4-PTassessment and management of constipation.pdf

Physical Therapy Assessment and Management of Constipation By Prof. Dr. Mona Abdel Khalek Dr. Mina Atef Dr. Ahmed Abd-Elhalim Definitions • Constipation is an acute or chronic condition in which bowel movement occur less often than usual or consist of hard dry stools that are painful or difficult...

Physical Therapy Assessment and Management of Constipation By Prof. Dr. Mona Abdel Khalek Dr. Mina Atef Dr. Ahmed Abd-Elhalim Definitions • Constipation is an acute or chronic condition in which bowel movement occur less often than usual or consist of hard dry stools that are painful or difficult to pass. Bowel habits vary but an adult who has not had a bowel movement in three days or a child who has not had a bowel movement in four days is considered constipated. Definitions (1)At least 25% of bowel movements associated with • Straining • Lumpy or hard stools • Incomplete bowel evacuation • Anorectal obstruction • < 3 bowel movements per week Causes of Constipation • • • • • • • • • • • Bowel obstruction Cancer Dehydration Hospital admission Endocrine and metabolic disorders: hyperparathyroidism, hypothyroidism, chronic renal disease Neuromuscular disorders: – Parkinson's disease, MS Electrolyte disturbances:- Hypercalcemia, Hypokalemia, Hypermagnesemia Pregnancy Depression Reduced mobility and balance problems Medication Opioid-induced constipation (OIC) Symptoms and Consequences of Constipation • Nausea +/- vomiting • Abdominal and Rectal pain • Flatulence • Loss of appetite • Fatigue • Depression • Nausea and reduced appetite  weight loss • Behavioral disturbances in dementia  increased use of psychotropic medications Quality of Life Systematic review: impact of constipation on quality of life in adults Belsey et al Alim, Ther & Pharm 2010 Types of constipation • General constipation • Outlet constipation Types of constipation • General constipation: occurs when the muscles of the large intestine (the colon) have problems with peristalsis, which are waves of muscle contractions that move waste out of the body in the form of stool. This causes the waste to move very slowly or not much at all. Types of constipation • Factors can lead to general constipation.: • Limited fluid and fiber intake • Imbalances in the diet (too much sugar and animal fat) • Too much sitting and little physical exercise or prolonged sitting • Lifestyle changes, such as pregnancy and travel • Medications taken for other conditions, such as pain medications • A sluggish colon • Improper use of laxatives Types of constipation • Outlet constipation: occurs when the stool is stuck in the rectum, which is usually due to dysfunction of the pelvic floor muscles. • If the pelvic floor muscles in the rectum are too tight and unable to relax, it becomes difficult for stool to be passed. • This can lead to straining during a bowel movement which causes the muscles to tighten even further. Physical therapy management for constipation Management of constipation • 1-Typical dietary fiber 25-35 grams per day. • Fiber helps general bowel health by bulking and softening stool which makes it easier to pass as: • Choose fresh fruits and raw vegetables rather than juice. • Eat the skin of cleaned fresh fruits and vegetables. • Choose bran and whole grain breads/cereals. • Eat less processed foods and more fresh foods. • 2- Increase fluid intake: especially water 6-8 glasses of water per day Management of constipation • 3-Proper position on the toilet: • To allow for the pelvic floor muscles to relax. • The knees are positioned higher than the hips, • use a foot stool if necessary. • Leaning forward and supporting the elbows on the knees. • Bulge out your abdomen, as you exhale. • • Use the abdominal muscles as a pump to gently push the stool out of the open sphincter Management of constipation Management of constipation • 4- Routine exercises : Exercise is believed to shorten transit time through the gastrointestinal tract and thus enhance evacuation of stool. • moving food through the intestines faster. • The longer the food stays in the bowel, the more water is lost from the stool. This makes them hard and dry, which is more difficult to pass. • The breathing and heart rate rise from aerobic exercise, it stimulates the natural contraction of intestinal muscles which moves stools out even quicker. Management of constipation • Type of exercise: • walking, • lower trunk rotation • stationary bicycling. • pelvic tilt • Pelvic floor muscle • leg lift Management of constipation • 5- Biofeedback Therapy: To correct the incoordination of the abdominal, rectal, puborectalis and anal sphincter muscles in order to achieve a normal and complete evacuation • After correcting the patient’s posture and the sitting angle i.e. leaning forward • The subject is asked to take a good diaphragmatic breath and to push and bear down as if to defecate. • The subject is encouraged to watch the monitor while performing this maneuver. The visual display of the pressure changes in the rectum and anal canal on the monitor provides instant feedback to the subject to understand and learn quickly Management of constipation • The good news is that treatment typically does not involve medications. Instead, treatment involves physical therapy in the form of biofeedback. During these private sessions, the physical therapist inserts a probe into the anal sphincter and places sticky pads on the abdomen, to detect the movement of anal sphincter and abdominal wall as simulation of defecation. • By feedback (either visual or verbal) on what is the activity of abdominal wall muscles and anal sphincter during a bowel movement. The physical therapist will lead patient through breathing exercises, as well as muscle strengthening and relaxation exercises, in order to help retraining the movement and coordination of pelvic floor. Management of constipation • The good news is that treatment typically does not involve medications. Instead, treatment involves physical therapy in the form of biofeedback. During these private sessions, the physical therapist inserts a probe into the anal sphincter and places sticky pads on the abdomen, to detect the movement of anal sphincter and abdominal wall as simulation of defecation. • By feedback (either visual or verbal) on what is the activity of abdominal wall muscles and anal sphincter during a bowel movement. The physical therapist will lead patient through breathing exercises, as well as muscle strengthening and relaxation exercises, in order to help retraining the movement and coordination of pelvic floor. Management of constipation Management of constipation • 6- Strength pelvic floor muscles: • How does constipation affect pelvic floor muscles? • Pelvic floor muscle strength is important for both bowel and bladder control. Chronic straining from constipation can lead to weakening of the pelvic floor muscles, excessive stress on pelvic organs and nerves, as well as bladder dysfunction and recurring accidental bowel leakage. Management of constipation • How does constipation affect the bladder? • The rectum is very close to the bladder. When the rectum is overfull (due to constipation), it can press on the bladder, reducing the amount of urine the bladder can hold. This may cause the patient to actually “leak” urine or make the patient feels as if he need to pass urine right away or frequently. Management of constipation • How does constipation affect fecal incontinence? • Weakened pelvic floor muscles, caused by constant straining during bowel movements, may contribute to recurring accidental bowel leakage called fecal incontinence. • Fecal incontinence happens when some of the stool seeps around the constipated stool and leaks out. Management of constipation • 7- Abdominal massage: • Abdominal massage was effective in decreasing abdominal spasticity and therefore in assisting the bowels in peristalsis, 15 to 20 minutes daily in a path following the ascending, transverse, and descending colons. • Use a gentle manual technique with lotion applied to the abdomen in effleurage or kneading. These patients reported a decrease in abdominal distension and flatulence as well as a return to normal bowel function in as little as 4 to 6 weeks. Abdominal massage Management of constipation • 8- Hot rolls: • Applied on the abdomen with the same direction as the colon to stimulate the normal peristaltic movement as well as for deep heating and relaxation of spasmd muscles .It can also be applied on the lower back region. • Hot rolls shouldn’t be applied during pregnancy, during menstruation or any inflammation in the abdominal cavity. Thank you