Visceral Mobilization and Functional Constipation in Stroke Survivors, A Randomized, Controlled, Double-Blind, Clinical Trial

Participants

• Number: 30 people (6 female and 24 male)
• Criteria of inclusion: age 40-70 years, stroke suffered more than 1 year earlier with hemiparesis secondary to a single unilateral event, capacity for independent gait (that is, at least 20 meters without assistance), a complaint of chronic constipation for at least 6 months according to the Rome III Consensus conference.
• Criteria of exclusion: incision or tumor in the abdominal region, fractures, rheumatic diseases, infectious processes in the acute phase, inability to understand the proposed evaluations, and the incapacity to walk or maintain balance in an independent manner.
• Groups of study: two groups obtained by randomization
  • Group 1: physical therapy with the addition of visceral OMT, 15 people (2 female and 13 male, mean age 63 years) who had suffered stroke 21 months earlier and had had constipation problems for 20 month on average
    • 13 people completed the study with the final evaluation
  • Group 2: physical therapy with the addition of sham treatment, 15 people (4 female and 11 male, mean age 68 years) who had suffered stroke 26 months earlier and had had constipation for 23 months on average; 13 people completed the study with the final evaluation

Interventions and evaluations

• Administration of a scale to assess intestinal symptoms at the beginning of the study and 1 week after the last session, as well as questions about the frequency of intestinal evacuation and qualitative symptomatology of constipation
• Computerized plantar pressure evaluation of the static balance before the intervention, after the first session and 1 week after the last session
• 5 therapy sessions over 2 weeks
• All patients continued their ongoing drug treatments (e.g. NSAIDs and/or antibiotics)
• Group physical therapy: kinesitherapy aimed at strengthening the muscles, promoting their stretching and improving proprioception
• Visceral OMT: visceral mobilization techniques directed to ascending colon, descending colon, sigmoid colon and sphincters (cardiac, pyloric, Oddi, duodenojejunal and ileocecal), with patients on their backs with knees bent
• Sham: superficial contact with no pressure on the abdomen (over the intestines) in correspondence to the loops of the large intestine

Results

• Primary outcome: while in the group with physical therapy alone the symptoms related to chronic functional constipation remained similar (2.3 ± 1.1 at the beginning of the study and 2.4 ± 2.3 a week after the last session) in the group with the addition of visceral OMT the symptoms decreased in a statistically significant manner (2.8 ± 1.08 at the beginning of the study and 1.5 ± 0.74 a week after the last session).
• Secondary outcomes: there were no statistically significant differences between the two groups. In the group with the addition of visceral OMT, anteroposterior sway, velocity of anteroposterior sway and velocity of mediolateral sway seem improved 1 week after the last session (less sway and more velocity) in a statistically significant manner.
• Further analysis: regarding the frequency of bowel movements, 1 week after the last session the group with the addition of visceral OMT presented a statistically significant higher percentage of people who could evacuate everyday or every other day.
  To confirm this, in the group with the addition of visceral OMT, compared to the beginning of the study, a week after the last session the number of people who evacuated once every 3 days or less dropped in a statistically significant manner, an event that did not occur in the group with physical therapy only. Similarly, only in the group with the addition of visceral OMT, compared to the beginning of the study, a week after the last session various symptoms related to constipation decreased, such as abdominal pain or disconfort, very hard stools, strain required to move bowl, excessive passing gas, sensation of incomplete bowl movements and anal pain.

Discussion

Compared to group physical therapy alone, the addition of visceral OMT has favored a reduction in constipation symptoms, both quantitatively and qualitatively. Therefore, although this is a very short-term assessment, we can start saying that, in the event of a stroke, visceral OMT seems to be useful in improving chronic constipation, which often requires multiple kinds of treatments, possibly expensive or invasive.

The results obtained agree with other past studies where OMT proved to be effective in restoring intestinal function in cases of irritable bowel syndrome or constipation, both in adults and in children.
Most likely, the usefulness of OMT derives from its ability to act on the autonomic and enteric nervous system, restoring a functional balance and reducing the nociceptive signals from the viscera to the marrow, promoting the phenomenon of neurogenic inflammation that, in return, alters gastrointestinal motility.

The positive effect on the autonomic nervous system could also explain the positive effects on balance. But not only that: the balance could be improved thanks to the action on the visceral fascia that, having been “released”, promoted a better movement of the rest of the fascial system, which forms a unit throughout the whole body.

Studies are needed to deepen the comparison between OMT and sham treatment because the latter, on the one hand, may have been recognized by patients as fictitious and, therefore, may have induced a nocebo effect (having understood that the treatment was not a real treatment, patients would not have expected any improvements); on the other hand, even if it consists of “simple” touch, it may have induced effects greater than the simple placebo.