A comprehensive physical therapy approach including visceral manipulation after failed biofeedback therapy for constipation

Participants

• Number: 1

• Description: a 41-years-old. She had to undergo an operation to resolve a situation of severe constipation, rectal pain and muscle spasms in the anal area. She had been suffering from constipation for 8 years following a cholecystectomy and from rectal pain for 4 years following a hemorrhoidectomy. In the past she had undergone a gastrectomy, reaching about 65kg of weight (with a weight loss of 50kg) and she had gone through 3 deliveries with episiotomy.

She had received 10 sessions of internal rectal biofeedback and electrical stimulation with strengthening, rest, and coordination exercises performed by her physician’s assistant, which resulted in greater muscle control, but which did not affect bowel function and quality of life.

The patient experienced considerable difficulty evacuating with very hard stools (2 to 4 on the Bristol Stool Chart). She therefore made daily use of laxatives and frequent use of enemas, while also reporting rectal bleeding of an intense red color during defecation. Once in 10 she had difficulty urinating, especially when she was feeling constipated.

Using the Visual Analog Scale, abdominal pain was approximately 3-5 out of 10, rectal pain during defecation was 5-7 out of 10, and suprapubic pain with urination problems was 3 out of 10. These pains were described as sharp, stabbing, throbbing and cramping.

According to the Rome III criteria, the patient had 5 out of 7 of the symptoms for chronic idiopathic constipation. According to the CSS, the level of constipation was 11 out of 30, while according to the PAC-SYM scale it was 16 out of 48. Using the PAC-QOL, the quality of life affected by constipation was 40 out of 112.

She drank 4-6 glasses of water and ate 15 grams of fibers a day and didn’t do any specific physical activity.
Imaging tests excluded slow transit constipation, rectocele, enterocele, or intussusception and suggested anal dyssynergia. Physical examination revealed reduced mobility of the spine from T10 to L4 as well as the coccyx and a kyphotic posture. Neurological examination revealed signs of pudendal nerve entrapment in the left Alcock’s canal. Visceral examination showed reduced motility of the small intestine and sigmoid colon, with various restrictions. Perineal examination found pelvic floor muscle weakness, as well as muscle spasms (also observed in the coccygeal area), and confirmed the hypothesis of rectal dyssynergia, with possible low-grade intussusception or internal rectal prolapse.

The end result was obstructed defecation syndrome secondary to pelvic floor dyssynergia.

Interventions and evaluations

• Evaluation of symptoms by physical, neurological, visceral, abdominal and perineal examination
• Evaluation of symptoms at the beginning and at the end of treatments
• Assessment one year after the end of treatments of constipation symptoms by CSS and PAC-SYM and quality of life by PAC-QOL
• 7 sessions over 3 months
• Comprehensive approach:
  • behavioral interventions: postural exercises, nutritional indications (increase in fibers and water intake), physical activity, intestinal self-massage, relaxation exercises with pelvic floor visualization and education in better evacuation habits to reduce effort;
  • exercises to strengthen the abdominal, lumbar and pelvic floor muscles;
  • neuromuscular re-education exercises of the pelvic floor;
  • manual therapy:
    • visceral manipulation of the colon, sigmoid colon, small intestine, rectum, urinary bladder, and urethra;
    • manipulation of the pudendal nerve;
    • lymphatic drainage of the perineum;
    • spinal mobilization;
    • myofascial release and treatment of trigger points.

Results

The patient saw her pain associated with defecation decrease to 1-2 out of 10 and no longer reported straining during evacuation. The pain when urinating disappeared, she reduced her use of laxatives by 50% and stopped resorting to enemas.

One year after the end of the treatments, the CSS showed no change, while the PAC-SYM (symptoms related to constipation) improved by 5 points and the PAC-QOL (quality of life) by as much as 20 points.

Discussion

An approach of physiotherapy or comprehensive manual therapy, in terms of both evaluation and  treatment, has shown to be particularly effective in this case of chronic constipation with dysfunctions deriving from previous surgeries. The consideration of behavioral and nutritional aspects and of the various systems involved in defecation and constipation is in fact essential to achieve the best possible result.

This case demonstrates how fundamental a multidisciplinary approach involving different professional profiles (including gastroenterologists, surgeons, manual therapists, dieticians, psychotherapists and nurses) is.

Visceral manipulation, which consists of gentle manual techniques to improve the mobility and motility of the organs and fascia associated with them, has proved to be a valid aid, as often emerges in clinical practice. In this regard, there are few studies on visceral manipulation and pelvic floor dysfunction.

For this reason, clinical studies are needed to validate the centrality of manual approach in case of constipation, in terms of both efficacy and cost-benefit analysis – also bearing in mind that manual therapy is a conservative intervention.