The Constipation Connection

If there is one “pelvic health” related area that orthopedic therapists should be discussing with their patients it is the question of whether the patient is experiencing constipation. There are multiple reasons why this applies in an orthopedic setting.

First, many patients seen in an orthopedic setting are taking prescription pain medication that has constipation as a side effect. Many times, these medications are prescribed with no explanation of this possible side effect or how to manage it.

Second, stool buildup takes up space in an area where pressure from this buildup can lead to altered neurologic input (nociceptive or just inaccurate). This can negatively impact your attempts to encourage pain free movement. We don’t currently know what direct impact (if any) this pressure differential has on muscle activation in the area, but it is possible that there could be an impact there as well.

Third, if the patient is experiencing constipation that, in combination with their other subjective and objective measurements, this might lead you to consider the pelvic floor as a source of pain/dysfunction. Additionally, if the pelvic floor is not working optimally as a result of the constipation, simply helping clear that up can be very helpful in getting the pelvic floor to help instead of hurt your movement patterns.

Finally, straining can have a very negative impact on many common orthopedic problems (especially low back and hip pain)-and working with patients on getting their bowels regulated can be just as important and beneficial as working on workplace ergonomics and frequent enough movement breaks from the computer.

It is helpful to let patients know that constipation actually refers more to the firmness of stool than to the size or frequency. It is possible to have daily bowel movements but still be experiencing constipation. I like to use the Bristol Stool Scale to get a better picture of how the patient’s bowels are moving, as many people don’t really have a good concept of what a normal bowel movement looks like (think about it-most people don’t really stand around comparing!).

If you have a patient who is experiencing constipation, there are a few simple/easy things you can encourage them to do that will be extremely helpful. First, adequate water intake is absolutely crucial-so there is yet another reason to have that discussion with your patients. The body pulls water into the stool to soften it-but if you don’t have enough water in your system, that won’t happen as effectively.   Secondly, ask about and then address fiber intake. Most dietitians recommend an intake of 28-32 grams depending on gender and body size, and some resources suggest that the average American intake is closer to 10-15 grams. There are lots of options for increasing fiber in the diet-my personal favorite is chia seeds or ground flax seeds, but if patients want a pill, they can also use psyllium husk powder (Metamucil is one brand of psyllium husk powder, but all types are essentially equivalent). It is important to increase fiber intake slowly if it is inadequate; otherwise gas will be a problem. Third, a good quality probiotic can be extremely beneficial. Fourth, magnesium oxide can really assist with bowel function. Finally, lifestyle adjustments such as discontinuing opioid use and increasing activity can really assist as well.

Do keep in mind that the pelvic floor itself may need to be addressed in patients with constipation, and also that there are some systemic issues that can have constipation as one component, so you do need to have your differential diagnosis hat on!

Do you currently talk about constipation with low back patients and other orthopedic patients? Are you finding it is a common problem?

4 responses to “The Constipation Connection

  1. Doug Schmidt says:

    I am sick and tired of reading articles that tell me to drink water and eat more fiber. I have struggled with constipation for so long and I know it is due to me hip/pelvic construction. Yet, there is not a single article that discusses this. I challenge any specialist to research how coccyx displacement and pressure due to long-leg extremities can cause constipation/lower rectal blockage which resulted in internal hemorrhoids and some “thing” that feels like a hard cord that runs across my inner rectum (yes, I put my finger in my ass to see if there’s a blockage), which all makes having a normal bowel movement impossible.

    1. Jennifer Stone says:

      Hi Doug,
      You are absolutely correct that orthopedic/biomechanical issues can contribute to constipation. It’s impossible in a short blog post to fully elaborate on all the causes and fixes for constipation (I literally have taught 8-10 hour long courses on this topic!), but a good PT will be able to address all of the above (lifestyle/diet factors if needed and also the orthopedic issues, be that muscle tightness, joint tightness, or both). I doubt you will find very many blog posts on this because the techniques to do so really need to be taught in person-blogs or written articles are a great place to discuss things that everyone can do (ie give dietary advice, drinking more, etc.) while joint and soft tissue mobilization are much more effectively taught in person. I hope that you are able to find some relief and help for your symptoms!

  2. Sue says:

    I too am sick of feeling like an idiot when talking to the doctors and physiotherapists. My diet is perfect. I have a weak gluteus Medius causing constipation issues. I have hypermobile hips. It’s about time I was diagnosed correctly. So angry !

    1. Jennifer Y Stone says:

      Thank you for sharing your experience, Sue! I am so sorry it has been so frustrating for you. There are SO many factors that can play into constipation, and it would be impossible to discuss them all in this format (I teach weekend courses where I talk about this for 2 full days because there are so many underlying causes!). Thank you for the reminder to look at ALL possible factors! I hope that most of the readers of this blog are very comfortable with evaluating the musculoskeletal issues you speak of and felt that they may not be as knowledgeable on the dietary ones, thus my choice of which to focus on. But yes, absolutely, the entire person needs to be evaluated and ALL imbalances addressed.

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