subthemes: realization/recognition of illness, matching emotional response), (3) impact of physical symptoms (subthemes: adverse effects of abnormal bowel habits, gaining bowel continence control leading to overall feeling of control, need to keep disease private), and (4) healthcare providers (viewed as important information sources). Themes did not differ by gender. Our model suggests that participants' understanding of bowel disease evolved over time with a "lightbulb" moment in preteens or early teens accompanied by increasing disease ownership and self-management. Clinicians should independently engage with patients in late childhood to address evolving emotional and information needs and encourage increasing autonomy. Future studies should explore communication approaches to meet transition needs of patients.

A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study.

The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure. A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522). Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7±15.0days. All fissures healed after 3months and remained healed 12months after the procedure. There were no complications related to the procedure. The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.

P.061 An outcome study of ischemic stroke patients admitted to a rehabilitation unit

Background: Earlier studies suggest that age and stroke severity are the main determinants in stroke patient disposition after rehabilitation. We examined these and other variables to determine those that correlated with returning home vs. long-term care (LTC). Methods: Chart review of ischemic stroke patients with initial alpha-FIM scores between 40 and 80 admitted to our Rehabilitation Unit from January 1, 2005 to December 31, 2014. Univariate and multivariate analyses were performed. Results: There were 162 suitable patients. 130 went home and 32 went to LTC. The multivariable analysis showed the following variables favored LTC disposition: age (1.2x increased risk with increased age, P<0.01), residence (17.5x increased risk if not starting at home, P<0.01), right vs. left hemisphere (5.4x greater risk with right hemisphere, p=0.01), bowel continence (10.6x greater risk if not continent, p<0.01), and caregiver (0.05x decreased risk if a caregiver is present, p<0.01). No differences were found for sex, diabetes mellitus, atrial fibrillation, previous stroke, congestive heart failure, COPD, obesity, hemianopsia or financial status. Conclusions: Numerous variables probably affect patient disposition after rehabilitation for acute ischemic stroke.

Outcomes and satisfaction in pediatric patients with Chait cecostomy tubes

Patients with spina bifida and other spinal dysraphisms commonly suffer from fecal incontinence and constipation, which can be treated with antegrade continence enemas. Currently, information regarding outcomes and satisfaction in children who have Chait cecostomy tubes is lacking. The aim of our study was to evaluate the effectiveness of Chait cecostomy tubes in management of constipation in children with spinal dysraphisms. A questionnaire was completed by patients and/or their families during office visits at the University of Iowa or Nationwide Children's Hospital during follow-up pediatric urology office visits. Two study groups completed the questionnaires: 1) Patients with neurogenic bowels who had a cecostomy tubein place (CT) and 2) patients with neurogenic bowels with no cecostomy tube (NCT). The survey used Likert scaled and nonrated questions to assessdemographics, bowel continence, and satisfaction. A total of 86 patients completed the questionnaire: 53 CT patients and 33 NCT patients. CT patients rated the effectiveness of their cecostomy tube in managing their constipation significantly higher than the NCT group rated the effectiveness of their conventional bowel management methods (p<0.001). Within the CT group, 48% of patients had complete or near complete continence, 40% had partial fecal incontinence, while only 12% remained incontinent. Of the CT respondents, 88% were overall satisfied with the cecostomy tube (Figure) and 92% would have the cecostomy tube placed again. In addition, hygiene, independence, and social confidence were significantly improved compared with baseline. Complications associated with the Chait tube included granulation tissue that required treatment (60%) and pain with irrigation (24%). CT patients reported significantly improved constipation management, fecal continence, and improved quality of life compared with NCT patients. Our pilot study demonstrates that the Chait cecostomy tube is a well-tolerated, effective means for treating constipation and achieving fecal continence with minimal side effects in patients with neurogenic bowels.

Urinary tract stone development in patients with myelodysplasia subjected to augmentation cystoplasty.

Patients with myelodysplasia who have undergone augmentation cystoplasty are at risk for urinary tract stones. We sought to determine the incidence and risk factors for stone development in this population. The charts of 40 patients with myelodysplasia who have undergone augmentation cystoplasty were reviewed. None had a prior history of urinary tract stones. All patients were seen on an annual basis with plain abdominal imaging, renal ultrasonography, and laboratory testing. Statistical analysis included a multivariable bootstrap resampling method and Student's t-test. Fifteen (37.5%) patients developed stones, 14 with bladder stones and 1 with a solitary renal stone, at a mean of 26.9 months after augmentation. Five (33.3%) developed recurrent bladder stones. The patient with a renal stone never developed a bladder stone. The mean follow-up for the stone formers was 117.2 months and for non-stone formers was 89.9 months. The stone incidence per year was 6.8%. Risk factors included a decline in serum chloride after augmentation (P = .02), female sex, younger age at time of augmentation, longer time period since augmentation, and bowel continence. A significant proportion of patients with myelodysplasia subjected to augmentation cystoplasty develop urinary tract stones, predominantly in the bladder. Dehydration may play a role in development of lower urinary tract stones as the decline in serum chloride suggests contraction alkalosis, which could lead to constipation and improved bowel continence. Therefore, improved hydration should be a goal in this cohort.

Prevalence and spectrum of functional disability of urban elderly subjects: A community-based study from Central India.

INTRODUCTION:One of the major determinants of the quality of life of elderly subjects is their functional status, which refers to their ability to perform normal daily activities. This study was carried out to determine the prevalence of functional disability in terms of restriction in the activities of daily livings (ADLs) in elderly subjects.MATERIALS AND METHODS:This community-based cross-sectional study was conducted in an urban area of Varanasi, India, with 616 elderly subjects (60 years and above) selected for the study by an appropriate sampling procedure. A predesigned and pretested questionnaire was used to elicit the desired information after taking consent from the study subjects. Statistical Package for Social Sciences (SPSS 21st version) was used for analysis; Chi-square test and z-test were used to test for statistical significance.RESULTS:Prevalence of functional disability in elderly subjects was 53.6% (95% confidence interval: 49.67–57.5%). Restriction of any ADL with maximum severity was observed in 13.5% of the subjects. Independence in ADLs was maximum (100%) for bowel continence and lowest for climbing stairs (47.4%). On the basis of Barthel Index score, 25.2% and 4.4% of the subjects had moderate and severe dependency, respectively. In comparison to mobility restriction, the proportion of subjects whose ADLs were not affected was significantly (P < 0.01) more in the self-care domain.CONCLUSION:Nearly half of the elderly subjects were functionally disabled on the basis of ADL performance. The number of persons of this age group in the domain of restricted mobility is quite high. It is necessary and also possible to design and implement programs that will involve all persons concerned with their care to improve the functional status of the geriatric population.

Factors Influencing Bladder and Bowel Continence in the Pediatric Spina Bifida Population

Factors Influencing Bladder and Bowel Continence in the Pediatric Spina Bifida Population

Bladder and bowel continence in bilateral cerebral palsy: A population study

The attainment of continence is an important milestone in all children, including those with disability. To describe the age of bladder and bowel continence in children with bilateral cerebral palsy (BCP), and the association with intellectual impairment (II) and severity of motor disability. The parents of 346 children with BCP were interviewed as part of a population-based prospective study of the children at 3, 7, and 17 years of age. The age of bladder and bowel continence by day and night was ascertained and compared with controls from the Avon Longitudinal Study of Parents and Children (ALSPAC). The median age for daytime bladder and bowel continence in BCP children was 5.4 years compared with 2.4 years in the controls. At 13.8 years of age, 59.4% of BCP children and 99% of controls were continent by day. In BCP children, there was no difference between the attainment of daytime bladder and bowel control. Night-time bladder and bowel control was slower and less completely attained, with 50% of BCP children continent by the age of 11.8 years compared with 3 years in control children. At 13.8 years of age, 51.9% of BCP children compared with 99.4% of controls were continent for bowel and bladder at night. Gross Motor Functional Classification Score (GMFCS) and intellectual ability (IA) (II) were strongly associated with continence attainment (P<0.0001), but gender was not. Delayed and less complete continence attainment was noted in other clinic series of children with cerebral palsy (including hemiplegics) and children with II. Severity of motor disability (GMFCS), and II impacted on other aspects of toilet training, such as: motivation, understanding, communication, and independence skills. The presence of neurogenic bladder and bowel dysfunction can occur in all levels of GMFCS. Thus, there are many reasons that can prevent continence attainment. Children with BCP achieved day and night-time bladder and bowel continence more slowly and less completely than controls, with 60.8% being continent by day and 54.6% by night at the age of 17 years. The majority of BCP children who were continent by day had achieved this by the age of 5.5 years (86%). At least 88% of BCP children with GMFCS I/II and normal, specific or mild learning impairment were continent for bladder and bowel by day and night. Expectations should be shared with parents, and failure to attain expected continence should be actively investigated.

Does percutaneous tibial nerve stimulation improve global pelvic function in women with faecal incontinence?

Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment for faecal incontinence. Many patients with faecal incontinence have coexisting pelvic floor disorders such as urinary incontinence and vaginal symptoms. We utilized a pelvic floor assessment tool to analyse any effect of PTNS on global pelvic floor function. Patients with faecal incontinence attending our institution who had failed to respond sufficiently to biofeedback were offered a course of PTNS. Patients underwent pre- and post-stimulation assessment with a validated electronic Personal Assessment Questionnaire - Pelvic Floor (ePAQ-PF) for pelvic floor disorders. Scores were compared to assess the effect of treatment on global pelvic floor function. During the study period pre- and post-stimulation ePAQ-PF data were available for 60 patients (55% of all patients starting PTNS). In this cohort there was a significant improvement in bowel continence, bowel related quality of life, irritable bowel syndrome and bowel evacuation with a large effect size for continence and bowel related quality of life. There was also a significant improvement in non-bowel related symptoms, including urinary pain and stress incontinence, urinary related quality of life and bowel related sexual function. Sixty-five per cent of those who answered the question reported improvement in global health after stimulation. For patients presenting with faecal incontinence, PTNS appears to have a positive effect on bowel related function in approximately two-thirds of patients. However, for treatment responders, improvement appears to relate mainly to improvement in bowel related function rather than a global pelvic floor effect.

Supporting patients to manage faecal incontinence.

British Journal of NursingVol. 25, No. 7 RegularsSupporting patients to manage faecal incontinenceSue WoodwardSue WoodwardSearch for more papers by this authorSue WoodwardPublished Online:15 Apr 2016https://doi.org/10.12968/bjon.2016.25.7.370AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Beeckman D, Woodward S, Rajpaul K, Vanderwee K (2011) Clinical challenges of preventing incontinence-associated dermatitis. Br J Nurs 20(13): 784–6,788,790. doi: https://doi.org/10.12968/bjon.2011.20.13.784 Link, Google ScholarBritish Society of Gastroenterologists (2016) Clinical Commissioning Report: Faecal Incontinence. http://tinyurl.com/gpp8es9 (accessed 5 April 2016) Google ScholarBurch J, Collins B (2010) Using biofeedback to treat constipation, faecal incontinence and other bowel disorders. Nurs Times 106(37): 18–21 Medline, Google ScholarCotterill N, Norton C, Avery KN, Abrams P, Donovan JL (2008) A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Dis Colon Rectum 51(1):82–7 Crossref, Medline, Google ScholarNational Institute for Health and Care Excellence (2007) Faecal incontinence in adults: management. [CG49]. http://tinyurl.com/zyvoey4 (accessed 5 April 2016) Google ScholarNorton C, Chelvanayagum S, eds (2004) Bowel Continence Nursing. Beaconsfield Publishers, Beaconsfield Google ScholarTariq SH (2007) Constipation in long-term care. J Am Med Dir Assoc 8(4):209–18 Crossref, Medline, Google ScholarWoodward S (2012) Management options for faecal incontinence. Nursing and Residential Care 14(5): 224–229 Link, Google Scholar FiguresReferencesRelatedDetails 14 April 2016Volume 25Issue 7ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 15 April 2016 Published in print 14 April 2016 Information© MA Healthcare LimitedPDF download

The effectiveness of bowel and bladder interventions in children with spina bifida.

Using the World Health Organization International Classification of Functioning, Disability and Health (ICF), the aim of this study was to identify effective strategies for managing urinary and bowel complications resulting from spina bifida. Charts of 210 children between 4- and 13-years-old with spina bifida were reviewed to quantify medical interventions and continence status. Standardized quality of life (QOL) questionnaires were administered to a subset of participants; child and parent interviews were carried out to examine the experience of living with bowel and bladder incontinence. Practitioners were also interviewed to understand their perspectives of intervention effectiveness. Chart review indicated less than half of children were continent for bowel and bladder. More variability existed in bowel continence programs, and practitioners considered bowel continence more difficult to achieve than bladder continence. No significant associations were found between continence status and QOL measures. Interviews, however, reflected how managing continence at home and school more broadly affects QOL. Among practitioners, some focused primarily on optimizing physical health while others focused on activity and participation. While continence is a goal, programs used to achieve this are individualized and outcomes may be affected by differential treatment effects, environmental factors, and/or stigma experienced by children.

Development and initial validation of a disease-specific bowel continence questionnaire for inflammatory bowel disease patients: the ICIQ-IBD.

Faecal incontinence (FI) related to inflammatory bowel disease (IBD) affects up to 74% of patients and is often under-reported in clinical encounters. A previous study found that several important bowel function concerns of patients with IBD are not addressed by existing FI questionnaires, especially differences between symptoms in relapse and remission. We have therefore adapted an existing FI assessment questionnaire specifically for patients with IBD. A total of 190 people participated in this study. Phase 1 (development): the initial draft of the new questionnaire was developed from previously collected data and from results of a modified Delphi survey of IBD clinicians; questions were refined through six rounds of cognitive interviewing (n=24). Phase 2 (validation): the final version was tested (n=166) and retested (n=143) 3-4 weeks later. Missing data were minimal (1-4%). Weighted kappa analysis showed moderate-to-good agreement for test-retest data. Factor rotational analysis revealed the relationship of questions with each other. The new questionnaire has two domains: 'Symptoms' and 'Quality of Life', recording remission and relapse scores with simple summary scores for each. An additional 10 stand-alone questions address issues of specific concern to patients with IBD. The questionnaire demonstrates the ability to capture changing symptoms and concerns between remission and relapse. The new questionnaire has good content validity and is stable and reliable. Further testing to establish sensitivity to change is needed. The scale can be used by patients, researchers and practitioners to assess severity, fluctuation and impact of IBD-related FI.

Sequence of Functional Loss and Recovery in Nursing Homes.

This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

Rehabilitation for paraplegics

Paraplegia permanently impairs the lives of patients and puts them at risk for other medical complications. Rehabilitation is very complex and has to be adjusted to the specific needs of the patient; it requires an interdisciplinary team with special training. Initial treatment of paraplegic patients aims to enable life at home whenever feasible or a nursing institution that can accommodate the patient's needs. For this, it is necessary that the patient is in stable condition, urinary and bowel continence has been established, ability to communicate is restored, and the patient is mobile within his/her means. Occupational rehabilitation should also have been started or at least offered. Another important element in the comprehensive care of paraplegic patients is lifelong follow-up.