Physiotherapists are one of the most visible and accessible
healthcare professionals seen by patients. They spend more
time with their patients than most other health
professionals. From evaluation to patient education to
actual patient care, physical therapists spend several hours
per week (and even months) with their patients. Inevitably,
they build trust and rapport with them. The
constancy and rapport developed in time provides an avenue
for patients to communicate their experiences.
One
of the most common gastrointestinal symptom reported to
physical therapists by patients is constipation. A 2005-2008
report of the National Health and Nutrition Examination
Surveys revealed a constipation rate of 10.2% among female
adults (95% Confidence interval) and 4% among male adults
(95% CI: 3.2, 5.0) over 20 years old (P<.001) (1).
Constipation was reported by Fuentes and colleagues to have
a real and potential problem as they tend to increase
mortality among patients who underwent orthopedic surgery
and treated by the traumatology team (2).
Chronic constipation can lead to bowel perforation and
stercoral peritonitis owing to highly compacted feces that
impede venous and arterial circulation in the colon wall as
they compress it. This leads to ischemia that result in
perforation and eventually peritonitis. In some cases this
culminates in death of the patient. This is actually a rare
condition that has been observed only 90 times in the past
century (3, 4).
Other complications of chronic constipation are:
hemorrhoids, anal fissure, fecal impaction and bowel
obstruction, and fecal incontinence (4).
Interestingly, Glia and Lindberg found that patients with
constipation have low scores for general well-being (mean of
85.5, while health population scored 102.9) (5).
In a large multinational survey of burden of constipation on
quality of life, Wald and colleagues found that there was
significant difference in the health-related quality of life
(HRQoL) between constipated and non-constipated persons (6).
Several components in the HRQoL were reduced---most
particular on psychological component (6). Improvement in
the quality of life should be considered by physiotherapist
as they treat patients with constipation for it impacts
their overall compliance to rehabilitation and achievement
of their set physical therapy goals.
Constipation is difficult to precisely define owing to a
wide variety in individual bowel frequency, consistency and
ease of expulsion. Constipation afterall is a symptom and
not a disease per se. It is however common for people to
have at least three bowel movements every week. Having less
frequent bowel movement does not exactly connote
constipation.
For some, straining, feelings of incomplete evacuation or
hard consistency of stool is associated with constipation.
Passing small pellet-sized or lumpy, large stools are
associated with slow bowel transit and are equally difficult
to move than normal stools.
Straining is difficult to qualify and quantify objectively.
In the absence of applying any diagnostic criteria, it is
only when the patient requires enema and disempaction that we
categorically relate their symptom as constipation.
The Rome III Diagnostic Criteria for Functional
Gastrointestinal Disorders (FGIDs) (7) is a widely used
classification system published in 2006 for diseases and
disorders involving clinical symptoms that cannot be
attributed to structural or tissue abnormality.
Functional Constipation, also known as chronic idiopathic
constipation, is constipation that has no anatomic nor
physiologic etiology. Persons who experience this disorder
may be generally healthy but has problem with defecation.
The Rome III criteria for functional constipation include
two or more of the following for at least 3 months with a
symptom onset at least 6 months prior to diagnosis:
a. Lumpy or hard stools in at least 25% of bowel movements.
b. Straining in at least 25% of defecations
c. Sensation of incomplete evacuation in at least 25% of
bowel movements
d. Sensation of anorectal obstruction or blockage in at
least 25% of bowel movements
e. Manual maneuvers to facilitate at least 25% of bowel
movements (such as digital evacuation and support of pelvic
floor).
f. Fewer than three defecations a week.
Also, their loose stools should be rarely present without
the use of laxatives and the signs and symptoms should not
qualify for irritable bowel syndrome.
Although this article primarily focus on adults, it is worth
noting the diagnostic criteria for children (aged 4 to 18
years) (8). Functional constipation is defined as any
constipation without an organic cause. Thus, Rome III
criteria merged the overlapping signs and symptoms of
functional constipation and functional fecal retention.
The criteria should be fulfilled for at least once per week
for at least two months prior to diagnosis. The criteria for
constipation should include two or more of the following in
a child with developmental age of at least 4 years (and the
signs and symptoms not meeting the criteria for the
diagnosis of irritable bowel syndrome):
a. Two or more defecations in the toilet per week.
b. At least one episode of fecal incontinence per week.
c. History of retentive posturing or excessive volitional
stool retention
d. History of painful or hard bowel movements
e. Presence of a large fecal mass in the rectum.
f. History of large diameter stools which may obstruct
the toilet.
Table 1 - Adapted from
Harrison's Principles of Internal Medicine, 18th Edition (9)
|
Type of
Constipation and Causes |
Examples |
| Recent
Onset |
|
| Colonic
Obstruction |
Neoplasm;
stricturej: ischemic, diverticular,
inflammatory |
| Anal
sphincter spasm |
Anal
Fissure, painful hemorrhoids |
| Medications |
See Table 2. |
| Chronic
|
|
| Irritable
bowel syndrome |
Constipation-predominant, alternating |
| Medications
|
Calcium
Channel Blockers, Antidepressant |
| Colonic
pseudoobstruction |
Slow-transit
constipation, megacolon (rare Hirshsprung's,
Chagas' diseases) |
| Disorders of
rectal evacuation |
Pelvic floor
dysfunction; anismus; descending perineum
syndrome; rectal mucosal prolapse; rectocele |
|
Endocrinopathies |
Hypothyroidism, hypercalcemia, pregnancy |
| Psychiatric
disorders |
Depression,
eating disorders, drugs |
| Neurologic
disease |
Parkinsonism, multiple sclerosis, spinal
cord injury |
| Generalized
muscle disease |
Progressive
systemic sclerosis |
|
Physical therapists often treat patients with symptoms of
chronic pain. Over the counter Nonsteroidal Antiinflammatory
Drugs (NSAIDs) like aspirin are commonly used. Among those over 65
years old, aspirin users were found to have functional
constipation rather than outlet delay (10).
Even though physical therapists are not expected to provide
full detailed advise about medicines and medication, a more
detailed list of medicines, herbal supplements and home
remedies are important for clinicians to arrive at the right
diagnosis.
Table 2 - Drugs to
lookout for in your patient's cabinet
|
Class of Drug |
Common Brands |
| Antacids |
Prilosec
OTC, Prevacid 24hr, Tums, Zantac 150, Gas X |
| Calcium
Supplements |
Caltrate,
CalMax, AlgaeCal Plus, Citracal Plus |
| Iron |
Feosol, Fer-in-Sol,
Slow-Fe |
|
Antidiarrheal agents |
Imodium,
Kaopectate II, Imodium A-D, Maalox Anti-diarrheal |
| NSAIDs |
Naproxen,
Naprelan Naprosyn, Aleve |
| Opiates |
The most
well known class to cause constipation.
Oxycodone is more likely to cause
constipation than transdermal fentanyl. |
|
Anticholineric agents |
Propulsid |
| Tricyclic
antidepressants |
Sinequan,
Adapin. Aventyl, Pamelor |
| Calcium
Channel Blockers |
Sular,
Norvasc, Cardene SR, Adalat, Procardia |
|
Antiparkinsonism Drugs |
Sinemet,
Exelon, Parlodel, Parcopa |
|
Sympathomimetics |
Didrex |
|
Antipsychotics |
Abilify,
Invega, Risperdal, Zyprexa |
| Diuretics |
Lasix, Bumex,
Aldactazide |
|
Antihistamines |
Claritin,
Alavert, Didrez |
|
The scope of physical therapy practice require attention to
this problem since constipation is a symptom of pelvic floor
disorders (11).
Table 3 - Medicines
Patients May Take To Relieve Constipation
- Adapted from WebMD.com (12)
and Epocrates.com (13)
|
Medicine |
How it Works |
| Linaclotide
(Linzess) |
Activates
guanylate cyclase-C, stimulating cGMP
production and increasing fluid secretion
and motility. Not given to persons younger
than 17 years old. Often taken by adults
with IBS at 1 capsule of 145 ot 290mcg more
than 30 minutes before first meal. |
| Polyethylene
glycol (Glycolax) |
PEG is an
osmotic laxative which drives water into the
lumen of the colon thereby softening the
stool. Taken by dissolving 17g packet in
liquid. Relief may occur after 4 days of
intake. Not to be taken for prolonged
periods. |
| Lubiprostone
(Amitiza) |
Activates
CIC-2 chloride channels that increase
intestinal fluid secretion and motility.
This reduces intestinal permeability and
stimulate recovery of mucosal barrier
function. Tablet of 24mcg taken PO BID, with
food and water. Not to be taken for
prolonged periods. |
| Lactulose (Duphalac) |
Increases
stool water content; increases stool acidity
and trapping NH4 ions (osmotic laxative).
One tablespoon (15ml) PO QD-BID. Results may
be seen after 24-48h of intake. |
| Psyllium |
Bulk
laxative. It increases stool bulk. To aid
movement of feces. Taken 3.4g PO qd then
increased slowly. It should be dissolved in
water or juice and requires additional
glasses of water to avoid bloating. |
|
A study conducted by Ramkumar and Rao revealed that use of
PEG, tegaserod, lactulose and psyllium are effective. Other
commonly used agents such as bisacodyl, stool softener,
senna, and milk of magnesia does not have adequate quality
data to evaluate their effectiveness (14).
Table 4 - Home
Remedies the patient may be taking to relieve constipation
- Adapted from
Top10HomeRemedies.com (15)
|
Top 10 Home
Remedies |
How They Are
Commonly Used |
| Lemon |
Mixed with
water, salt or sugar and taken by patients
in the morning. |
| Flax Seed |
Rich in
fiber and omega-3 fatty acids, this is taken
daily before going to bed. |
| Castor Oil |
Laxative. A
teaspoon usually swallowed by patients. |
| Fiber |
Adds volume
to feces. Fruits and veggies rich in fiber
are: beans, potatoes, carrots, prunes, nuts,
peas, etc. |
| Water |
In some
cases, patients would keep water overnight
in copper vessels. Regular intake of 8
glasses is recommended. |
| Spinach |
Eaten raw or
cooked. Drink a mixture of half glass of raw
spinach juice and half glass of water. |
| Molasses |
Two
tablespoons are usually taken before
sleeping. This is not recommended for those
with diabetes or who have difficulty
digesting high-caloric foods. |
| Cabbage |
Rich in
dietary fiber which help cleanse the body. A
cup of cabbage juice may be used by patients
to relieve constipation. |
| Grapes |
Laxative
effect provided by cellulose, sugar and
organic acid in grapes. Raisins soaked in
water may also be used. |
| Figs |
High in
fiber. Fresh and dried figs often used and
eaten with skin just prior to sleeping. |
|
What physiotherapists can do?
Physiotherapist can assist the patient deal with
constipation through skillful evaluation, comprehensive
education, and prompt referrals.
Educating the patients about healthy bowel movement
practices should be done. Patients should be encouraged to
do the following:
a. Respect the call of nature. The natural movement of the
bowel is at its peak once it is felt. One may miss the
opportunity if ignored.
b. Encourage having a daily habit. Mornings typically have
the most effective colonic activity. They may have breakfast
before going to the bathroom to "jumpstart" their gut.
Natural peristalsis is stimulated by food traversing the
stomach.
c. Increase fluid intake to at least 8 glasses per day. Low
fluid consumption was a predictor of constipation among
women. Markland and colleagues found conclusive evidence for
effectiveness of increased fluid intake in preventing
constipation (1).
d. Eat 15 to 25 grams per day of high-fiber rich foods. This
will add bulk to the stool thereby easing its flow through
the bowel. The daily fiber requirement is approximately
equal to at least 3 medium-sized apple with skin, 1 cup of
raspberries, 5 cups of brown rice, 2 cups of cooked green
peas, or 3 cups of boiled broccoli. Inform patients with
pelvic floor dysfunction that fiber intake will not relieve
them of constipation. Advise the patient to gradually
increase fiber intake by 5 grams per day. Bloating can
happen but lessens through regular intake.
e. Exercise regularly. Aside from its overall cardiovascular
benefit, upright position and movement improve peristalsis
(12).
Patients and their family members should be taught on pelvic
floor anatomy, normal bladder and bowel function, food and
other substances that can cause constipation.
Toilet training of patients with constipation should
emphasize proper breathing techniques to avoid straining.
Patients should perform "huffing" expiration technique while
evacuating. By huffing, the abdominal oblique muscles are
activated which assist in peristalsis.
Techniques to prevent pudendal nerve impingement that may
occur with prolonged sitting in the toilet should be done.
This is properly demonstrated by raising one of the foot on
a stool while sitting and the trunk leaning forward.
Patients can also benefit from massaging of the abdominal
wall (16). A constant firm pressure applied in a circular
motion by fingers along the normal colonic peristaltic flow
from the right lower quadrant of the abdomen and inching
upward close to the right subcostal area then transversely
to the left upper quadrant and later descending to the left
lower quadrant of abdomen. This movement should then proceed
slightly upward towards the umbilicus and descend finally
towards the hypogastric area.
The patient with pelvic floor dysfunction (PFD) are the best
candidate with constipation for physical therapy. This
problem occurs after years of chronic constipation and the
practice to strain and evacuate. It is estimated that around
half of those with chronic constipation have dyssynergia or
PFD (17).
Pelvic floor dysfunction encompass several problems related
to pelvic pain, sexual dysfunction, bladder and bowel
disorders (constipation and incontinence). The problem with
PFD is on the delayed pelvic floor muscle relaxation that
should coincide with abdominal wall motion. This may sound
simple but in reality it is counterintuitive when the body
maintains the pelvic floor at a constant tone rather than
relaxed.
Physical therapists with advance training specializing in
this field are skilled in rectal and vaginal examination
(11). They can help patients avoid expensive medical
treatment, complications, and delayed recovery period.
Rectal examination will begin with inspection of the
perineum if there are any external hoemorrhoids, scars,
fistulas or fissures. The skilled physiotherapist may ask
the patient to strain and observe the degree of perineal
descent which normally range from 1 to 3.5cm.
If the degree of descent is less than the normal range,
pelvic laxity is probable. This may be due to multiparity or
weakness after childbirth and years of straining.
Digital rectal examination should be directed to assess if
there is tenderness in the puborectalis muscle. The patient
should then be asked to do a Valsalva Maneuver and try to
expel the finger of the physical therapist.
Balloon expulsion test should be done for patients with
suspected pelvic floor dysfunction. This is done by having
the patient evacuate a balloon filled with 50ml of water.
This can also be done as part of the biofeedback treatment.
Biofeedback is one of the physiotherapist's best
armamentarium for pelvic floor dysfunction. It has been
found beneficial for up two-thirds of patients who underwent
treatment with this modality. It is used to retrain the
pelvic muscles to relax adequately during defecation.
The most common biofeedback techniques employed by
therapists are sensory training, manometric feedback and
electromyographic feedback.
Sensory training is the earliest biofeedback technique
employed. The most common method is with the water-filled
balloon of varying volume that the patient has to
consciously sense in the rectum and allow its withdrawal by
relaxation. This is challenging for the patient considering
that the water-filled balloon can conform to the lumen of
the rectum and does not exert firm pressure on the lumen
wall.
Manometry is a more objective means of detecting and
measuring the anal canal pressure through solid-state
probes, balloons, or perfused catheters.
Like manometry, electomyography utilize intraluminal probes
or electrodes taped in the perianal skin for measurement and
detection of pelvic floor muscle activity. The muscle
activity are then transmitted as a video recording for the
patient to monitor. The technique requires the patient to
relax the pelvic floor muscle and, as the patient becomes
more skilled in relaxing, gradually increase the abdominal
pressure. The physical therapist provides verbal feedback to
the patient so they will recognize when the pelvic floor is
relaxing and how the muscle contracts.
When comparing different biofeedback methods, Heyman et al
noted that outpatient intra-anal electromyographic
biofeedback training; electromyographic biofeedback training
plus intrarectal balloon training; and electromyographic
biofeedback trainng, balloon training, and home training
were found to produce significant increase in unassisted
bowel movement.
Heyman et al concluded that employing electromyographic
biofeedback alone was just as effective as with the addition
of balloon training, home training, or both (18).
Studies on biofeedback as a treatment option for children
are still equivocal in their findings. Some reported
effectiveness in the short term treatment but has no clear
long-term benefit (19).
Kegel exercise is effective in improving bowel and bladder
contince. It should be incorporated in the home exercise
program as 10 repititions of pelvic floor muscle
contractions held for 3 seconds. This is done in the supine
position and progressed eventually to sitting upright and
standing. This is to be repeated 3 times per day. Patients
can check if they are doing it right by contracting their
pelvic floor muscles while urinating. If the urination
stops, then they are doing it correctly.
Patients, particularly those older than 40 years old, should
be referred for immediate physician consultation when their
symptom of constipation is associated with weight loss,
anemia, change in stool caliber, rectal bleeding. Procedures
such as sigmoidoscopy with or without barium enema, or
colonoscopy may be done to rule out colon cancer (a
structural cause for constipation).
Physical therapists are entrusted with the patient's life
and health condition owing to their professional stature,
clinical expertise and wisdom gained through years of
practice. Constipation as a symptom may be mundane to even
raise the alarm in the clinician's day. But it is in fact an
important symptom of various clinical condition and a
harbinger of unnecessary morbidity and unwanted mortality.
Constipation is an important clue to the patient's overall
health status and clinical well being that investing time to
understand such complaints when they come up and address
them accordingly resonates with huge dividends for the
benefit of the patient and the therapist's conscientious
performance of professional duty.
Last revised: May 21, 2013
by Richard Philip Kochoa, PT, MD
References
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Fiber and Liquids With Constipation: Evidence From the
National Health and Nutrition Examination Survey. The
American Journal of Gastroenterology. 108, 796-803. May
2013.
2. Fuentes, R, et al. Constipation Opposes Well-Being.
Revista de Enfermia. 2004.
3. Huang, WS et al. Management of patients with stercoral
perforation of the sigmoid colon: report of five cases.
World Journal of Gastroenterology. 2006.
4. Leung, L. et al. Chronic Constipation: An Evidence-Based
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2011.
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http://www.top10homeremedies.com/home-remedies/home-remedies-for-constipation.html
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