Abdominal massage plus advice, compared with advice only, for neurogenic bowel dysfunction in MS: a RCT.

Background: Between 50% and 80% of people with multiple sclerosis (PwMS) experience neurogenic bowel dysfunction (NBD) (i.e. constipation and faecal incontinence) that affects quality of life and can lead to hospitalisation.
Objectives: To determine the clinical effectiveness and cost-effectiveness of abdominal massage plus advice on bowel symptoms on PwMS compared with advice only. A process evaluation investigated the factors that affected the clinical effectiveness and possible implementation of the different treatments.
Design: A randomised controlled trial with process evaluation and health economic components. Outcome analysis was undertaken blind.
Setting: The trial took place in 12 UK hospitals.
Participants: PwMS who had 'bothersome' NBD.
Intervention: Following individualised training, abdominal massage was undertaken daily for 6 weeks (intervention group). Advice on good bowel management as per the Multiple Sclerosis Society advice booklet was provided to both groups. All participants received weekly telephone calls from the research nurse.
Main Outcome Measures: The primary outcome was the difference between the intervention and control groups in change in the NBD score from baseline to week 24. Secondary outcomes were measured via a bowel diary, adherence diary, the Constipation Scoring System, patient resource questionnaire and the EuroQol-5 Dimensions, five-level version (EQ-5D-5L).
Results: A total of 191 participants were finalised, 189 of whom were randomised (two participants were finalised in error) (control group, n  = 99; intervention group, n  = 90) and an intention-to-treat analysis was performed. The mean age was 52 years (standard deviation 10.83 years), 81% ( n  = 154) were female and 11% ( n  = 21) were wheelchair dependent. Fifteen participants from the intervention group and five from the control group were lost to follow-up. The change in NBD score by week 24 demonstrated no significant difference between groups [mean difference total score -1.64, 95% confidence interval (CI) -3.32 to 0.04; p  = 0.0558]; there was a significant difference between groups in the change in the frequency of stool evacuation per week (mean difference 0.62, 95% CI 0.03 to 1.21; p  = 0.039) and in the number of times per week that participants felt that they emptied their bowels completely (mean difference 1.08, 95% CI 0.41 to 1.76; p  = 0.002), in favour of the intervention group. Of participant interviewees, 75% reported benefits, for example less difficulty passing stool, more complete evacuations, less bloated, improved appetite, and 85% continued with the massage. A cost-utility analysis conducted from a NHS and patient cost perspective found in the imputed sample with bootstrapping a mean incremental outcome effect of the intervention relative to usual care of -0.002 quality-adjusted life-years (QALYs) (95% CI -0.029 to 0.027 QALYs). In the same imputed sample with bootstrapping, the mean incremental cost effect of the intervention relative to usual care was £56.50 (95% CI -£372.62 to £415.68). No adverse events were reported. Limitations include unequal randomisation, dropout and the possibility of ineffective massage technique.
Conclusion: The increment in the primary outcome favoured the intervention group, but it was small and not statistically significant. The economic analysis identified that the intervention was dominated by the control group. Given the small improvement in the primary outcome, but not in terms of QALYs, a low-cost version of the intervention might be considered worthwhile by some patients.
Future Work: Research is required to establish possible mechanisms of action and modes of massage delivery.
Trial Registration: Current Controlled Trials ISRCTN85007023 and NCT03166007.
Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 58. See the NIHR Journals Library website for further project information.
Competing Interests: Maureen Coggrave reports personal fees from Hollister Incorporated (Libertyville, IL, USA) and Wellspect HealthCare (Weybridge, UK), both outside this study. John Norrie was a member of the National Institute for Health Research (NIHR) Commissioning Board from 2010 to 2016, is currently an editor on the NIHR Journals Editorial Board and is Deputy Chairperson of the NIHR Health Technology Assessment General Board. Peter Donnan reports grants from Shire plc (Dublin, Ireland), Novo Nordisk A/S (Bagsværd, Denmark), GlaxoSmithKline plc (London, UK), AstraZeneca plc (Cambridge, UK) and Gilead Sciences Inc. (Foster City, CA, USA), outside this study. He is also a member of the New Drugs Committee of the Scottish Medicines Consortium.