PT Classroom - Straining To Ease: The Physical Therapist Role in Patients with Constipation  ׀ by Richard Philip Kochoa, PT, MD


Dr. Richard Philip Kochoa is a registered physiotherapist in the State of Texas. He is currently working with Avant Healthcare Professionals. He received his medical degree as a Shonee Henry Scholar at the University of St. La Salle College of Medicine and earned his pre-medicine course at the Riverside College, Philippines. He is an accomplished writer who maintains a column in a weekly magazine and international news organization.


Straining To Ease: The PT Role in Patients with Constipation

Physiotherapists are one of the most visible and accessible healthcare professionals seen by patients. They spend more time with their patients than most other health professionals. From evaluation to patient education to actual patient care, physical therapists spend several hours per week (and even months) with their patients. Inevitably, they build trust and rapport with them. The constancy and rapport developed in time provides an avenue for patients to communicate their experiences.

One of the most common gastrointestinal symptom reported to physical therapists by patients is constipation. A 2005-2008 report of the National Health and Nutrition Examination Surveys revealed a constipation rate of 10.2% among female adults (95% Confidence interval) and 4% among male adults (95% CI: 3.2, 5.0) over 20 years old (P<.001) (1).

Constipation was reported by Fuentes and colleagues to have a real and potential problem as they tend to increase mortality among patients who underwent orthopedic surgery and treated by the traumatology team (2).

Chronic constipation can lead to bowel perforation and stercoral peritonitis owing to highly compacted feces that impede venous and arterial circulation in the colon wall as they compress it. This leads to ischemia that result in perforation and eventually peritonitis. In some cases this culminates in death of the patient. This is actually a rare condition that has been observed only 90 times in the past century (3, 4).

Other complications of chronic constipation are: hemorrhoids, anal fissure, fecal impaction and bowel obstruction, and fecal incontinence (4).

Interestingly, Glia and Lindberg found that patients with constipation have low scores for general well-being (mean of 85.5, while health population scored 102.9) (5).

In a large multinational survey of burden of constipation on quality of life, Wald and colleagues found that there was significant difference in the health-related quality of life (HRQoL) between constipated and non-constipated persons (6).

Several components in the HRQoL were reduced---most particular on psychological component (6). Improvement in the quality of life should be considered by physiotherapist as they treat patients with constipation for it impacts their overall compliance to rehabilitation and achievement of their set physical therapy goals.

Constipation is difficult to precisely define owing to a wide variety in individual bowel frequency, consistency and ease of expulsion. Constipation afterall is a symptom and not a disease per se. It is however common for people to have at least three bowel movements every week. Having less frequent bowel movement does not exactly connote constipation.

For some, straining, feelings of incomplete evacuation or hard consistency of stool is associated with constipation. Passing small pellet-sized or lumpy, large stools are associated with slow bowel transit and are equally difficult to move than normal stools.

Straining is difficult to qualify and quantify objectively. In the absence of applying any diagnostic criteria, it is only when the patient requires enema and disempaction that we categorically relate their symptom as constipation.

The Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders (FGIDs) (7) is a widely used classification system published in 2006 for diseases and disorders involving clinical symptoms that cannot be attributed to structural or tissue abnormality.

Functional Constipation, also known as chronic idiopathic constipation, is constipation that has no anatomic nor physiologic etiology. Persons who experience this disorder may be generally healthy but has problem with defecation.

The Rome III criteria for functional constipation include two or more of the following for at least 3 months with a symptom onset at least 6 months prior to diagnosis:

a. Lumpy or hard stools in at least 25% of bowel movements.

b. Straining in at least 25% of defecations

c. Sensation of incomplete evacuation in at least 25% of bowel movements

d. Sensation of anorectal obstruction or blockage in at least 25% of bowel movements

e. Manual maneuvers to facilitate at least 25% of bowel movements (such as digital evacuation and support of pelvic floor).

f.  Fewer than three defecations a week.

Also, their loose stools should be rarely present without the use of laxatives and the signs and symptoms should not qualify for irritable bowel syndrome.

Although this article primarily focus on adults, it is worth noting the diagnostic criteria for children (aged 4 to 18 years) (8). Functional constipation is defined as any constipation without an organic cause. Thus, Rome III criteria merged the overlapping signs and symptoms of functional constipation and functional fecal retention.

The criteria should be fulfilled for at least once per week for at least two months prior to diagnosis. The criteria for constipation should include two or more of the following in a child with developmental age of at least 4 years (and the signs and symptoms not meeting the criteria for the diagnosis of irritable bowel syndrome):

a. Two or more defecations in the toilet per week.

b. At least one episode of fecal incontinence per week.

c. History of retentive posturing or excessive volitional stool retention

d. History of painful or hard bowel movements

e. Presence of a large fecal mass in the rectum.

f.  History of large diameter stools which may obstruct the toilet.


Table 1 - Adapted from Harrison's Principles of Internal Medicine, 18th Edition (9)

Type of Constipation and Causes Examples
Recent Onset  
Colonic Obstruction Neoplasm; stricturej: ischemic, diverticular, inflammatory
Anal sphincter spasm Anal Fissure, painful hemorrhoids
Medications See Table 2.
Irritable bowel syndrome Constipation-predominant, alternating
Medications Calcium Channel Blockers, Antidepressant
Colonic pseudoobstruction Slow-transit constipation, megacolon (rare Hirshsprung's, Chagas' diseases)
Disorders of rectal evacuation Pelvic floor dysfunction; anismus; descending perineum syndrome; rectal mucosal prolapse; rectocele
Endocrinopathies Hypothyroidism, hypercalcemia, pregnancy
Psychiatric disorders Depression, eating disorders, drugs
Neurologic disease Parkinsonism, multiple sclerosis, spinal cord injury
Generalized muscle disease Progressive systemic sclerosis

Physical therapists often treat patients with symptoms of chronic pain. Over the counter Nonsteroidal Antiinflammatory Drugs (NSAIDs) like aspirin are commonly used. Among those over 65 years old, aspirin users were found to have functional constipation rather than outlet delay (10).

Even though physical therapists are not expected to provide full detailed advise about medicines and medication, a more detailed list of medicines, herbal supplements and home remedies are important for clinicians to arrive at the right diagnosis.


Table 2 - Drugs to lookout for in your patient's cabinet

Class of Drug Common Brands
Antacids Prilosec OTC, Prevacid 24hr, Tums, Zantac 150, Gas X
Calcium Supplements Caltrate, CalMax, AlgaeCal Plus, Citracal Plus
Iron Feosol, Fer-in-Sol, Slow-Fe
Antidiarrheal agents Imodium, Kaopectate II, Imodium A-D, Maalox Anti-diarrheal
NSAIDs Naproxen, Naprelan Naprosyn, Aleve
Opiates The most well known class to cause constipation. Oxycodone is more likely to cause constipation than transdermal fentanyl.
Anticholineric agents Propulsid
Tricyclic antidepressants Sinequan, Adapin. Aventyl, Pamelor
Calcium Channel Blockers Sular, Norvasc, Cardene SR, Adalat, Procardia
Antiparkinsonism Drugs Sinemet, Exelon, Parlodel, Parcopa
Sympathomimetics Didrex
Antipsychotics Abilify, Invega, Risperdal, Zyprexa
Diuretics Lasix, Bumex, Aldactazide
Antihistamines Claritin, Alavert, Didrez

The scope of physical therapy practice require attention to this problem since constipation is a symptom of pelvic floor disorders (11).

Table 3 - Medicines Patients May Take To Relieve Constipation - Adapted from (12) and (13)

Medicine How it Works
Linaclotide (Linzess) Activates guanylate cyclase-C, stimulating cGMP production and increasing fluid secretion and motility. Not given to persons younger than 17 years old. Often taken by adults with IBS at 1 capsule of 145 ot 290mcg more than 30 minutes before first meal.
Polyethylene glycol (Glycolax) PEG is an osmotic laxative which drives water into the lumen of the colon thereby softening the stool. Taken by dissolving 17g packet in liquid. Relief may occur after 4 days of intake. Not to be taken for prolonged periods.
Lubiprostone (Amitiza) Activates CIC-2 chloride channels that increase intestinal fluid secretion and motility. This reduces intestinal permeability and stimulate recovery of mucosal barrier function. Tablet of 24mcg taken PO BID, with food and water. Not to be taken for prolonged periods.
Lactulose (Duphalac) Increases stool water content; increases stool acidity and trapping NH4 ions (osmotic laxative). One tablespoon (15ml) PO QD-BID. Results may be seen after 24-48h of intake.
Psyllium Bulk laxative. It increases stool bulk. To aid movement of feces. Taken 3.4g PO qd then increased slowly. It should be dissolved in water or juice and requires additional glasses of water to avoid bloating.

A study conducted by Ramkumar and Rao revealed that use of PEG, tegaserod, lactulose and psyllium are effective. Other commonly used agents such as bisacodyl, stool softener, senna, and milk of magnesia does not have adequate quality data to evaluate their effectiveness (14).


Table 4 - Home Remedies the patient may be taking to relieve constipation - Adapted from (15)

Top 10 Home Remedies How They Are Commonly Used
Lemon Mixed with water, salt or sugar and taken by patients in the morning.
Flax Seed Rich in fiber and omega-3 fatty acids, this is taken daily before going to bed.
Castor Oil Laxative. A teaspoon usually swallowed by patients.
Fiber Adds volume to feces. Fruits and veggies rich in fiber are: beans, potatoes, carrots, prunes, nuts, peas, etc.
Water In some cases, patients would keep water overnight in copper vessels. Regular intake of 8 glasses is recommended.
Spinach Eaten raw or cooked. Drink a mixture of half glass of raw spinach juice and half glass of water.
Molasses Two tablespoons are usually taken before sleeping. This is not recommended for those with diabetes or who have difficulty digesting high-caloric foods.
Cabbage Rich in dietary fiber which help cleanse the body. A cup of cabbage juice may be used by patients to relieve constipation.
Grapes Laxative effect provided by cellulose, sugar and organic acid in grapes. Raisins soaked in water may also be used.
Figs High in fiber. Fresh and dried figs often used and eaten with skin just prior to sleeping.

What physiotherapists can do?

Physiotherapist can assist the patient deal with constipation through skillful evaluation, comprehensive education, and prompt referrals.

Educating the patients about healthy bowel movement practices should be done. Patients should be encouraged to do the following:

a. Respect the call of nature. The natural movement of the bowel is at its peak once it is felt. One may miss the opportunity if ignored.

b. Encourage having a daily habit. Mornings typically have the most effective colonic activity. They may have breakfast before going to the bathroom to "jumpstart" their gut. Natural peristalsis is stimulated by food traversing the stomach.

c. Increase fluid intake to at least 8 glasses per day. Low fluid consumption was a predictor of constipation among women. Markland and colleagues found conclusive evidence for effectiveness of increased fluid intake in preventing constipation (1).

d. Eat 15 to 25 grams per day of high-fiber rich foods. This will add bulk to the stool thereby easing its flow through the bowel. The daily fiber requirement is approximately equal to at least 3 medium-sized apple with skin, 1 cup of raspberries, 5 cups of brown rice, 2 cups of cooked green peas, or 3 cups of boiled broccoli. Inform patients with pelvic floor dysfunction that fiber intake will not relieve them of constipation. Advise the patient to gradually increase fiber intake by 5 grams per day. Bloating can happen but lessens through regular intake.

e. Exercise regularly. Aside from its overall cardiovascular benefit, upright position and movement improve peristalsis (12).

Patients and their family members should be taught on pelvic floor anatomy, normal bladder and bowel function, food and other substances that can cause constipation.

Toilet training of patients with constipation should emphasize proper breathing techniques to avoid straining. Patients should perform "huffing" expiration technique while evacuating. By huffing, the abdominal oblique muscles are activated which assist in peristalsis.

Techniques to prevent pudendal nerve impingement that may occur with prolonged sitting in the toilet should be done. This is properly demonstrated by raising one of the foot on a stool while sitting and the trunk leaning forward.

Patients can also benefit from massaging of the abdominal wall (16). A constant firm pressure applied in a circular motion by fingers along the normal colonic peristaltic flow from the right lower quadrant of the abdomen and inching upward close to the right subcostal area then transversely to the left upper quadrant and later descending to the left lower quadrant of abdomen. This movement should then proceed slightly upward towards the umbilicus and descend finally towards the hypogastric area.

The patient with pelvic floor dysfunction (PFD) are the best candidate with constipation for physical therapy. This problem occurs after years of chronic constipation and the practice to strain and evacuate. It is estimated that around half of those with chronic constipation have dyssynergia or PFD (17).

Pelvic floor dysfunction encompass several problems related to pelvic pain, sexual dysfunction, bladder and bowel disorders (constipation and incontinence). The problem with PFD is on the delayed pelvic floor muscle relaxation that should coincide with abdominal wall motion. This may sound simple but in reality it is counterintuitive when the body maintains the pelvic floor at a constant tone rather than relaxed.

Physical therapists with advance training specializing in this field are skilled in rectal and vaginal examination (11). They can help patients avoid expensive medical treatment, complications, and delayed recovery period.

Rectal examination will begin with inspection of the perineum if there are any external hoemorrhoids, scars, fistulas or fissures. The skilled physiotherapist may ask the patient to strain and observe the degree of perineal descent which normally range from 1 to 3.5cm.

If the degree of descent is less than the normal range, pelvic laxity is probable. This may be due to multiparity or weakness after childbirth and years of straining.

Digital rectal examination should be directed to assess if there is tenderness in the puborectalis muscle. The patient should then be asked to do a Valsalva Maneuver and try to expel the finger of the physical therapist.

Balloon expulsion test should be done for patients with suspected pelvic floor dysfunction. This is done by having the patient evacuate a balloon filled with 50ml of water. This can also be done as part of the biofeedback treatment.

Biofeedback is one of the physiotherapist's best armamentarium for pelvic floor dysfunction. It has been found beneficial for up two-thirds of patients who underwent treatment with this modality. It is used to retrain the pelvic muscles to relax adequately during defecation.

The most common biofeedback techniques employed by therapists are sensory training, manometric feedback and electromyographic feedback.

Sensory training is the earliest biofeedback technique employed. The most common method is with the water-filled balloon of varying volume that the patient has to consciously sense in the rectum and allow its withdrawal by relaxation. This is challenging for the patient considering that the water-filled balloon can conform to the lumen of the rectum and does not exert firm pressure on the lumen wall.

Manometry is a more objective means of detecting and measuring the anal canal pressure through solid-state probes, balloons, or perfused catheters.

Like manometry, electomyography utilize intraluminal probes or electrodes taped in the perianal skin for measurement and detection of pelvic floor muscle activity. The muscle activity are then transmitted as a video recording for the patient to monitor. The technique requires the patient to relax the pelvic floor muscle and, as the patient becomes more skilled in relaxing, gradually increase the abdominal pressure. The physical therapist provides verbal feedback to the patient so they will recognize when the pelvic floor is relaxing and how the muscle contracts.

When comparing different biofeedback methods, Heyman et al noted that outpatient intra-anal electromyographic biofeedback training; electromyographic biofeedback training plus intrarectal balloon training; and electromyographic biofeedback trainng, balloon training, and home training were found to produce significant increase in unassisted bowel movement.

Heyman et al concluded that employing electromyographic biofeedback alone was just as effective as with the addition of balloon training, home training, or both (18).

Studies on biofeedback as a treatment option for children are still equivocal in their findings. Some reported effectiveness in the short term treatment but has no clear long-term benefit (19).

Kegel exercise is effective in improving bowel and bladder contince. It should be incorporated in the home exercise program as 10 repititions of pelvic floor muscle contractions held for 3 seconds. This is done in the supine position and progressed eventually to sitting upright and standing. This is to be repeated 3 times per day. Patients can check if they are doing it right by contracting their pelvic floor muscles while urinating. If the urination stops, then they are doing it correctly.

Patients, particularly those older than 40 years old, should be referred for immediate physician consultation when their symptom of constipation is associated with weight loss, anemia, change in stool caliber, rectal bleeding. Procedures such as sigmoidoscopy with or without barium enema, or colonoscopy may be done to rule out colon cancer (a structural cause for constipation).

Physical therapists are entrusted with the patient's life and health condition owing to their professional stature, clinical expertise and wisdom gained through years of practice. Constipation as a symptom may be mundane to even raise the alarm in the clinician's day. But it is in fact an important symptom of various clinical condition and a harbinger of unnecessary morbidity and unwanted mortality.

Constipation is an important clue to the patient's overall health status and clinical well being that investing time to understand such complaints when they come up and address them accordingly resonates with huge dividends for the benefit of the patient and the therapist's conscientious performance of professional duty.

Last revised: May 21, 2013
by Richard Philip Kochoa, PT, MD


1. Markland, AD et al. Association of Low Dietary Intake of Fiber and Liquids With Constipation: Evidence From the National Health and Nutrition Examination Survey. The American Journal of Gastroenterology. 108, 796-803. May 2013.
2. Fuentes, R, et al. Constipation Opposes Well-Being. Revista de Enfermia. 2004.
3. Huang, WS et al. Management of patients with stercoral perforation of the sigmoid colon: report of five cases. World Journal of Gastroenterology. 2006.
4. Leung, L. et al. Chronic Constipation: An Evidence-Based Review. Journal of the American Board of Family Medicine. 2011.
5. Glia, A. And Lindberg, G. Quality of Life in Patients With Different Types of Functional Constipation. Scandinavian Journal of Gastroenterology. 1997.
6. Wald, A. Et al. The burden of constipation on quality of life: results of a multinational survey. Alimentary Pharmacology and Therapeutics. 2007
7. Rome Foundation. Appendix A: Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. 2006.
8. Rasquin, A. Et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2006.
9. Harrison's Principles of Internal Medicine, 18th Edition. 2012.
10. Toney, R and Agrawai, R. Medication Induced Constipation and Diarrhea. Practical Gastroenterology. 2008
11. American Physical Therapy Association. Today's Physical Therapist: A Comprehensive Review of A 21st-Century HealthCare Professional. 2011
14. Ramkumar, D and Rao S. Efficacy and Safety of Traditional Medical Therapies for Chronic Constipation: Systematic Review. The American Journal of Gastroenterology. 2005.
16. Harrington, KL and Haskvitz, EM. Managing A Patient's Constipation With Physical Therapy. Physical Therapy. 2006.
18. Heyman, S. Et al. Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Diseases of the Colon and Rectum. 1999
19. Bassotti, G. et al. Biofeedback for pelvic floor dysfunction in constipation. BMJ 2004.
20. Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatrics

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