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Randomized Controlled Trial of a Natural Food-Based Fiber Solution to Prevent Constipation in Postoperative Spine Fusion Patients

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Randomized Controlled Trial of a Natural Food-Based Fiber Solution to Prevent Constipation in Postoperative Spine Fusion Patients 1.5 ANCC Contact Hours Randomized Controlled Trial of a Natural Food-Based Fiber Solution to Prevent Constipation in Postoperative Spine Fusion Patients Deborah Wittig-Wells ▼ Pam Sapp ▼ Melinda Higgins ▼ Erica Davis ▼ Jessica Carter ▼ Ani Jacob BACKGROUND: Constipation after orthopaedic surgery orthopaedic surgery occurs frequently, likely due to a occurs frequently, likely due to a combination of high levels combination of high levels of opioid medications for of opioid medications for severe pain management and severe pain management and mobility limitations after mobility limitations after surgery. It can result in serious surgery (Ross-Adjie, Monterosso, & Bulsara, 2015). complications, increased cost, and patient discomfort. Although constipation may be considered mild and PURPOSE: This study evaluated a natural food-based fiber self-limiting, it can increase the length of hospital stay and increase financial burdens for both the patient and the in- solution to prevent constipation in postoperative orthopae- stitution. Constipation may lead to significant morbidity dic patients. and, in rare cases, death (Davies et al., 2008). Reported METHODS: A posttest control group-randomized study rates of constipation in postoperative orthopaedic patients design was used. Dependent variables were presence of are between 40% and 60% (Park, Kim, Yun, & Yu, 2016; postoperative constipation, time to first bowel movement Ross-Adjie et al., 2015). Because constipation frequently (BM), and total number of postoperative BMs. Descriptive occurs in the postoperative orthopaedic population, pre- statistics, Student’s t tests, and Mann–Whitney nonparamet- vention and treatment of constipation are essential. ric 2-group tests with chi-square analysis were used. Level Dietary fiber is thought to improve gastrointestinal of significance for all tests was p < .05. Forty-six partici- (GI) motility and is recommended as the first line of ther- pants were evaluated. apy for prevention and treatment of constipation by na- RESULTS: Ages were similar for both the intervention and tional gastroenterology groups (American Gastroenterological Association, Bharucha, Dorn, control groups. Bowel Function Index (BFI) scores were Lembo, & Pressman, 2013; Locke, Pemberton, & Phillips, not significantly different (p = .448). No significant group 2000). Fiber agents are commonly used to bulk the stool, differences were present for the individual BFI item scores whereas increased fruit and fiber intake helps promote (p > .05). The number of patients with a BM during the more frequent passage of stools (Dreher, 2018; Liu, 2011). first 3 days was not significantly different (p = .489). There were no significant differences found between the 2 groups Deborah Wittig-Wells, PhD, MSN, RN, NE-BC, Director of Nursing regarding laxative administration (p > .05 for all laxatives). Research, Emory University Orthopaedics and Spine Hospital, Tucker, GA. CONCLUSION: Further studies are indicated that address Pam Sapp, MN, RN, OCNS-C, ACNS-BC, Clinical Nurse Specialist, Emory natural fibers and pharmaceutical methods for the preven- University Orthopaedics and Spine Hospital, Tucker, GA. tion of constipation after spinal surgery. Melinda Higgins, PhD, Associate Research Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA. Erica Davis, BSN, Staff Nurse, Emory University Orthopaedics and Spine Introduction Hospital, Tucker, GA. Constipation in hospitalized patients is a common prob- Jessica Carter, BSN, RN, Staff Nurse, Emory University Orthopaedics and lem, particularly in postoperative patients. Multiple fac- Spine Hospital, Tucker, GA. tors contribute to the development of constipation in Ani Jacob, BSN, RN, Staff Nurse, Emory University Orthopaedics and the postoperative patient, including changes in fluid in- Spine Hospital, Tucker, GA. take, diet, and mobility (Davidson, 2006). Although a The authors declare no conflicts of interest. number of pharmacological agents can contribute to Correspondence: Deborah Wittig-Wells, PhD, MSN, RN, NE-BC, Nursing constipation, opioid medications in postoperative pa- Administration, Emory University Orthopaedics and Spine Hospital, 1455 tients often lead to constipation, even in patients with Montreal Rd, Tucker, GA 30084 ([email protected]). no history of bowel difficulties. Constipation after DOI: 10.1097/NOR.0000000000000606 © 2019 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2019 • Volume 38 • Number 6 367 Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. The vast majority of studies on dietary fiber for con- and consistency. Meta-analysis was not done because of stipation are not randomized controlled trials (RCTs) heterogeneity of study populations and methods. The and have been conducted in nursing home residents reviewers concluded that additional trials are needed to and nonhospitalized individuals with chronic constipa- further confirm these results. tion (Suares & Ford, 2011). Research on the prevention Because fruit juices contain sorbitol, fructose, and phy- of constipation in the postoperative orthopaedic patient tochemicals, as well as water and fiber components, fruits population is sparse, and most of the studies on consti- juices are generally considered helpful for the prevention pation are limited in scope or methods. of constipation. Apple, prune, and pear juices are often Systematic reviews of the small number of RCT stud- recommended for the prevention and treatment of consti- ies regarding constipation found evidence of benefit pation (American Gastroenterological Association et al., from dietary fiber when used as a treatment of constipa- 2013; Bae, 2014). Yet, no studies were found to support tion (Suares & Ford, 2011; Yang, Wang, Zhou, & Xu, apple juice specifically as treatment for the prevention of 2012). Specifically, individuals included in the analysis constipation in the postoperative orthopaedic population. received dietary fiber regimen and had significantly No RCT studies have been conducted to date on the more frequent bowel movements (BMs) than those who effects of prune and apple juice ingestion combined to did not receive dietary fiber. create a palatable dietary fiber solution for the preven- Studies have shown that administration of dietary tion of constipation in postoperative orthopaedic pa- fiber may prevent constipation in postoperative patients tients. The purpose of this RCT was to evaluate the ef- with no history of constipation (Kaçmaz & Kas¸içi, 2007; fectiveness of a prune juice and apple juice fiber solution Ouellet, Turner, Pond, McLaughlin, & Knorr, 1996; to prevent constipation in postoperative orthopaedic Schmelzer, 1990). In one underpowered study of post- patients. Results of this study will add to the evidence operative orthopaedic patients (N = 16), 2.5 g of wheat base for the use of natural oral agents to prevent consti- bran was consumed by the experimental group (N = 8) pation in postoperative patients. for 4 days after surgery (Schmelzer, 1990). The study concluded that the experimental subjects who ate more wheat bran did have more BMs and requested fewer Materials and Methods laxatives than the control group. This study was conducted in an academic orthopaedic Using a quasi-experimental study design (N = 81), specialty hospital in the southeastern region of the one study found that the dietary addition of 20 g of United States on an inpatient unit. Study approval was wheat bran once a day in postoperative orthopaedic pa- obtained from the institutional review board prior to tients significantly increased spontaneous BMs and de- data collection. Data collection was completed over a creased laxative administration (Ouellet et al., 1996). 12-month period. Because of serious methodological problems (poorly described methods), study findings are not generaliza- STUDY DESIGN ble. In a more recent nonrandomized study of postop- A posttest, control group-randomized study design was erative orthopaedic patients (N 60) conducted in Iran, = used to evaluate the effects of administering a dietary an unspecified amount of dietary bran wheat was ad- fiber solution orally for 3 days after surgery. The de- ministered on postoperative days (POD) 2–4 (Kaçmaz & pendent variable for this study was the presence of post- Kas¸içi, 2007). In addition to the bran, study patients re- operative constipation, time to first BM, and total num- ceived education about strategies to decrease constipa- ber of postoperative BMs. Random assignment to tion (increasing fluid intake and activity levels; set time groups was done using a computerized randomization for defecation). Although the time to defecation was sig- scheme, with investigators blinded to group assignment nificantly less and the number of BMs significantly until after study enrollment. higher for the experimental group on the fifth POD, the authors failed to address significant differences between groups for those same outcome variables on POD 1 be- SAMPLE SELECTION fore the study intervention had begun. Constipation Subjects for this study were adult patients undergoing outcome variables were found to be similar between the posterior spine fusion that required at least a 3-day hos- two groups. Anecdotal findings of this study included pital stay. Inclusion criterion was tolerating oral fluids. complaints by the experimental group patients that the Exclusion criterion was
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