This study investigated the incidence, risk factors, and outcomes of fecal incontinence after acute brain injury using data from the Traumatic Brain Injury Model Systems national database. The study found that: 1) The incidence of fecal incontinence was 68% at admission to rehabilitation, 12.4% at discharge, and 5.2% at 1-year follow-up. 2) Risk factors for fecal incontinence at admission included lower Glasgow Coma Scale scores, longer duration of coma and posttraumatic amnesia, longer hospital length of stay, and incidents of urinary tract infection and frontal contusion. 3) Risk factors for fecal incontinence at discharge included

1. 231
Incidence, Risk Factors, and Outcomes of Fecal Incontinence
After Acute Brain Injury: Findings from the Traumatic Brain
Injury Model Systems National Database
Amy 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). Although
Incidence, risk factors, and outcomes of fecal incontinence logistic regression analyses were significant (P .001), and
after 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 problem
injury. 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 incontinence
factors 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- Rehabilitation
bilitation inpatients from 17 TBIMS centers who were admitted
to acute care within 24 hours of traumatic brain injury and seen
at 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 the
length of coma, length of posttraumatic amnesia (PTA), ad- disorder is unknown because those affected are often unwilling
mission 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, because
follow-up, and incidences of pelvic fracture, frontal contusion, when it happens, it is impossible to disguise. It is easier and
and 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 be
admission to inpatient rehabilitation, 12.4% at rehabilitation associated with loose stool, normal stool consistency, or even
discharge, and 5.2% at 1-year follow-up. Analysis of variance constipation. This inadvertent loss of stool occurs because the
and 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 material
bilitation admission and admission GCS score, length of coma is lost. Additionally, fecal incontinence has several medical
and PTA, LOS, and incidence of UTI and frontal contusion. consequences, including skin irritation, pressure ulcers, and
Fecal 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 for
position, admission GCS score, length of coma, PTA, LOS, fecal incontinence in patients with brain injury. It is recognized
FIM 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 brain
Kolakowsky-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 of
Felicia F. Rubin Family Brain Injury Research Fund. Data were contributed from the access to bathroom facilities, lack of awareness of the need to
Traumatic 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 may
supporting 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 can
organization 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, VA
23298-0542.
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. 232 FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein
Brain Injury Model Systems (TBIMS) centers to address 3 the time elapsed between onset of injury and the time each
primary objectives: (1) to identify the incidence of fecal incon- patient was able consistently to follow commands (GCS motor
tinence 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 of
care for persons with TBI and on maintaining a standardized Procedure
national database for analyses of treatment and outcomes. For A comprehensive program of inpatient rehabilitation was
the 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 language
examination. Criteria for inclusion in the database include (1) therapy. Admission decisions were based on the rehabilitation
being at least 16 years old, (2) presentation to the emergency team’s perceptions of the patients’ rehabilitation needs, with
department 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’ injuries
participating center, and (4) consent to participate. Data were was obtained from hospital records. Admission and discharge
collected 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 by
uals who were consecutively enrolled in any of the 17 medical certified interdisciplinary team members by using the standard
centers in the system. These centers represent geographically protocols established by the Uniform Data Set for Medical
diverse regions of the United States, and each includes emer- Rehabilitation.8
gency 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-up
tation services. To improve sample representativeness, interview with the subject is the method of first choice. If this
standardized protocols are used to provide for the inclusion of is not possible, a telephone interview is attempted; if this is
individuals with a previous brain injury, a preexisting neuro- unsuccessful, data are collected through a mail questionnaire
logic 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 Analysis
present 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-year
to determine absolute change, admission scores were sub- follow-up incontinence, and (3) discharge variables predicting
tracted from discharge scores, and admission and discharge 1-year follow-up incontinence. Variables were entered and
scores were subtracted from 1-year follow-up scores, and (2) removed from the model based on .05-entry and 1.0-removal
FIM efficiency: to control for variation in length of stay (LOS), criteria. Repeated execution of the estimation algorithms were
FIM 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 discharge
score of less than 5 on the bowel-management subscale of the predicting 1-year follow-up because the 2Log likelihood
FIM 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 were
cludes intentional control of bowel movements and, if neces- automatically recoded during the analyses by using the Helmert
sary, 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 RESULTS
admitted to the emergency department) was used as a measure
of injury severity. To determine an accurate GCS score for
Incidence and Risk Factors of Fecal Incontinence at
subjects who were intubated, we used the conversion formula
established 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 risk
Arch Phys Med Rehabil Vol 84, February 2003

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), duration
NOTE. 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 showed
factors of fecal incontinence on admission, demographics, in-
greater injury severity across all measures, as well as lower
jury 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 rehabilitation
acteristics for each incontinence group is provided in table 1.
LOS (F1,973 223.80, P .001) differed significantly between
There were no significant differences between the 2 groups for
the 2 groups. On average, persons with fecal incontinence at
age, 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 also
duration 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 were
P .001) (table 2). On average, persons with fecal incontinence
incontinent at rehabilitation discharge were more likely to have
stayed 11 days longer in acute care than persons who were
sustained a pelvic fracture or developed a UTI some time
continent.
during their acute or rehabilitation LOS.
Data were further examined to determine if relationships
existed between incidence of comorbidities and conditions and
fecal incontinence at rehabilitation admission. Incidence of Incidence and Risk Factors of Fecal Incontinence
pelvic fracture, frontal contusions to the brain, and urinary tract at 1-Year Follow-Up
infections (UTIs) were included in analyses. With regard to Incidence of fecal incontinence declined further at 1-year
admission fecal incontinence, chi-square analyses were statis- follow-up, to 5.2%. Demographics, injury characteristics, and
tically 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 2
centages of pelvic fractures were similar for persons who were groups in age (F1,877 71.60, P .001), residence at discharge
continent (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 identified
Incidence and Risk Factors of Fecal Incontinence at for gender, ethnicity, or residence preinjury. Persons with fecal
Rehabilitation 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 were
nence decreased to 12.4%. Demographics, injury characteris- continent at 1-year follow-up were more likely to have been
tics, 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. 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-Year
to live currently in a private residence. Follow-Up
Concerning injury characteristics, ANOVAs revealed signif- Incontinence at discharge can be predicted by using the
icant between-group differences for all variables analyzed (ta- multivariate model that included acute LOS, rehabilitation
ble 7), including admission GCS (F1,854 5.03, P .05), dura- LOS, admission GCS score, highest GCS score, lowest GCS
tion of unconsciousness (F1,904 16.63, P .001), follow-up score, length of coma, length of PTA, and Rancho Los Amigos
FIM score (F1,904 1668.78, P .001), FIM change from dis- Levels of Cognitive Functioning (RLA), whether a patient had
charge to follow-up (F1,855 62.57, P .001), and FIM change frontal contusions, and whether a patient had a UTI (Wald
from admission to follow-up (F1,826 134.46, P .001). A trend statistic 145.01, P .001). Overall, the percentage of persons
was also noted for duration of PTA (F1,650 3.70, P .055). who were correctly classified by the multivariate model was
The incontinent group showed greater injury severity across all 92.8%. However, even though the correct prediction rate for
measures, as well as lower functional gains for both time continence was 100%, the prediction rate for incontinence
periods. 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 at
between 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 (Wald
care and 63 more days in inpatient rehabilitation than persons statistic 110.82, P .001). Overall, the percentage of persons
who 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 for
existed between incidence of medical complications and fecal continence was 100%, the prediction rate for incontinence
incontinence 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 from
cluded in the analyses. With regard to fecal incontinence, discharge variables at 1-year follow-up differed slightly in that
chi-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 .001
Arch Phys Med Rehabil Vol 84, February 2003

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 in
fied by the multivariate model was again 97.2%. However, as concomitant illness with aging (eg, peripheral neuropathy), and
with 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 have
nence was 0%. Although statistically significant, none of the 3 influenced bowel incontinence. Additionally, an age bias may
regression 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 after
This high incidence is not surprising given the significant TBI were associated with an increased incidence of bowel
cognitive and motor deficits that often result after moderate to incontinence. Although there may be no direct relation between
severe TBI. In fact, the typical individual with TBI who is actual injury severity and continence, bowel continence is
admitted to the TBIMS programs is functioning at an RLA likely a functional deficit that reflects impaired cognitive and
level of between IV (agitated and confused) and V (confused motor deficits. The association between injury severity and
and 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 persistent
rehabilitation 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 incontinence
1-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 significant
improvements 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. 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 irritation
than be directly caused by it, damage to the frontal lobes associated with infection. Likewise, the pain associated with
specifically could cause both increased injury severity and pelvic fractures and the effects of the pain medications used to
incontinence. Frontal lobe injuries, a common occurrence in treat the fractures (both the initial sedating effects and the
TBI 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 plexus
result in a direct increase in the social control of bowel conti- injuries that effect motor and sensory input to the pelvic floor
nence. 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 likelihood
an overriding pathway to monitor and control the need to that patients will be placed in nursing homes.16,17 This study
defecate. Typically lacking in the infantile (poorly myelinated) confirms a similar likelihood for TBI, both at rehabilitation
and senile (demented) brain, this frontal lobe locus of conti- discharge and 1-year postinjury. Again this relationship may
nence is likely to be injured in many individuals with moderate reflect the notion that bowel incontinence is a marker for
or severe TBI, causing the noted high incidence of initial greater injury severity, but there may also be a direct causal
incontinence. It is not surprising, therefore, to find a significant relation. Bowel incontinence results in significant physical
association between increased frontal-lobe contusions and requirements of patients and caretakers, often necessitating
bowel 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 difficulty
portion 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 that
focal peripheral nerve injuries. Increased injury severity alone lead to increased acute rehabilitation LOS. Moreover, if bowel
may result in all 3 conditions independently. Individuals with incontinence is not resolved sufficiently, it may be a main
greater injury severity would be more likely to require indwell- factor in discharging a patient to an institution, as opposed to a
ing Foley catheters, require longer intensive and acute care home. In fact, landmark research by Granger et al17 found
hospitalization stays, and receive antibiotics, all of which bowel incontinence to be the strongest predictor of nursing
would increase their risk for UTIs. Similarly, fractures are home placement after stroke.
more likely to occur in high speed and result in impact injuries
of greater severity. Although these factors could occur inde- CONCLUSION
pendently, there may be direct associations. UTIs (and the Bowel incontinence after TBI is a significant functional
factors 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. FECAL INCONTINENCE AFTER TBI, Foxx-Orenstein 237
tent 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. Top
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encouraged. injury rehabilitation. Part II: Measurement tools for a nationwide
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Arch Phys Med Rehabil Vol 84, February 2003