Keeping in pace with the rapid growth and development in the medical field, physiotherapy is also widening its horizons. It has become an integral part of management of a wide variety of diseases. Its largest concern is related to the management of constipation in patients.
Constipation may be defined as infrequent motions (fewer than 3 times a week) or the need to strain at defecation. It has been reported to affect between 2 & 34% of adults. It is more prevalent in women and people over the age of 65 years.
a. NORMAL TRANSIT CONSTIPATION
i. Most prevalent subgroup of constipation
ii. In this, the stools move through the colon at a normal rate and stool frequency is normal yet patients believe that they are constipated because of a perceived difficulty with evacuation or the presence of hard stools.
b. DEFECATORY DISORDERS
i. Result from pelvic floor or anal sphincter dysfunction such as pelvic floor dyssynergia, spastic pelvic floor syndrome and anismus.
ii. In this, the external and sphincter contracts and tightens rather than relaxing and opening during defection.
iii. It is characterized by straining and incomplete bowel emptying
c. SLOW TRANSIT CONSTIPATION
i. Result from decreased neuromuscular function of the colon
ii. It is usually idiopathic
iii. Assorted with symptoms of an infrequent urge to defecate, bloating and abdominal pain discomfort, in addition to dry, hard stools.
Rome II criteria is commonly used for the diagnosis. It includes:
a. Bowel frequency of < 3 times per week
b. Need to strain more than 25% of the time during defection
c. Lumpy or hard stools for more than 25% of bowel movements.
d. Sensation of incomplete evacuation or anorectal blockage for more than 25% of bowel movements.
e. Need for manual maneuvers (digital evacuation or support of the pelvic floor) to facilitate more than 25% of bowel movements
Two or more of these symptoms must be present for atleast 12 (consecutive or non-consecutive) weeks within the 12 month period.
COMPLICATIONS: Include prolapsed, pelvic floor muscle weakening, perineal descent.
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.
Normal transit and slow transit constipation are managed well by directly modifications, exercises and abdominal massage, whereas defecatory disorders require retraining of pelvic floor muscle function.
Constipation may be defined as infrequent motions (fewer than 3 times a week) or the need to strain at defecation. It has been reported to affect between 2 & 34% of adults. It is more prevalent in women and people over the age of 65 years.
ETIOLOGY & CLASSIFICATION:
The etiology for constipation is often multifactorial possible the sign of an underlying organic disease. It may also be attributable to lesions or structural abnormalities within the colon. These abnormalities may result in compression or narrowing of the intestines and rectum, causing difficulty in passing stools. Once disease and structural abnormalities are ruled out, constipation can be subdivided into:a. NORMAL TRANSIT CONSTIPATION
i. Most prevalent subgroup of constipation
ii. In this, the stools move through the colon at a normal rate and stool frequency is normal yet patients believe that they are constipated because of a perceived difficulty with evacuation or the presence of hard stools.
b. DEFECATORY DISORDERS
i. Result from pelvic floor or anal sphincter dysfunction such as pelvic floor dyssynergia, spastic pelvic floor syndrome and anismus.
ii. In this, the external and sphincter contracts and tightens rather than relaxing and opening during defection.
iii. It is characterized by straining and incomplete bowel emptying
c. SLOW TRANSIT CONSTIPATION
i. Result from decreased neuromuscular function of the colon
ii. It is usually idiopathic
iii. Assorted with symptoms of an infrequent urge to defecate, bloating and abdominal pain discomfort, in addition to dry, hard stools.
DIAGNOSIS:
It is difficult because constipation is a symptom rather than a disease, and its diagnosis is based primarily on the patients’ perception of normal bowel function.Rome II criteria is commonly used for the diagnosis. It includes:
a. Bowel frequency of < 3 times per week
b. Need to strain more than 25% of the time during defection
c. Lumpy or hard stools for more than 25% of bowel movements.
d. Sensation of incomplete evacuation or anorectal blockage for more than 25% of bowel movements.
e. Need for manual maneuvers (digital evacuation or support of the pelvic floor) to facilitate more than 25% of bowel movements
Two or more of these symptoms must be present for atleast 12 (consecutive or non-consecutive) weeks within the 12 month period.
COMPLICATIONS: Include prolapsed, pelvic floor muscle weakening, perineal descent.
PT MANAGEMENT OF CONSTIPATION
a. Lifestyle changesi. 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.
Normal transit and slow transit constipation are managed well by directly modifications, exercises and abdominal massage, whereas defecatory disorders require retraining of pelvic floor muscle function.