Anyone with SCI knows that bowel care can be a lot of work. It can take up a significant chunk of the day, shape when you can work or make plans, and come with the ever-present worry of constipation, incontinence, or auto nomic dysreflexia.
Research backs that up. In the Winter 2024 edition of The Spin, we covered Simon Fraser University and ICORD researcher Dr. Victoria Claydon’s review of the evidence on SCI and bowel dysfunction. The evidence showed that about three-quarters of people with SCI considered bowel care a major problem, and more than half reported a moderate to severe impact on quality of life. So why isn’t more research focused on making bowel care easier?
Dr. Ines Bersch-Porada has been asking these types of questions for a long time. A physiotherapist, researcher, and Head of the International FES (Functional Electrical Stimulation) Centre® at the Swiss Paraplegic Centre, Ines has worked in SCI rehabilitation for 35 years. She began using functional electrical stimulation—a technique that uses electrical impulses to activate muscles via nerve—in 1992. She quickly noticed something unexpected: when electrical stimulation was used to improve trunk stability, it also seemed to help with bowel management.
“When I first started working with functional electrical stimulation in 1992, we noticed quite early on that when we used it to treat trunk stability, users would report positive side effects on their bowel management,” she says.
The observation stuck with her. At the time, however, bowel function wasn’t the focus of the treatment—and the technology and scientific understanding weren’t yet advanced enough to investigate the effect properly.
“It was not my primary goal,” Ines says. “But it was always in my mind. We could see in the clinic that electrical stimulation has an effect on the bowel, but we didn’t know how.”
Over the next three decades, electrical stimulation technology became more programmable, while researchers learned more about how the nervous system regulates functions such as digestion and bowel control. Ines eventually decided it was time to take that clinical observation into the research lab.
The result was a pilot study that tested whether stimulating the abdominal muscles could make bowel care more efficient for people with chronic SCI.
A Stimulating Addition
The idea is relatively straightforward. After SCI, people may have difficulty generating the abdominal pressure needed to help empty the bowel. Using electrodes placed on the skin to deliver electrical impulses to the abdominal muscles, the resulting muscle contractions can increase pressure inside the abdomen and stimulate movement through the bowel.
Importantly, this isn’t a futuristic device or an implanted system. The study used a commercially available, programmable electrical stimulator—the same general type of equipment already used in rehabilitation for things like muscle strengthening and motor learning.
The researchers simply programmed it specifically for bowel care.
For the study, 20 people with chronic SCI used electrical stimulation at home for 16 weeks. Rather than changing their existing bowel routine, participants added a 30-minute stimulation session beforehand.
“We asked all participants to stimulate for half an hour before their planned bowel management,” Ines says. “This meant that, depending on their personal bowel routine, they didn’t necessarily have to stimulate every single day.”
That meant the treatment could fit around their usual schedules. Someone who normally did bowel care twice a week stimulated twice a week, while someone who did it every day stimulated every day.
Participants didn’t have to travel to a clinic for each treatment, either. “They or their caregivers were taught how to use the equipment, and we held regular online or telephone appointments to check if everything was running smoothly and to answer any questions,” says Ines.
That practical, at-home approach was important to the research team. “I don’t want to set up a treatment that isn’t accessible because you have to come into the clinic to do it,” she adds. “Right from the beginning, we wanted this to be something that could be done at home.”
Participants did, however, make five clinic visits over the 16-week study so researchers could assess their bowel and bladder function and track the effects of the stimulation.
Speeding Up the Process
The results were encouraging. After 16 weeks, participants spent an average of eight minutes less on defecation. Their bowel transit time—the amount of time it takes food to move through the digestive system—also decreased, by an average of about 32.5 hours.
That second finding surprised Ines. “I was very surprised about the transit time,” she says. “In some cases, it was drastically shortened—going from nearly 100 hours down to almost 60 hours.”
For comparison, she notes that normal bowel transit is generally much faster, at around 28 to 32 hours. The participants weren’t back to that range, but the change was still substantial.
Participants also reported being more satisfied with their bowel management after the intervention. Many noticed less bloating and felt more secure about the possibility of incontinence.
“We had one patient with a lower-level lesion who completely stopped experiencing incontinence during the stimulation period,” Ines says.
The researchers also found that the treatment was well tolerated. No serious adverse events were reported, and participants generally found the system convenient to use.
But there was an important catch: the improvements didn’t stick around when the stimulation stopped.
After the treatment period, participants went through a follow-up period without stimulation. Defecation time returned to roughly where it had been before treatment. In other words, the stimulation appears to work as a tool for managing bowel function, rather than producing a permanent change.
For Ines, that’s not necessarily a disappointment. “If we think about medication: you take medication, you have an effect—and if you stop the medication, you don’t have an effect anymore,” she says. “So why should we expect that this is something different?”
The fact that the improvements reversed after stimulation stopped also strengthens the researchers’ confidence that the treatment itself was responsible for the changes.
From Pilot to Practice
Although this was a pilot study, the approach is already surprisingly close to real-world use. The equipment is commercially available, the treatment is non-invasive, and the participants in the study were able to use it at home.
As with many medical devices, however, cost remains an important barrier to access.
Bersch-Porada says the type of programmable stimulator required for the treatment costs roughly 1,000 Swiss francs (about $1,700 CAD), compared with around 100 Swiss francs (about $170 CAD) for simpler devices that are covered by insurance. The less expensive devices generally can’t be programmed with the specific stimulation pattern needed for bowel care.
“I don’t think training or equipment are significant issues that would negatively impact everyday implementation,” Ines explains. “The main barrier is the cost of the stimulation device and the electrodes.
For people in Canada who are interested in trying this approach, Ines recommends speaking with a healthcare professional who understands electrical stimulation and can ensure the device is programmed appropriately.
That’s particularly important for people who experience autonomic dysreflexia (AD). Because the stimulation causes the abdominal muscles to contract, it could potentially trigger an AD episode in someone with an existing bladder or bowel trigger.
In other words, while the technology itself is relatively simple, using it safely and effectively isn’t necessarily as simple as buying a stimulator and turning it on.
The Road Ahead
The pilot study was designed to answer a basic question: does electrical stimulation help with bowel management, and is it practical for people with SCI to use?
So far, the answer appears to be yes. But with just 20 participants, there is still a lot to learn about who benefits, how the treatment should be optimized and whether it belongs in standard bowel care.
That’s where Ines’ next project comes in. Her team received a grant worth 1.2 million Swiss francs—about $2.1 million CAD—to launch a larger international study involving research sites in Switzerland, Norway, and Canada.
“We learned a lot from the pilot study and planned the next one accordingly,” says Ines.
Rather than simply testing whether stimulation works, researchers will compare different types of stimulation—sensory and motor—to better understand which approach works best, and for whom. They’re also planning to look at the gut microbiome—a community of microorganisms living in the digestive tract. Because it can take longer for stool to move through the bowel after SCI, changes in bowel function may also affect the health of this microbial community.
“This will give us insights into intestinal health and whether we can improve it,” she says.
The Canadian arm of the study will be led by Dr. Chester Ho, a professor at the University of Alberta and Medical Director at Glenrose Rehabilitation Hospital. The team hopes to begin recruiting participants as early as January 2027, pending the necessary approvals.
For Ines, this is the kind of research that should be prioritized.
“The research my team and I conduct follows the philosophy that we want to sustainably improve care,” she says. “This means we focus on current, everyday problems that most severely impact a person’s quality of life and try to address them with innovative treatment methods.”
After decades of seeing the potential of electrical stimulation in the clinic, Ines believes the approach is ready to move closer to everyday care. What’s still needed is the evidence—and the healthcare system—to make it a routine option.
“The real question is when we will manage to firmly establish it as a standardized treatment method within the healthcare system so that the costs for the stimulators and the therapy itself are covered,” she says. “Unfortunately, I don’t have an answer for that yet.”
