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Risk factors for constipation in patients with acute and subacute ischemic stroke: A retrospective cohort study

  • Yun Sun
    Affiliations
    Department of Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China

    Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Yajun Lin
    Affiliations
    Department of Rehabilitation Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Juehan Wang
    Affiliations
    Department of Rehabilitation Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Zhisheng Xu
    Affiliations
    Department of Rehabilitation Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Wangxiao Bao
    Affiliations
    Department of Rehabilitation Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Zuobing Chen
    Affiliations
    Department of Rehabilitation Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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  • Xiaofeng Yang
    Correspondence
    Corresponding author.
    Affiliations
    Department of Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China

    Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 310001 Hangzhou, China
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      Highlights

      • NIHSS score is the independent risk factors of the poststroke constipation, and patients with NIHSS score >8.5 had higher risk for constipation.
      • A significant interaction between constipation and behavioral performance has been identified.

      Abstract

      Background

      The objective of this study was to examine the incidence of constipation and the risk factors for patients with ischemic stroke in acute and subacute stage.

      Methods

      In this retrospective cohort study, patients with acute and subacute ischemic stroke in the Department of Rehabilitation, First Affiliated Hospital, Zhejiang University School of Medicine between 2019 and 2021 were analyzed. Univariate and multivariate analysis were conducted using demographic characteristics, clinical evaluations, and stroke related complications, to explore the risk factors of constipation after stroke.

      Results

      Of the 222 patients with acute and subacute ischemic stroke, 128 (57.7 %) developed constipation. Univariate analysis revealed that pulmonary infection, NIHSS, ADL, KWST scores and nutritional status were significantly associated with post-stroke constipation (p < 0.05). Binomial logistic regression showed that NIHSS score is the independent risk factors of the poststroke constipation, and patients with NIHSS score >8.5 had higher risk for constipation.

      Conclusions

      Current findings suggested a significant interaction between constipation and NIHSS score in stroke patients, providing new insights into therapeutic target for neural functional recovery among patients with acute and sub-acute ischemic stroke.

      Keywords

      1. Introduction

      Stroke is the major cause of death and disability in adults older than 50 years worldwide [
      • Gorelick P.B.
      The global burden of stroke: persistent and disabling.
      ]. Patients with acute and subacute ischemic stroke are at risk of many complications, including urinary tract infection (15.5 %), pneumonia (8.8 %), and constipation (7.0 %) [
      • Ingeman A.
      • Andersen G.
      • Hundborg H.H.
      • Svendsen M.L.
      • Johnsen S.P.
      Processes of care and medical complications in patients with stroke.
      ]. Constipation characterized by infrequent bowel evacuations or difficult stool passage is a common gastrointestinal motility disorder after ischemic stroke, with a reported incidence ranging from 29 % to 79 % [
      • Lin C.J.
      • Hung J.W.
      • Cho C.Y.
      • Tseng C.Y.
      • Chen H.Y.
      • Lin F.C.
      • et al.
      Poststroke constipation in the rehabilitation ward: incidence, clinical course and associated factors.
      ], and an average incidence of 48 % in a meta-analysis of 1,385 participants [
      • Li J.
      • Yuan M.
      • Liu Y.
      • Zhao Y.
      • Wang J.
      • Guo W.
      Incidence of constipation in stroke patients: A systematic review and meta-analysis.
      ]. Sources of heterogeneity among previous studies include different populations, inclusion/exclusion criteria, disease courses, and definitions of constipation.
      Psychological, physiological, endocrine, nutritional, and behavioral factors have been identified as concomitant causes of poststroke constipation. The pathogenesis of poststroke constipation remains unclear; however, many factors exacerbate constipation, including insufficient water input, low dietary fiber intake, immobilization, bed rest, changes in bowel habits, and the side effects of drugs [
      • Li J.
      • Yuan M.
      • Liu Y.
      • Zhao Y.
      • Wang J.
      • Guo W.
      Incidence of constipation in stroke patients: A systematic review and meta-analysis.
      ,
      • Camara-Lemarroy C.R.
      • Ibarra-Yruegas B.E.
      • Gongora-Rivera F.
      Gastrointestinal complications after ischemic stroke.
      ]. The lesion location, volume and severity of stroke, and peripheral sympathetic nerve activity are also independent risk factors [
      • Lin C.J.
      • Hung J.W.
      • Cho C.Y.
      • Tseng C.Y.
      • Chen H.Y.
      • Lin F.C.
      • et al.
      Poststroke constipation in the rehabilitation ward: incidence, clinical course and associated factors.
      ,
      • Liu Z.
      • Ge Y.
      • Xu F.
      • Xu Y.
      • Liu Y.
      • Xia F.
      • et al.
      Preventive effects of transcutaneous electrical acustimulation on ischemic stroke-induced constipation mediated via the autonomic pathway.
      ]. By contrast, physical activity, preventive laxative use, and probiotics combined with early enteral tube nutrition protect against constipation [
      • Lim S.F.
      • Ong S.Y.
      • Tan Y.L.
      • Ng Y.S.
      • Chan Y.H.
      • Childs C.
      Incidence and predictors of new-onset constipation during acute hospitalisation after stroke.
      ], suggesting a better quality of life and positive effect on recovery after stroke [
      • Zhong D.Y.
      • Li L.
      • Ma R.M.
      • Deng Y.H.
      The effect of probiotics in stroke treatment.
      ]. However, much uncertainty still exists about the relation between risk factors and poststroke constipation.
      Patients with stroke may develop difficulties with balance, movement, speech, swallowing, urination, and defecation [
      • Langhorne P.S.D.
      • Robertson L.
      • MacDonald J.
      • Jones L.
      • McAlpine C.
      • Dick F.
      • et al.
      Medical complications after stroke a multicenter study.
      ,
      • Pezzini A.
      • Grassi M.
      • Del Zotto E.
      • Giossi A.
      • Volonghi I.
      • Costa P.
      • et al.
      Complications of acute stroke and the occurrence of early seizures.
      ], which are additional risk factors for poststroke constipation. The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate neurological function, while the Kubota Water-Swallowing Test (KWST), and Barthel Index (BI) were used to assess the functions of swallowing and activities of daily living (ADL), respectively. Based on the behavioral assessments, nutritional supplementation, complications, and demographic characteristics, we analyzed the risk factors for constipation in acute and subacute stroke, which facilitated the management of constipation after ischemic stroke. The present study therefore set out to assess the effect of risk factors of constipation for patients with ischemic stroke in acute and subacute stage, and provide potential therapeutic target for neural functional recovery.

      2. Materials and methods

      2.1 Patients enrollment

      350 in-hospital patients with ischemic stroke who were admitted to the Department of Rehabilitation, The First Affiliated Hospital, Zhejiang University School of Medicine during January 1, 2019 to March 31, 2021 were enrolled. Ischemic infarction was determined by Magnetic resonance imaging (MRI) or tomography (CT), and the patients were diagnosed as ischemic stroke according to the International Classification of Diseases, Tenth Revision (ICD-10). Patients received nutritional support via oral nutrition support and enteral tube feeding under the guidance of a specialized nutritionist. For patients receiving oral nutrition support, an adequate balanced diet was provided. If oral nutrition is not possible or insufficient, enteral tube feeding may be used to ensure nutrient intake (1500–2000 kcal per day). All in-hospital patients received individualized rehabilitation training, including physical therapy (PT), occupational therapy (OT), and speech therapy (ST).
      Patients were excluded if they had a previous history of other neurological diseases, malignant tumors, systemic organ failure, or primary gastrointestinal disease (including chronic constipation). Patients with chronic stroke (over three month) and patients who died were also excluded. (Fig. 1). The study has been reviewed by the Ethics Committee of the First Affiliated Hospital (No. 2021_765), and the subjects have signed informed consents.
      Figure thumbnail gr1
      Fig. 1Flow chart for the inclusion of patients. 222 S patients with acute and subacute ischemic stroke were enrolled in the study.

      2.2 Diagnosis of constipation

      The diagnosis of constipation was based on the Rome III Criteria [
      • Rao S.S.
      • Meduri K.
      What is necessary to diagnose constipation?.
      ], including any two or more of the following symptoms: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage, manual maneuvers, and <3 defecations per week. The constipation was assessed once a week in hospital. Physicians prescribed laxatives or stool softeners to solve the problem of post-stroke constipation.

      2.3 Data collection

      Demographic data, clinical assessments, imaging and laboratory examination were collected by two trained researchers following standard protocols. The baseline data was collected at the admission to the hospital.
      1) Baseline demographics: Age, sex, length of hospital-stay and the course of disease were recorded for those who enrolled this study.
      2) Stroke-related complications: Medical complications of ischemic stroke occurred during the acute and subacute stage were recorded. While pulmonary infection, urinary tract infection, abnormal liver function, and hypokalemia were considered as major complications.
      3) Neurological function assessment: Severity of the neurological function was assessed using the National Institutes of Health Stroke Scale (NIHSS) [
      • Chalos V.
      • van der Ende N.A.M.
      • Lingsma H.F.
      • Mulder M.
      • Venema E.
      • Dijkland S.A.
      • et al.
      National institutes of health stroke scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke.
      ] score at the time of admission, ranging from 0 to 42, which contains the level of consciousness, gaze, visual field, facial paralysis, upper and lower limb movement, ataxia, sensation, language, dysphonia, and neglect/ extinction.
      4) The function of swallowing was tested using the Kubota water swallowing test (KWST) scale [
      • Hirata A.
      • Funato H.
      • Nakai M.
      • Iizuka M.
      • Abe N.
      • Yagi Y.
      • et al.
      Ginger orally disintegrating tablets to improve swallowing in older people.
      ]. The patient was instructed to swallow a 30 ml of water, a score of 1 is given when swallowing at once in 5 s without cough, a score of 2 is given when swallowing more than twice without cough, score 3 indicates swallowing water at once with cough, swallowing more than twice with cough is level 4, and level 5 is coughing frequently, or inability to swallow water.
      5) Activities of daily living: The Barthel Scale/Index (BI) is a 10-item scale of the performance in activities of daily living with an overall score of 0 to 100, including controlling bowels, controlling bladder, grooming, toilet use, feeding, transfer, mobility, dressing, stairs, and bathing [
      • MacIsaac R.L.
      • Ali M.
      • Taylor-Rowan M.
      • Rodgers H.
      • Lees K.R.
      • Quinn T.J.
      • et al.
      Use of a 3-item short-form version of the Barthel index for use in stroke: systematic review and external validation.
      ].
      6) Clinical nutrition: Clinical nutrition is to provide an optimal nutritional support in critically ill patients, mainly includes oral nutrition support and nasal tube feeding.

      2.4 Statistical analysis

      Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, Chicago, IL, USA) version 22.0. Descriptive analyses were conducted to for all demographic and clinical variables. Continuous variables are given as mean ± SD, and compared by t-test. Categorical variables are presented as frequencies (%) and were compared by the Chi-Square test. Univariate analysis and binary logistic regression analysis was performed to calculate odds ratios (ORs) and to determine the effects of each variable for constipation. Those risk factors with a p < 0.05 were then entered into the multivariate analysis [
      • Sterne J.A.
      • White I.R.
      • Carlin J.B.
      • Spratt M.
      • Royston P.
      • Kenward M.G.
      • et al.
      Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.
      ,
      • Ingeman A.
      • Andersen G.
      • Hundborg H.H.
      • Svendsen M.L.
      • Johnsen S.P.
      In-hospital medical complications, length of stay, and mortality among stroke unit patients.
      ]. The α level was set at 0.05.

      3. Results

      3.1 Baseline characteristics

      A total of 222 S patients met the inclusion criteria and were recruited (Fig. 1), and the baseline characteristics of participants were shown in Table. 1. The mean age was 65.42 ± 13.37 years, 144 (64.9 %) were male and 78 (35.1 %) were female. 142 (64.0 %) patients were in acute stage and 80 (36.0 %) patients in subacute stage, while the length of stay were 28.42 ± 14.11 days. The average baseline NIHSS score was 8.46 ± 6.74, ADL score was 40.97 ± 27.07, and KWST score was 2.18 ± 1.17. Besides, 75 (33.8 %) patients developed pneumonia after ischemic stroke, 59 (26.6 %) had liver dysfunction, 101 (45.5 %) had urinary tract infection (UTI), and 73 (32.9 %) had hypokalemia. Based on the nutritional status, 146 (65.8 %) patients received oral feeding and 76 (34.2 %) received nasal tube feeding.
      Table 1Comparisons between patients with and without constipation following acute and sub-acute ischemic stroke.
      VariablesTotalConstipationNon-constipationP value
      Number, n22212894
      Age, year65.42 ± 13.3766.32 ± 13.3964.20 ± 13.320.244
      Sex, n(%)0.260
       Male, n1447965
       Female, n784929
      Length of stay28.42 ± 14.1128.39 ± 12.8828.47 ± 15.700.968
      Disease stage0.778
       Acute1428359
       Subacute804535
      Pneumonia0.000
       Yes755817
       No1477077
      Hepatic dysfunction0.166
       Yes593920
       No1638974
      UTI0.221
       Yes1016338
       No1216556
      Hypokalemia0.193
       Yes734726
       No1498168
      Nutrition0.000
       Oral1466680
       Nasal tube766214
      NIHSS8.46 ± 6.7410.63 ± 7.605.51 ± 3.710.000
      ADL40.97 ± 27.0731.25 ± 25.0754.20 ± 23.990.000
      KWST2.18 ± 1.172.44 ± 1.201.82 ± 1.040.000
      UTI: urinary tract infection; NIHSS: National Institutes of Health Stroke Scale; ADL: activities of daily living; KWST: Kubota water swallowing test.
      The medications prescribed by physicians included Aspirin (n = 153), Clopidogrel (n = 145), Statins (n = 191), Citicoline (n = 48), Mecobalamin(n = 53), Warfarin (n = 5), Low molecular weight heparin (n = 56), Rivaroxaban (n = 24), and Butylphthalide (n = 114).

      3.2 Incidence of new-onset constipation

      Overall, 128 of 222 patients were diagnosed as new-onset constipation, suggesting an incidence of post-stroke constipation was 57.7 %. No differences of age, gender, length of hospital stay was found between the patients with and without constipation.

      3.3 Risk factors of constipation after stroke

      Compared with the patients without constipation, we found that NIHSS score (10.63 ± 7.60 vs 5.51 ± 3.71, p < 0.001), KWST (2.44 ± 1.20 vs 1.82 ± 1.04, p < 0.001) were significant higher in patients with constipation, with a lower score of ADL (31.25 ± 25.07 vs 54.20 ± 23.99, p < 0.001). Also, poststroke pneumonia and nasal tube feeding during hospitalization were significantly associated with constipation. No significant difference in hepatic dysfunction, UTI and hypokalemia was found (Table. 1).
      In order to define the significance of these relevant risk factors on the probability of poststroke constipation, we performed multivariate analysis using binomial logistic regression analysis (Table 2). By analyzing the pulmonary infection, NIHSS, ADL, KWST scores and nutritional status, we found that NIHSS score may be independent risk factors for poststroke constipation (OR: 0.909, 95 % CI: 0.837–0.988, P < 0.05).
      Table 2Binomial logistic regression analysis of risk factors predicting constipation after ischemic stroke.
      CovariatesOR95 %CIP value
      Pneumonia1.9060.890–4.0830.097
      NIHSS0.9090.837–0.9880.024
      ADL1.0090.987–1.0310.435
      KWST0.9910.719–1.3650.954
      Nasal tube feeding2.1320.914–4.9740.080
      OR: odds ratio; CI: confidence interval; NIHSS: National Institutes of Health Stroke Scale; ADL: activities of daily living; KWST: Kubota water swallowing test.
      Receiver operating characteristic (ROC) analysis revealed that NIHSS > 8.5 had a sensitivity of 54 % and a specificity of 80 % to poststroke constipation. The area under the curve (AUC) was 0.725, p < 0.001 (Fig. 2).
      Figure thumbnail gr2
      Fig. 2Receiver operating characteristic (ROC) curve revealing the risk of NIHSS for constipation in patients with acute and subacute ischemic stroke.

      4. Discussion

      Previous studies have proven an improvement of long-term fatality, disability and recurrence rates in Chinese stroke patients during the past 20 years [
      • Tu W.J.
      • Chao B.H.
      • Ma L.
      • Yan F.
      • Cao L.
      • Qiu H.
      • et al.
      Case-fatality, disability and recurrence rates after first-ever stroke: a study from bigdata observatory platform for stroke of China.
      ]. Constipation is a frequent complaint after ischemic stroke. Poststroke constipation has negative effects on the quality of life and patients with constipation may have a poor prognosis, because excessive straining to defecate can increase the intracranial pressure [
      • Harari D.
      • Norton C.
      • Lockwood L.
      • Swift C.
      Treatment of constipation and fecal incontinence in stroke patients: randomized controlled trial.
      ,
      • Coggrave M.N.C.
      • Cody J.D.
      Management of faecal incontinence and constipation in adults with central neurological diseases.
      ]. Scant attention has been paid to poststroke gastrointestinal disorders, and the relationship between behavioral assessments and constipation has not been fully elucidated. Our retrospective study enrolled 222 S patients and examined the correlations of demographic characteristics, neurological deficits, swallowing, ADL, medical complications, nutritional patterns, and poststroke constipation, to identify risk factors.
      The incidence of poststroke constipation was 57.7 %, in line with previous studies. Univariate analysis confirmed that higher NIHSS score, lower ADL score, and swallowing ability, pneumonia, and nasal tube feeding were significantly associated with the development of poststroke constipation. In the multivariate analysis, NIHSS were independent risk factors for poststroke constipation. Evidence have suggested that constipation status is independently associated higher incidence of ischemic stroke and all-cause mortality [
      • Sumida K.
      • Molnar M.Z.
      • Potukuchi P.K.
      • Thomas F.
      • Lu J.L.
      • Yamagata K.
      • et al.
      Constipation and risk of death and cardiovascular events.
      ], however, little was found on the relationship between new-onset constipation and mortality and disability in stroke patients.
      Numerous factors can influence the perception of constipation in patients with acute and subacute ischemic stroke. Fabrizio et al. [
      • Cardin F.
      • Minicuci N.
      • Droghi A.T.
      • Inelmen E.M.
      • Sergi G.
      • Terranova O.
      Constipation in the acutely hospitalized older patients.
      ] found that constipation after stroke was significantly associated with ADL on admission. Patients with a low ADL score may have deficits in cognition, and especially motor ability [
      • Kasner S.E.
      Clinical interpretation and use of stroke scales.
      ]. Impaired motor capacity leads to fewer voluntary activities and reduced gastrointestinal motility, while cognitive impairment leads to a decline in the patient’s ability to judge defecation timing and inhibits the defecation reflex [
      • Zietemann V.
      • Georgakis M.K.
      • Dondaine T.
      • Muller C.
      • Mendyk A.M.
      • Kopczak A.
      • et al.
      Early MoCA predicts long-term cognitive and functional outcome and mortality after stroke.
      ,
      • Abzhandadze T.
      • Rafsten L.
      • Lundgren Nilsson A.
      • Palstam A.
      • Sunnerhagen K.S.
      Very early MoCA can predict functional dependence at 3 months after stroke: a longitudinal.
      ]. We speculate that rehabilitation training and early cognitive intervention could increase ADL scores, rule out constipation symptoms, and improve the quality of life of stroke patients.
      Nasal tube nutrition was also an associated risk factor, with a relative risk over 2.132 times higher than that of oral nutrition. In clinical practice, nasal tube feeding should be provided as soon as possible to patients with, or at risk of, malnutrition under the premise of gastrointestinal tolerance [
      • Wøien H.B.I.
      Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU.
      ,
      • Cahill N.E.
      • Dhaliwal R.
      • Day A.G.
      • Jiang X.
      • Heyland D.K.
      Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study.
      ]. However, studies have shown that the use of nasal tube feeding may induce abdominal distention, diarrhea, and constipation, mainly through its high osmotic pressure, fast infusion speed, low temperature, and poor absorption of fat [
      • Cahill N.E.
      • Dhaliwal R.
      • Day A.G.
      • Jiang X.
      • Heyland D.K.
      Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study.
      ], which predicts a poor prognosis for stroke patients. Malnutrition can also trigger poststroke infection and other complications, and is an important factor affecting patients' neurological function and living ability [
      • Davis J.P.
      • Wong A.A.
      • Schluter P.J.
      • Henderson R.D.
      • O'Sullivan J.D.
      • Read S.J.
      Impact of premorbid undernutrition on outcome in stroke patients.
      ]. We also found that nutritional patterns were associated with swallowing ability. Patients with poor swallowing function were more likely to use nasal tube feeding, and swallowing ability was also a risk factor for poststroke constipation in our study. This suggests that we should actively enhance the swallowing function of stroke patients, which may not only affect the nutritional methods but also the incidence of constipation, which is crucial for recovery from stroke.
      In addition, we found that the NIHSS score was an independent risk factor for constipation after stroke. The higher the NIHSS score, the higher the incidence of poststroke constipation, consistent with previous studies. The NIHSS is used to assess stroke severity, and showed good reliability and validity for predicting the long-term prognosis of stroke in prospective clinical studies [
      • Kasner S.E.
      Clinical interpretation and use of stroke scales.
      ]. Our results found less neurological deficits in the non-constipation group, suggesting a potential value of treating constipation to improve the long-term prognosis of stroke. In previous studies, more severe stroke was associated with a gradual loss of overall autonomic regulation, decreased parasympathetic tone, and a progressive shift toward sympathetic innervation [
      • Liu Z.
      • Ge Y.
      • Xu F.
      • Xu Y.
      • Liu Y.
      • Xia F.
      • et al.
      Preventive effects of transcutaneous electrical acustimulation on ischemic stroke-induced constipation mediated via the autonomic pathway.
      ,
      • De Raedt S.
      • De Vos A.
      • De Keyser J.
      Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area?.
      ,
      • Xiong L.
      • Leung H.W.
      • Chen X.Y.
      • Leung W.H.
      • Soo O.Y.
      • Wong K.S.
      Autonomic dysfunction in different subtypes of post-acute ischemic stroke.
      ]. This shift toward sympathetic innervation may inhibit intestinal and intestinal peristalsis, impair colonic motility, and lead to constipation [
      • Camara-Lemarroy C.R.
      • Ibarra-Yruegas B.E.
      • Gongora-Rivera F.
      Gastrointestinal complications after ischemic stroke.
      ,
      • Schaller B.J.
      • Graf R.
      • Jacobs A.H.
      Pathophysiological changes of the gastrointestinal tract in ischemic stroke.
      ].
      Other complications occurring after stroke were associated with poststroke constipation. The presence of complications, particularly pneumonia, was associated with longer hospital stays and increased mortality in patients with acute stroke [
      • Ingeman A.
      • Andersen G.
      • Hundborg H.H.
      • Svendsen M.L.
      • Johnsen S.P.
      In-hospital medical complications, length of stay, and mortality among stroke unit patients.
      ]. We found that patients with pneumonia tended to develop constipation after stroke. Pulmonary infections can cause intestinal infections, which can in turn affect intestinal function and lead to constipation [
      • Camilleri M.
      Gastrointestinal motility disorders in neurologic disease.
      ]. However, this needs to be confirmed by further research. Therefore, preventing or reducing the incidence of pulmonary infection is important for improving the treatment of patients with acute stroke. However, in the present study, there was no significant age and gender difference in prevalence of constipation.
      Our study had some limitations. First, as a retrospective study, there may have been selection bias. No assessment was made prior to their stroke. Second, despite the high incidence of constipation among stroke patients, there are a lack of high-quality studies and no unified standard for diagnosing constipation. Future studies need to develop effective and reliable screening standards for poststroke constipation. Many factors can cause constipation, such as reduced activity, insufficient intake of water or nutrients, drugs, etc. It is difficult to exclude the influence of such factors and more extensive, multi-center prospective studies are needed. We supposed post-stroke constipation may be associated with in-hospital death and disability, however, no prognostic information was collected in this study, which is also a limitation of this study.

      5. Conclusions

      In conclusion, the incidence of constipation was closely associated with neurological deficits, behavioral performance, pulmonary infection, and nutrition pattern in stroke patients. Therefore, the rehabilitation of stroke patients should be individualized and comprehensive based on the NIHSS, ADL, swallowing and nutritional function assessments. Early prevention and intervention are needed to reduce the occurrence of poststroke constipation and promote the recovery of stroke patients.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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