these voiding problems may result from medication , cognitive changes , 
 physical impairments , or neurological etiologies1 . patients with spinal cord injury in the thoracic region were 
 selected for this study , and we monitored changes in their bowel function after performing 
 manual therapy along the colon . at the early stage of injury , the internal layer of the 
 rectum and the anal sphincter muscle are in a stage of complete incontinence2 . the reflex of the voiding function is 
 restored by recovery of the central lumbar - sacral spinal cord after the acute stage3 . peristalsis of the intestine and right side 
 colon are maintained by innervation from the vagus nerve so that feces are transported to 
 the large intestine . after spinal cord injury , patients suffer from many kinds of problems 
 such as decreased muscle power and sensation , and impairment of the respiratory system and 
 other functions . especially , spinal cord injury causes paralysis and high spasticity of the 
 anal sphincter , or results in problems of voiding dysfunction4 . in this study , we selected patients with thoracic and lumbar spinal 
 cord injury for treatment with manual therapy , as an intervention for defecation function . our objective was to improve and enhance bowel function , to achieve the goal of patients 
 independence in activity of daily living ( adl ) . twenty in - patients with spinal cord injury were selected at a hospital . there were 13 males 
 and 7 females ( mean age 39.70  5.25 ) . the content of therapy included exercise therapy , setting up the habit of defecation ( i.e. 
 have a bowel movement at a regular time every day ) , maintaining a stable psychological 
 status of patients , drinking a certain quantity of water , having food fiber , mechanical 
 stimulation and combination medication . manual therapy was applied to the patients abdomen 
 to modulate tension and improve peristalsis of the colon . a secondary goal was to exercise 
 the pelvic floor muscles to help the patients to excrete . each patient was positioned in 
 supine lying , with the hip and knee flexed at 90 degrees , with both legs on the therapist s 
 thigh to completely relax the patient s abdomen . then , the therapist pressed down and pushed 
 along the colon ascendens , transverse colon , colon descendens and colon sigmoidem on the 
 surface of the abdomen . vibration stimulus was applied to the small intestine through the abdomen . if 
 tension or spasm appeared in the abdomen , the therapist inhibited two key points , one point 
 being 2 fingers above the patient s umbilicus , and the other point being to the right and 
 below , 1/3 of the distance between the umbilicus and anterior superior iliac spine ( asis ) . the fingers were pressed down on two points until the tension or spasm in the abdomen was 
 released . , the dietary habit 
 did not change and the amounts of food and water taken were the same as before . the paired 
 t - test was used to compare excretion timing and dosages of glycerine enema before and after 
 treatment . all the subjects enrolled in the study receiving manual therapy 5 times a week for 12 
 weeks . all the subjects 
 seemed to be very comfortable after manual therapy for the abdomen after 2 days to 1 week . some patients reported their feces could be excreted in 2 hours after manual therapy was 
 implemented . the statistical analyses found significant differences in both timing of bowel 
 movement and dosage of glycerine enema . a statistically significant improvement was found in 
 the mean time of bowel movement ; it decreased from 94.00  16.35 minutes to 60.50  10.50 
 minutes after receiving manual therapy for 3 months . the dosage of glycerine enema was 
 decreased from 68.05  8.90  ml to 31.50  11.82  ml ( table 2 , p<0.01 ) . therefore , the methods of manual therapy and stimulation of 
 key points on the abdomen effectively improved the bowel function . the main purpose 
 of the excretion therapy was to evacuate fecal matter from the colon in a regular interval 
 time . for spinal cord injury patients , the spinal reflex recovers gradually , so therapy for 
 bowel function is necessary during this period . the large intestine serves to desiccate the 
 fecal matter as it is transported from the ileum to the rectum5 . therefore , methods should be used to stimulate the colon sigmoideum 
 at a certain time for the patient . besides this , in order to stimulate the stomach and the colon , patients 
 drank a hot drink slowly before recieving manual therapy for the abdomen . if the rectum 
 reflex was areflexic due to upper motor neuron injury , lubricant oil was applied inside the 
 anus to stimulate the rectum with a finger . the kind of food and water content has great influence on bowel frequency and the hardness 
 of fecal matter . some foods that are rich in vitamins , raw vegetables , fruit , cold water and 
 milk soften fecal matter and promote peristalsis of the gut . the quantity of food and the 
 meal time play very important roles in establishment of the habit of defecation6 . for example , it is necessary to teach patients to 
 establish regular habits , to control their bowel function , and to keep good habits in adl , 
 they must maintain a certain exercise regime or do some exercises when they are sitting in a 
 wheelchair . we emphasize that plenty of water in the food must be taken by patients in each 
 meal everyday , otherwise there will be difficulty in defecation if the fecal matter becomes 
 over desiccated . although spinal cord injury patients want to have bowel movement everyday , they will 
 exhaust much energy and time , and also they will feel fatigue easily after they have 
 defecated . it becomes 
 difficult to defecate if fecal matter is kept in the colon over 3 days . it is dangerous to 
 cause paralytic ileus if fecal matter is kept in the colon for a long time . the best timing 
 for evacuation is after breakfast , it can stimulate gastro - intestinal reflex hyperthyroid 
 activities to make evacuation easy . moreover , a training plan for defecation should be set 
 according to the lifestyle habits of the patient and implementation of the plan for 
 defecation management7 . several kinds of ability for defecation free of joint motion , residual muscle power and 
 sensation ( patient can look from mirror if no sensation around anus ) , sitting balance , hand 
 function ( ability to use auxiliary device ) and transfer ability , are needed for spinal cord 
 injury patients . if patients need to succeed at defecation independently , they must make 
 flexible use of the abilities mentioned above , as well as exercise rolling and taking off 
 and putting on clothes . in addition , patients should be trained to look in a mirror and 
 insert a turunda into the anus with an auxiliary device while lying on their sides . if 
 patients need to transfer to a sitting toilet , they must have the ability to take off their 
 trousers and transfer on the toilet pedestal within five minutes of inserting a turunda into 
 the anus . after the training process for the above , patients can achieve this independence 
 goal gradually , and they can check their bowel movements themselves as well as cleaning the 
 anus with an auxiliary device after a bowel movement .