As much as we would like to avoid the topic, poop happens. Or in many uncomfortable cases, it doesn’t. According to the statistics, approximately 20% of adults between 40-75 have constipation. And those numbers are just the base level, run-of-the-mill, stopped-up versions. The actual numbers increase significantly with additional factors:
- Older > Younger
- Female > Male
- Psychologic factors – stress or anxiety
So are you constipated? Many consider themselves not to be constipated if anything at all is coming out. However, the actual Rome IV definition (most recent consensus of the medical community – May 2016) might surprise you.
Under ‘normal’ circumstances, here’s what happens:
- Peristalsis (involuntary pumping contractions in the colon) delivers fecal matter to the rectum (usually 1-4 days to pass through the entire GI tract)
- Once stool is in the rectum, “sampling” occurs – meaning the internal sphincter relaxes to determine gas, liquid or solid
- External sphincter contracts to hold in stool during sampling
- Once you’re at the appropriate location, sitting or squat to increase the anorectal angle (best position of pelvic muscles to release stool)
- External anal sphincter and pelvic floor muscles relax
- SLIGHT bearing down assists in getting the stool out (should be mostly a passive event, though!)
- Pelvic floor muscles (puborectalis in particular), internal and external anal sphincter return to normal resting state once you’re done.
When this process is disrupted at any level, constipation follows. Here’s the medical jargon for being “stopped up” (ie, functional constipation):
Some version of these symptoms happening >25% of the time consistently over 3 months (must include 2 or more of the following):
- Lumpy or hard stools
- Sensation of not emptying completely
- Sensation of blockage at the anus
- Manual pressure or support required to get stool out
- Fewer than 3 spontaneous poops per week
And for those who learn better visually…here is the Bristol Stool Chart. Basically if you usually have type 3 or lower, that’s constipation.
TYPES and CAUSES
Did you know there are different kinds of constipation? Travel, lack of activity, dietary changes and medication are all examples of things that can get in the way of regularity.
The Rome IV group addressed the various complexities of bowel function, identifying many factors that drive it. Some of those include altered gut bacteria or immune function, opiod use, and hormone function. (In reality, a very large percentage of medications have constipation as a side effect, not just opiods.)
Understanding the underlying cause(s) of constipation is needed to best determine the appropriate steps to resolve it. That is why it can be very confusing. Sometimes a treatment will help constipation and other times it will worsen it. It’s important that the type of constipation is identified in order to best treat it.
HOME OPTIONS – HOW TO HELP YOURSELF
Some constipation is normal. It happens to almost everyone every now and then and can often be treated at home. There are so many options for over-the-counter treatments – supplements, laxatives, stool softeners, probiotics, prebiotics, enemas, etc.These are available for a reason. At the right time and for the right (short-term) reason – they work! But the most important factor here is “short-term”. Once constipation becomes long-term, or even life-long, then it needs to be addressed by other methods.
Some simple changes you can make to help move things along….
- Body positioning – getting the right angle to allow poop to exit. That means knees above the hips and body leaning forward. Think of approximating as close as possible to a squat. To help with this, use a stool under the feet on either side of the toilet. You can make your own, or there are others available, like the “squatty potty”.
- Fiber and Fluid Intake – The VERY first thing you should do to try to address constipation is drink water. Yes, fiber is important (and sorely lacking in the US diet), but if it is not matched with increased water then it can actually back you up more.
- Dietary modification – Getting fiber from your diet is the best, supplementing with over-the-counter fiber mix-in’s is next. There are lots of good sources of fiber, some better than others. Start with small increases each day – add 2-5g of fiber (plus water!!) daily for 3-4 days to get started.
So what about when even THAT doesn’t help? Now what?
Here is where physical therapy can be a game-changer. Usually in some combination with the above factors, PT can provide the missing link toward easy, consistent pooping!
PHYSICAL THERAPY TREATMENT OPTIONS
For functional constipation, especially with outlet-obstruction, pelvic floor dysfunction (PFD) is a major contributing factor. Good news! “Pelvic floor rehabilitation or biofeedback is the treatment of choice for PFD [pelvic floor dysfunction], and its efficacy has been proven in clinical trials.” That means PT for constipation works!
Here are some ways we can help:
- Exercise – Sometimes the last thing you want to do is move when you’re backed up. However, activity actually boots digestive transit time (ie, moves things along). PT can introduce you to comfortable and effective exercise / movement strategies.
- Manual techniques – There are a range of hands-on techniques that address constipation and the most appropriate depends on your particular issue.
- For some, the neural component or ‘messaging’ from the nervous system to the colon, needs to be addressed. Research has shown that people receiving thoracic/lumbar mobilizations showed “significantly larger declines in…transit time” than those receiving dietary fiber modification alone.
- Those with scar tissue from surgeries or long-term constipation may benefit abdominal ‘I-love-u’ massage and/or visceral mobilization techniques to allow improved peristalsis.
- Pelvic floor training – If it moves through the system, but can’t get out at the end, that’s outlet-obstruction. PT can teach you to retrain the coordination of pelvic floor alone and with other muscles, retrain the ano-rectal communication and reduce any asymmetry or tension patterns that limit pelvic floor coordination.
- Gadgetry: There are several options that can help give you information about just what’s going on. Biofeedback (BFB) is basically a form of EMG – it measures muscle activity and gives you the information. Balloon retraining can be helpful in the case of altered compliance or rectal awareness (can’t tell if / when the muscles should contract or relax). Perineal electrical stimulation is another option, but usually used for fecal incontinence more than constipation.
- A note about BFB…. Most of the research done on pelvic floor treatment of constipation has been done using biofeedback, which is why it might be the thing your MD recommends. Here’s the thing, though – biofeedback just means information you receive about your body. A mirror is a powerful (and simple) BFB tool. There is a HUGE range of more technical options available, from clinic EMG units to simple apps on your phone. These are options, but also have limitations. Many of us don’t use them as much anymore because of their limitations, but they can be helpful in the right situation.
- Breath and mechanics retraining – Training the respiratory diaphragm, abdominals and pelvic floor to coordinate appropriately keeps the pressure where you want it, when you want it. This is such a well-known correlation, you can easily find advice online such as “yoga positions to help you poop”. However, a PT can instruct you in the exact positioning and coordination training that would benefit your particular issue. We also have tools, such as the Redcord Neurac system, which help retrain the neuromuscular system directly for faster and more consistent results.
Permission to use copyright image from Pelvic Guru, LLC
MEDICAL TESTING AND TREATMENT OPTIONS
If you’ve tried the self-care and PT routes but still have the same symptoms – now what? Here is where medical testing and treatment may be most helpful.
Some of the more commonly used tests to determine what’s going on are these:
- Defecogram – use barium and X-ray to watch defecation – evaluates completeness of emptying, anorectal angle
- Colonic transit studies (Sitz marker study) – identifies problem with transit time of stool; you swallow radiopaque markers and X-rays are taken 3-7 days later to see if markers have traveled all the way through and/or how many are left / where they are stopping (avg normal is 24-72 hours transit)
- Anorectal Dysfunction studies – series of studies measuring rectal sensation; rectal compliance; internal and external sphincter pressure at rest, contraction, and filling; rectal reflexes; and expulsion patterns
- Scopes – anoscope, sigmoidoscopy, or colonoscopy – flexible tube with light/camera on the end – biopsies are able to be taken if needed (diverticulitis, polyps, cancerous lesions).
Medication is a consideration as well. Providing a list of FDA approved medications and supplements is not within the scope of this post. However, many are available and can be helpful should the more conservative measures mentioned above not get things going.
Keep in mind the “short-term” warning though! Remember that taking stimulant laxatives for a long period of time causes abdominal distension, chronic diarrhea, excessive gas, nausea, and vomiting. Moreover, you can become dehydrated if you do not drink enough water while taking laxatives, thereby worsening the constipation.
Other treatment options such as sacral nerve stimulation or botox injection have not been supported by research as of yet to be effective in the treatment of constipation.
CONCLUSION – Whatever method or combination of methods are used, improving the mechanics of defecation can only help for long-term relief. Even if medication or other interventions are needed, reducing the need for straining can only help maintain the outcomes.
We are here to help! Pelvic physical therapists are trained not only in the pelvic floor function and bowel retraining, but also in pressure regulation, abdominal and trunk coordination with the pelvis and breathing / respiration training.
*Bowel Disorders Brian E. Lacy,1 Fermín Mearin,2 Lin Chang,3 William D. Chey,4 Anthony J. Lembo,5 Magnus Simren,6 and Robin Spiller7 Gastroenterology 2016;150:1393–1407
*Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice Simren, M, Palsson, O, Whitehead, W. Curr Gastroenterol Rep. 2017; 19(4): 15.
*Prevalence of Chronic Constipation and Its Associated Factors in Pars Cohort Study: A Study of 9000 Adults in Southern Iran. Moezi, P, et al.Middle East J Dig Dis. 2018 Apr; 10(2): 75-83.
*The effects of Maitland Orthopedic Manual Therapy on Improving Constipation. Koo, J-P, Choi, J-H, and Kim, N-J. J Phys Ther Sci. 2016 Oct; 28(10): 2857-2861.
*Epidemiology and Management of Chronic Constipation in Elderly Patients. Roque, MV and Bouras, EP. Clin Interv Aging. 2015; 10: 919-930.