As much as we would like to avoid the topic, poop happens. Or in many uncomfortable cases, it doesn’t. According to the statistics, approximately 20% of adults between 40-75 have constipation. And those numbers are just the base level, run-of-the-mill, stopped-up versions. The actual numbers increase significantly with additional factors:
- Older > Younger
- Female > Male
- Psychological factors (stress, anxiety)
So, are you constipated? Many consider themselves not to be constipated if anything at all is coming out. However, the actual Rome IV definition (most recent consensus of the medical community - May 2016) may surprise you.
Constipation is defined as having 2 or more of the symptoms below happening greater than 25% of the time consistently over 3 months:
- Lumpy or hard stools
- Sensation of not emptying completely
- Sensation of blockage at the anus
- Manual pressure/support required to get stool out
- Fewer than 3 spontaneous poops per week
And for those who learn better visually, here is the Bristol Stool Chart. Basically, if you commonly have types 1, 2 or 3, that’s constipation.
THE DEFECATION PROCESS
Under normal circumstances, here’s what happens:
- Peristalsis (involuntary waves of muscular pumping contractions in the colon) delivers fecal matter to the rectum (usually 1-4 days to pass through the entire GI tract)
- Once stool is in the rectum, “sampling” occurs. This means the internal sphincter relaxes to determine gas, liquid or solid
- External sphincter contracts to hold in stool during sampling
- Once you’re at the appropriate location, you sit or squat to increase the anorectal angle (best position of pelvic muscles to release stool)
- External anal sphincter and pelvic floor muscles relax
- SLIGHT bearing down assists in getting the stool out (should be mostly a passive event, though!)
- Pelvic floor muscles (puborectalis in particular), internal and external anal sphincter return to normal resting state once you’re done
When this process is disrupted at any level, constipation follows.
TYPES AND CAUSES
Did you know there are different kinds of constipation? Travel, lack of activity, dietary changes and medication are all examples of things that can get in the way of your regularity.
The Rome IV group addressed the various complexities of bowel function, identifying many factors that drive it. Some of those include altered gut bacteria, depressed immune function, altered hormone function, and opioid use. In fact, a very large percentage of medications have constipation as a side effect, not just opioids.
Understanding the underlying cause(s) of constipation is essential. This is where it gets confusing. Sometimes a treatment will help constipation, while other times it will actually worsen the condition. It’s important that the type of constipation is identified in order to best treat it.
DIY HOME OPTIONS
Some constipation is normal. It happens to almost everyone, every now and then, and can often be treated at home. There are so many options for over-the-counter treatments like supplements, laxatives, stool softeners, prebiotics, probiotics, and enemas. These are available for a reason. And, at the right time and for short-term use, they do work! But the most important factor here is short-term. Once constipation becomes long-term, or life-long, then it should be addressed by a healthcare professional.
Here are 3 simple changes you can make to help move things along:
1. Fluid and fiber intake – The VERY first thing you should do to try to address constipation is drink more water. While fiber is also very important (and sorely lacking in the U.S. diet), if it is not matched with increased water consumption, the fiber can actually back you up more.
2. Dietary modification – Getting fiber from your diet is best. Supplementing with over-the-counter fiber mix-in’s is next best. There are lots of good sources of fiber, some better than others. Start with small increases each day, such as having oatmeal for breakfast, some fruit at lunch, and an extra serving of vegetables at dinner. Adding just a few extra grams of fiber (plus water!!) daily can make a huge difference. Also consider reducing the amount of meat you consume as it takes longer to digest.
3. Body positioning – Find the right angle to help you poop. This means having your knees above your hips, with your body leaning forward. Think of approximating as close as possible to a squat. To help maintain this position, apply a stool or lift under your feet on the sides of the toilet. There are name brand ones available, like the Squatty Potty, or you can make your own.
So what if THAT doesn’t help? Now what?
Here is where a physical therapist comes in. In fact, PT can be a game-changer. Usually in some combination with the above factors, it can provide the missing link to easy, consistent pooping!
PHYSICAL THERAPY OPTIONS
For functional constipation, especially with outlet-obstruction, pelvic floor dysfunction (PFD) is typically a major contributing factor. Good news! According to the latest studies, pelvic floor physical therapy including biofeedback is the treatment of choice for PFD, and its efficacy has been proven in clinical trials. That simply means it works!
Here are some ways a pelvic health specialist can help:
Exercise – Sometimes the last thing you want to do is move when you’re backed up. However, activity actually boots digestive transit time (ie, moves things along). A qualified physical therapist can introduce you to comfortable, safe and effective exercises and movement strategies.
Manual therapy techniques – There are a range of hands-on techniques that address constipation and the most appropriate depends on your particular issue. For some, the neural component or ‘messaging’ from the nervous system to the colon, needs to be addressed. Research has shown that people receiving thoracic and lumbar mobilizations showed “significantly larger declines in transit time” than those receiving dietary fiber modification alone. Those with scar tissue from surgeries or long-term constipation may also benefit manual therapy including abdominal ‘I-love-u’ massage and/or visceral mobilization techniques to allow improved peristalsis.
Pelvic floor muscle retraining – If it moves through the system but can’t get out at the end, that’s outlet-obstruction. PT can teach you how to retrain the coordination of your pelvic floor along with other muscles. It can also retrain the ano-rectal communication and reduce any asymmetry or tension patterns that limit pelvic floor coordination.
Gadgetry – There are several options that can help give you information about what’s going on:
1. Biofeedback is basically a form of EMG, measuring muscle activity and giving you feedback about what’s going on with your muscles. Through the application of electrodes, vaginal or rectal probes, you are actively involved in the learning process to know how to consciously feel and control your pelvic floor muscles.
*A note about biofeedback: Most of the research conducted on pelvic floor treatment for relief of constipation was done using biofeedback. This is why it might be what your physician still recommends. Here’s the thing, though... biofeedback just means information you receive about your body. A mirror is also a powerful (and simple) biofeedback tool that can be utilized by your pelvic health specialist to guide you through gentle exercises, so that you can learn which muscles to use, when to use them, and how hard to contract them. Compared to a mirror, there is a HUGE range of more technical options available, from clinic EMG units to apps on your phone. However, many of us in the field simply don’t use these gadgets as much anymore because of their limitations.
2. Balloon retraining can be helpful in the case of altered compliance or rectal awareness (when you can’t tell if / when the muscles should contract or relax). Compliance issues mean you’re getting faulty information. It may feel like you can’t tell something is there or it may feel like something is there when it’s not.
3. Perineal electrical stimulation is another option, but it is usually used for fecal incontinence more than constipation. It’s a good option if there is significant weakness or laxity in the anal structure itself though.
Breath and mechanics retraining – Training the respiratory diaphragm, abdominals and pelvic floor to coordinate appropriately keeps the pressure where you want it and when you want it. A pelvic health specialist instructs you in the exact positioning and coordination training that would benefit your particular issue. At Activcore, we also have tools, such as the Redcord suspension exercise system, which helps retrain the neuromuscular system directly for faster, more consistent and lasting results.
MEDICAL TESTING AND TREATMENT OPTIONS
If you’ve tried the self-care and pelvic PT, but still have the same symptoms — now what? Here is where medical testing and treatment may be most helpful. Some of the more commonly used tests to determine what’s going on include:
Defecogram – Use of barium and X-ray to watch defecation, and to evaluate completeness of emptying and the anorectal angle
Colonic transit studies (Sitz marker study) – Identifies problem with transit time of stool; you swallow radiopaque markers and X-rays are taken 3-7 days later to see if markers have traveled all the way through, how many are left, and where they are stopping (avg normal is 24-72 hours transit)
Anorectal dysfunction studies – A series of studies measuring rectal sensation, rectal compliance, rectal reflexes, expulsion patterns, as well as internal and external sphincter pressure at rest, contraction, and filling
Scopes (anoscope, sigmoidoscopy, colonoscopy, etc.) – A flexible tube with light/camera on the end to view inside the GI tract, and to take biopsies (if needed) for diverticulitis, polyps, and cancerous lesions.
Medication is a consideration as well. Providing a list of FDA approved medications and supplements is not within the scope of this post; however, many are available and can be helpful should the more conservative measures (mentioned above) not get things going.
Keep in mind the short-term warning though! Remember that taking stimulant laxatives for an extended period of time can cause abdominal distension, chronic diarrhea, excessive gas, nausea, and vomiting. Moreover, you can become dehydrated if you do not drink enough water while taking laxatives, thereby worsening the constipation.
Other treatment options such as sacral nerve stimulation and Botox injections have not been supported by research to be effective in the treatment of constipation.
Whatever method or combination of methods you take, seeing a pelvic health specialist to improve the mechanics of defecation and reduce the need for straining will help you get long-term relief.
If you are having signs and symptoms of constipation or you’ve had unsuccessful treatment in the past, click here to find an Activcore location near you.
You can learn more about this topic by visiting our Pelvic Health page.
- Bowel Disorders. Brian E. Lacy, Fermín Mearin, Lin Chang, William D. Chey, Anthony J. Lembo, Magnus Simren, Robin Spiller. Gastroenterology 2016;150:1393–1407
- Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Simren, M, Palsson, O, Whitehead, W. Curr Gastroenterol Rep. 2017; 19(4): 15.
- Prevalence of Chronic Constipation and Its Associated Factors in Pars Cohort Study: A Study of 9000 Adults in Southern Iran. Moezi, P, et al.Middle East J Dig Dis. 2018 Apr; 10(2): 75-83.
- The effects of Maitland Orthopedic Manual Therapy on Improving Constipation. Koo, J-P, Choi, J-H, and Kim, N-J. J Phys Ther Sci. 2016 Oct; 28(10): 2857-2861.
- Epidemiology and Management of Chronic Constipation in Elderly Patients. Roque, MV and Bouras, EP. Clin Interv Aging. 2015; 10: 919-930.
ABOUT THE AUTHOR:
Beth Kemper is a physical therapist and double board certified Women’s Health Clinical Specialist (WCS) and Pelvic Rehabilitation Practitioner (PRPC). She has more than 20 years of experience in the study and practice of pelvic health.
Beth works as the Lead Physical Therapist at Activcore in Atlanta, Georgia, located just 2 miles from Emory University. She also serves as Activcore's National Director of Pelvic Health.
With an extensive clinical background and education, Beth is uniquely qualified to handle more complex conditions like pelvic floor dysfunction, including bowel, bladder and sexual health problems. She holds a double Bachelors degree in Biology and Chemistry from Meredith College, as well as a Masters degree in Physical Therapy from Emory University, ranked among the top 10 PT schools in the country. She also has advanced post-graduate training in manual therapeutic interventions and pelvic rehabilitation for all genders and throughout the lifespan.
Beth is the founding physical therapist member of Emory Hospital's Pelvic Multidisciplinary Team. She also co-founded a PT clinic in her hometown of Asheville, NC before returning to settle in Decatur, GA. She is a mother, dancer, hiker, wife, friend, runner and physical therapist, passionate about pelvic therapy.
Beth goes beyond the pelvic floor and looks at the whole body to help you recover from pain and injury, and safely return to a fulfilling life of sport, activity and wellness. She is among less than 1% of all physical therapists across the United States who possess dual board certification as both a Women’s Health Clinical Specialist (WCS) and a Pelvic Rehabilitation Practitioner (PRPC) for all genders. These designations make her exceptionally equipped to treat you from head to toe. Additionally, she is recognized nationally as a leading authority in the application of Redcord, a suspension exercise system designed to help you develop a smarter, balanced body through the power of neuromuscular activation. [READ MORE]