Are You Constipated?

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Are You Constipated?

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Physical Therapy for Constipation

Author: Terri Nishimoto PT, CLT

For most people, what goes on in the bathroom stays in the bathroom.  Yet the reality is that constipation is the most common reason patients will visit a GI specialist in the Unites States.

Physical Therapists specialize in getting patients to move better.  And, with pelvic floor physical therapy, PTs can help get patient’s bowels moving better as well.

Are you constipated?

The accepted definition of constipation is from the Rome III Criteria, and you must have two or more of the following:

  • Straining
  • Lumpy hard stools
  • Sensation of incomplete evacuation
  • Sensation of anorectal obstruction/blockage
  • Manual maneuvers to facilitate defecation
  • Less than three defecations per week

So even if you have a bowel movement every day, but you have to strain and your stools are hard then you officially have constipation.

Bristol Stool ChartWhat is a normal bowel movement?

Even the MD TV programs are addressing bowel concerns.   Dr. Oz likened a healthy stool to be like a “silent Acapulco diver” that should arrive in one piece preferably in an “S” shape.  Take a look at the diagram to the right to identify your BM type.  The goal is to have stools looking like Type 4.

What are the types of constipation?

There are multiple factors when it comes to the causes of constipation.  It can be a sign of an organic disease or there may be obstructions or structural abnormalities within the colon.

When patients come to physical therapy for constipation, such diseases and structural abnormalities have been ruled out.  In physical therapy, there are three types of constipation that are commonly treated.

  1. Normal Transit Constipation
    In this type of constipation the stool moves through the colon at a normal rate.  The issue is the stool is hard and difficult to pass.  The usual culprit is poor dietary habits.
  2. Slow Transit Constipation
    In this type, the stool moves through the colon at a slower or decreased rate.  One of the main causes is a side effect of medications.  Other causes may be linked to other conditions such as thyroid dysfunction, MS and Parkinson’s disease.  Stress can also shut down the entire gut system.
  3. Outlet Constipation
    This is probably the most common type of constipation that will be referred to physical therapy.  The stool is difficult to evacuate either due to pelvic floor muscles that contract rather than relax, or the muscles are in spasm or they are basically too shortened or tense.   In other words, the stool comes to the gate, but the gate doesn’t open.

Often, patients have a combination of the three types of constipation.

How can physical therapy help?

First it is very important that you work with your MD or medical provider to evaluate and rule out any organic disease or structural abnormalities in the colon.  When you initiate physical therapy, your PT will work with you to establish a good treatment plan towards alleviating your constipation.

PT for normal transit constipation

The physical therapy treatment for normal and slow transit constipation is similar.

  1. Food and bowel diary: It is very beneficial to really evaluate your food and fluid intake; it helps you learn what foods help, and what foods hinder your system.  Intolerance to certain foods can actually shut down the GI system.  Any supplements and probiotics should be discussed with your PT and medical provider.  Documenting your “output” can also provide good information on your progress.  There are some very clever “poop apps” you can use on your phone!
  2. Colon massage: Daily or twice a day am and pm bowel/abdominal massages can help improve colon transit time.  Your PT can show you how to do this technique.
  3. Exercise: The NIH (National Institute of Health) says exercising regularly helps keep your digestion system active.  So not only are aerobic exercises good for your heart and bones but for your bowels as well. In addition, there are also specific exercises targeted to the muscles that can help motility and they are:  the diaphragm, the psoas (hip flexors) and the abdominals.  Again your PT will teach you how to use these muscles correctly.
  4. Electrical Stimulation: There are studies showing promise for improving slow-transit constipation with transcutaneous electrical stimulation.

PT for outlet constipation

If the cause of your constipation is due to dysfunctional pelvic floor muscles, then physical therapy will most definitely be beneficial.

  1. Pelvic floor myofascial and trigger point release: Your physical therapist will identify trigger points in the muscles and release the muscles that are in spasm or are too shortened.  This includes muscles of the pelvic floor, abdominals, hips and lower back.
  2. Defecation mechanics: Yes there is a more optimal/ergonomic way of positioning your body while doing the deed. Squatting allows the pelvic muscle that slings around the rectum to relax so that the stool can pass with less difficulty.  If you watch Shark Tank, you may have seen the “squatty potty” but you don’t have to go out and buy one.  You can use two foot stools to “assume the squat”.
squatty potty

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  • Proper evacuation: Your physical therapist can also show you the proper way to empty.  Prolonged straining can cause the rectal walls to weaken and possible hemorrhoids to develop.  There are ways to use breath control and the use of the abdominals or the belly to help.
  • Biofeedback: Biofeedback requires the use of special sensors that monitor the activity of the pelvic floor and abdominal muscles.  It has been proven effective in training the coordination of the muscles during defecation.
  • Exercise: The role of exercise has already been mentioned regarding the benefit for motility.   Your physical therapist will train you in relaxing the tense and tight muscles, and strengthening and toning the weak muscles.   This includes the muscles outside of the pelvic floor!

    Moving better from the inside and the outside is the goal of physical therapy.  Remember, constipation is not a disease, but a condition with multiple causes and multiple treatments.  Just know that it is possible to improve the discomfort and frustration that can result from chronic constipation.

    If you have any questions regarding pelvic floor physical therapy please call any one of our three locations:

    Denver: 720-402-3801
    Louisville: 303-954-8423
    Englewood: 303-788-7353

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    About the Author:

    Co-founder of N2 Physical Therapy, Terri received her Physical Therapy Degree from the University of Colorado Health Sciences Center.

    Terri brings a diverse background in neurological, orthopedic and sports medicine physical therapy to her practice, and has expanded her focus to include pelvic floor rehabilitation, perinatal and oncology physical therapy. Terri holds certifications in the Feldenkrais Method, Manual Lymphatic Drainage and Trigger Point Dry Needling.