Here’s a phrase I never thought I would say: constipation is one of my clinical interests and passions.
Yep, you read that correctly.
And here is another: all therapists should care about constipation, because it impacts the systems and structures that you are working with. If we are taking our rightful places as primary musculoskeletal care providers for our patients, it is vital that we are aware of all the issues (and hopefully some solutions for those issues!) that may impact our patients’ health and well being.
Constipation is the second most common diagnosis in an ambulatory care setting, accounting for more than 2 million physician visits annually. Risk factors for it include being female, low socioeconomic status, history of abuse, history of depression, use of medication associated with constipation, and decreased activity levels. Those last two are bolded because many of our patients are experiencing both of these risk factors when they come in to see us. Consequences of constipation can include increased low back and pelvic girdle pain, difficulty activating and controlling the core musculature, and more. What’s more, constipation can impact individuals across the lifespan-the youngest person I have treated for constipation was 2 years old and the oldest so far has been 97- so whatever our area of practice focus, we likely have patients who are struggling with it. Recall too that patients have no reason to think that their constipation is linked to their musculoskeletal challenges, so the onus is on us to bring it up.
Now, most people don’t just hang out at the water cooler at work chatting about how their bowel movements are going, so simply asking “are you constipated?” is not helpful in many instances. I find it helpful to have a visual reference like the Bristol Stool Scale (Hyperlink: https://www.researchgate.net/figure/Bristol-Stool-Form-Scale_fig1_260984440) and ask patients about their stool consistency and frequency. Frequency between 3 times per day and 3 times per week is generally considered normal, and we ideally want them to generally have consistency of type 3 or 4 on the Bristol Stool Scale. It is possible for patients to have daily bowel movements and still be constipated (very small/hard movements with lots of straining OR very loose bowel movements can indicate constipation if the other symptoms match). The gold standard for diagnosing constipation is a KUB, but in many cases making a clinical diagnosis based on subjective symptoms is adequate to guide treatment.
There are 3 types of constipation.
Normal transit constipation is the most common and refers to a situation where the bowels move fecal matter along at a normal rate, but the patient perceives difficulty with evacuation and/or experiences hard stool.
Slow transit constipation is typically due to medication (pain medications, muscle relaxers, and CNS inhibitors), neurologic dysfunction, or a metabolic issue (diabetes and thyroid issues especially) and is characterized by a slowing of peristalsis, leading to decreased frequency, though stool may not be hard or difficult to pass.
Outlet dysfunction constipation refers to a situation where the individual’s muscles are working against themselves-the external anal sphincter and pelvic floor muscles are contracting and “kinking off” the colon as the colon and abdominal muscles are attempting to pass stool.
Fortunately, there are some easy things that we as physical therapists can suggest to assist with all of the types of constipation.
Bowel massage can be a useful way to help facilitate peristalsis by cuing the smooth muscle contraction (and providing some input to the brain so that it manages homeostasis better!). This can be done on people of any age. Pressure should be light enough to not cause any pain. Patients can also be taught to do this on themselves.
Ensuring proper hydration can make a huge difference for individuals with constipation. If there isn’t adequate water in the body, we can’t pull it into the stool to keep it soft and well formed.
Proper potty mechanics and proper toileting posture can make a huge difference for individuals who have issues with constipation. These techniques are particularly effective for individuals dealing with outlet dysfunction constipation, but are honestly beneficial for all people when stooling (note: patients can use footstools or even a delivery box, it doesn’t have to be the product shown, but everyone needs more unicorns and funny commercials that are quite physiologically accurate in their lives, so there you go!).
Diaphragmatic breathing cues the parasympathetic (“rest and digest”) nervous system, and can help stimulate peristalsis. It has also been shown to decrease the sensitivity of the central nervous system, which can help with pain, resulting in people potentially holding their muscles less tightly and moving more freely.
Additional things that can be helpful include low impact cardiovascular exercise (walking, swimming, biking, etc.), activity/movement in general, appropriate intake of fiber, appropriate intake of magnesium, and adequately chewing food (which is hopefully ingested in a variety of colors, textures, and types).
Honestly, each of these tips could potentially be a blog post of its own, and this is a huge topic that I can’t possibly do justice to in a single blog post (unless you want to read for days). Let me know if there are any areas that you would like to see elaborated on, I’d be happy to do so!
Bottom line, bowel health absolutely can impact musculoskeletal health and there are easy, high impact, low risk things that we can suggest to our patients to help manage their digestive health. I promise, if you start asking people, you will be surprised by how many agree they have some issues with constipation, and if you start offering them some of these suggestions you and they will hopefully be surprised by how much their quality of life improves.
Alame et al. Evaluation of Constipation. Clinical Colorectal Surgery. 2012: 25. 5-11
Harrington et al. Managing a patient’s constipation with physical therapy. Physical Therapy. 2015; 86: 1511-1519.
Lewinsky-Gaupp et al. Successful physical therapy for constipation related to puborectalits dyssynergia improves symptom severity and quality of life. Diseases Colon and Rectum. 2008; 51: 1686-1691.
Yang et al. Outcome of behavioural treatment for idiopathic chronic constipation. Internal Medicine Journal. 2014; 858-863.