Constipation

Done Bye: Mariam Droubi.

What is constipation?

Constipation refers to bowel movements that are

infrequent or hard to pass.[2] Constipation is a common
cause of painful defecation. Severe constipation includes
obstipation (failure to pass stools or gas) and
fecal impaction, which can progress to bowel obstruction
and become life-threatening.
You are considered constipated if you have two or more
of the following for at least 3 months:
Straining during a bowel movement more than 25% of
the time.
Hard stools more than 25% of the time.
Incomplete evacuation more than 25% of the time.
Two or fewer bowel movements in a week.

Causes:

The causes of constipation can be divided

into congenital, primary, and secondary.[2]
The most common cause is primary and
not life threatening.[12] In the elderly,
causes include: insufficient dietary fiber
intake, inadequate fluid intake, decreased
physical activity, side effects of
medications, hypothyroidism, and
obstruction by colorectal cancer.[13]

Constipation is usually caused by a disorder of bowel function rather than a

structural problem. Common causes of constipation include:
Inadequate water intake
Inadequate fiber in the diet
A disruption of regular diet or routine; traveling
Inadequate activity or exercise or immobility
Eating large amounts of dairy products
Stress
Resisting the urge to have a bowel movement, which is sometimes the result of
pain from hemorrhoids
Overuse of laxatives (stool softeners) which, over time, weaken the bowel muscles
Hypothyroidism
Neurological conditions such as Parkinson's disease or multiple sclerosis
Antacid medicines containing calcium or aluminum
Medicines (especially strong pain medicines, such as narcotics, antidepressants, or
iron pills)
Depression
Eating disorders
Irritable bowel syndrome
Pregnancy
Colon cancer
In some cases, lack of good nerve and muscle function in the bowel may also be a
cause of constipation.

Symptoms:

Infrequent bowel movements and/or difficulty

having bowel movements
Swollen abdomen or abdominal pain
Pain
Vomiting
stomach aches and cramps
feeling bloated
feelingsick
loss of appetite

How Is Constipation Diagnosed?

Most people do not need extensive testing to diagnose constipation. Only a

small number of patients with constipation have a more serious medical
problem. If you have constipation for more than two weeks, you should see
a doctor so he or she can determine the source of your problem and treat it.
If constipation is caused by colon cancer, early detection and treatment is
very important.
Tests your doctor may perform to diagnose the cause of your constipation
include:
Blood tests if a hormonal imbalance is suspected
Barium studies to look for obstruction of the colon
Colonoscopy to look for obstruction of the colon
The vast majority of patients with constipation do not have any obvious
illness to explain their symptoms and suffer from one of two problems:
Colonic inertia. A condition in which the colon contracts poorly and retains
stool
Obstructed defecation. A condition in which the person excessively
strains to expel stool from the rectum

Preventions:

Constipation is usually easier to

prevent than to treat. Following the
relief of constipation, maintenance with
adequate exercise, fluid intake, and
high fiber diet is recommended.[5]
Children benefit from scheduled toilet
breaks, once early in the morning and
30 minutes after meals.

PhysioTherapy MANAGEMENT OF
CONSTIPATION:

a. Lifestyle changes
i. Modify Diet (increase fiber and fluid intake)
ii. Exercise regularly
b. Educate the patient about toileting techniques to avoid
straining during a bowel movement in order to decrease
the risk of developing pudendal nerve dysfunction. These
techniques are:
i. Leaning forward while sitting on the toiled with feet
positioned on a step stool (this position decreases the
anorectal angle, thus easing the evacuation of stools)
ii. Perform huffing (forced respiratory expiration) rather
than straining during defecation (this technique activates
the abdominal oblique muscles, which assist in the
propulsion of stools)

c. Propulsive abdominal bowel massage to promote bowel mobility

throughout the colon. It helps in increasing peristalsis in the gut. It is
beneficial as its safe, non-invasive technique and can be performed by
the patient independently.
i. Technique: Apply constant moderate pressure to the abdomen with 2
or 3 fingers. Small, clockwise circular movements are initiated at the
right anterior superior iliac spine, which is located at the base of the
ascending colon. The progression of the massage occurs cranially, up
the ascending colon towards the base of the rib cage, where it meets
the transverse colon. The circular movements are continued across the
transverse colon toward the left upper quadrant of the abdomen and
then down over the descending colon toward the left anterior superior
iliac spine. This massage should be performed daily for 10 minutes.
d. Exercises to strengthen pelvic floor and sphincter muscles. Aerobic
exercises also help in increasing gut transit.
e. Retraining pelvic floor muscle functioning during evacuation. This
can be done by using Biofeedback. Patients can be trained to relax
their External Anal Sphincter (EAS) during straining as well as to
coordinate abdominal contractions to assist stool propulsion into the
rectum

PHYSICAL THERAPY TREATMENT FOR

CONSTIPATION / PELVIC FLOOR DYSSYNERGIA

Constipation is a common disorder primary care physicians and

gastroenterologists diagnose on a regular basis. There are many causes, but
when constipation is due to pelvic floor dyssynergia, which are restricted pelvic
floor muscles around the anal region that contract instead of relax during
attempted bowel movements, a licensed physical therapist, trained in pelvic floor
dysfunction can reverse constipation and help you resume normal bowel
function.
The pelvic floor is a group of muscles at the base of the pelvis that help control
sexual, urinary and bowel function. These muscles, namely the puborectalis,
levator ani and coccyxgeus must relax and contract properly to maintain urinary
and fecal continence, sexual function and proper voiding habits. When the pelvic
floor muscles fail to relax and contract properly, this can be referred to as pelvic
floor dyssynergia. The inability to relax and contract the pelvic floor muscles
correctly can lead to symptoms of constipation, straining with bowel movements,
and feelings of incomplete evacuation.
Some of the physical therapy treatments for constipation include external and
internal rectal myofascial release techniques, trigger point release techniques,
biofeedback therapy to help down train tight muscles and/or up train weak
muscles, instruction to correct bowel techniques to prevent straining, instruction
in home exercise program to stretch and strengthen pelvic floor, hip and gluteal
muscles.

Manual therapy is needed to reduce the tension, adhesions, and knots in muscles
that cause them to become dysfunctional. This treatment is always with a patients
permission, may be uncomfortable, but overall a very successful approach to
rehabilitate faulty pelvic muscles patterns that resulted in constipation.
Biofeedback therapy helps retrains your pelvic floor muscles ability to contract and
relax within their full range of motion. It is a treatment which requires insertion of a
rectal sensor (sensor is the size and length of a pinky) to measure pelvic floor muscle
tension through electromyography (EMG). The EMG activity is visually displayed on
the biofeedback unit so you can see what your muscles are doing and learn to better
control these muscles with verbal and tactile cueing from the physical therapist.
Identifying the internal sensations associated with the relaxation and how to maintain
the ability for your pelvic floor muscles to be at a relaxed state throughout the day is
taught as well.
Specific stretching and strengthening exercises are taught for the pelvic floor; the
abdomen and pelvic girdle (the gluteal, hamstring and adductor musculature).
Manual therapy such as soft tissue mobilization and trigger point release are
administered to tight and restricted tissue both to the lower abdominal region and
pelvic floor musculature to help increase blood flow, decrease restrictions and
promote healing. Education regarding normal bowel function and identification of
problematic toileting habits is also an important step to recovery.
By complying with a pelvic floor physical therapists recommendations, you can be
well on your way to pain free and stress free bowel function no more constipation!

What Are the Treatments for

Constipation?

Most cases of constipation respond to conservative treatment, such as

dietary and exercise changes or mild laxatives.
Your doctor will probably start treatment by recommending more fiber or
bulk in your diet. Except for fiber or bulking agents, over-the-counter
laxatives should be avoided. Your doctor will also encourage you to take
adequate time for moving your bowels and not to suppress the urge to
have a bowel movement. Increasing exercise is also important if you lead
a sedentary lifestyle. For stubborn constipation in older children or adults,
the doctor may recommend a non-digestible sugar called lactulose or
specially formulated electrolyte solutions. Polyethylene glycol (MiraLAX)
is available over the counter for short-term use in constipation in children
and adults..
Fecal impaction is a more serious form of constipation that sometimes
affects the elderly and disabled. To release hardened material in the
rectum, a doctor inserts a gloved finger and manually breaks up the
solidified stool. A gentle enema using warm water or mineral oil may also
be helpful.