Research report

Using massage to ease constipation

31 January, 2011

Abdominal massage can relieve constipation symptoms and boost quality of life IN THIS ARTICLE Outlining the physical and psychosocial effects of constipation Exploring why people find discussing constipation difficult What to consider before starting abdominal massage therapy

Author
Kristina Lms is a senior lecturer in the department of nursing at Ume University, Sweden ABSTRACT Lms K (2010) Abdominal massage to manage constipation. Nursing Times; 107: 4, early online publication. Background Constipation is a painful and serious condition which patients often find difficult to talk about. It is usually treated with laxatives alone. Aim To determine whether abdominal massage is an effective treatment for constipation. Method The study involved 60 people with constipation. Half received 15 minutes of abdominal and hand massage a day, five days a week for eight weeks, in addition to prescribed laxatives. The rest received only prescribed laxatives. Interviews with participants were also conducted. Results Abdominal massage used alongside laxatives reduced abdominal pain, increased bowel movements and improved quality of life compared with laxative use alone. Patients reported positive experiences of abdominal massage but it did not reduce their laxative use.

Conclusion Abdominal massage was considered to be a pleasant treatment that can be offered as an option in constipation management. Keywords: Constipation, Massage, Bowel function,Gastroenterology

This article has been double-blind peer reviewed

5 KEY POINTS

1.

Constipation is a serious and painful condition and can be fatal if left untreated 2. Nurses should overcome negative attitudes to patients with constipation by better understanding the condition 3. Abdominal massage can reduce abdominal pain, increase bowel movements and improve quality of life for people with constipation 4. Abdominal massage is a pleasant treatment that can be offered as a treatment option in constipation management. 5. A trusting and open nurse-patient relationship is crucial for abdominal massage to be effective
Constipation is an unpleasant involving unpleasant physical symptoms, such as bloating, nausea, and cramps. It is often associated with the use of laxatives as it can cause a total blockage of faeces, which can be life-threatening if left untreated. The intimate nature of constipation can also make it difficult to talk about, leading to feelings of loneliness and social isolation Constipation appears to be more common among women than men. A Swedish study found around 20% of women had problems with constipation compared with just 8% of men (Walter et al., 2002). It also appears to become more common with age; while reasons for this are unclear it may be because older people are more affected by disease than younger people and use more medications that lead to constipation. Abdominal massage to treat constipation was discussed in the literature as far back as the late 1800s (Garry, 1889). It has gained renewed interest but recent studies have been small with methodological flaws, providing few recommendations for practice (Ernst, 1999). This study set out to discover whether abdominal massage is an effective treatment for constipation.

Constipation

In addition to its physical symptoms, a major problem associated with constipation is the highly private nature of the condition. This can make it difficult for patients to discuss, even with healthcare professionals. Bodily functions are often seen as taboo subjects and patients can experience feelings of shame, discomfort and vulnerability when discussing symptoms. Friedrichsen and Erichsen (2004) interviewed 11 people withcancer about their experiences of constipation. They found it led to physical suffering, occupied the participants thoughts, and was a reminder of death. They also reported difficulties in talking about constipation due to its intimate nature. According to Annells and Koch (2002), constipation can have a major impact on quality of life and daily activities. Its unpleasant symptoms, such as nausea and cramps, can deter people from socialising, leading to isolation. Many people with constipation report feeling ignored and offended when in contact with healthcare professionals, who sometimes see constipation as a minor problem (Annells and Koch, 2002). Raising the issue can be daunting so it is essential that healthcare professionals treat patients who have constipation with respect.

Aim
This study was undertaken to determine whether abdominal massage can be used as an effective treatment for constipation, either alone or combined with the use of laxatives.

Method
The study involved 60 participants with constipation according to Rome II criteria (Thompson et al., 1999), which define functional constipation as two or more of the following being present for at least 12 weeks in the last 12 months:

Straining in more than of defecations; Lumpy or hard stools in more than of defecations; Sensation of incomplete evacuation in more than of defecations Sensation of anorectral obstruction or blockade in more than of defecations; Manual manoeuvres needed to facilitate more than of defecations;

Fewer than three defecations per week.

Participants were aged 36-85 years (average 63 years), and 51 were women. Seven were wheelchair users, five lived in communal housing services and the remainder lived in their own accommodation. Half the participants were randomised to an intervention group and half to a control group. The intervention group received 15 minutes of abdominal and hand massage a day, five days a week for eight weeks, in addition to their prescribed laxatives. They were instructed to reduce laxative intake when they experienced improved bowel function. The control group was told to use their prescribed laxatives as usual. Study participants also took part in interviews.

Massage sessions
The mechanisms behind the effects of massage are not fully understood. However, one theory is that touch stimulates the parasympathetic nervous system. This is said to increase bowel motility and digestive secretions and relax gastrointestinal sphincters (Diego et al., 2007, Purves et al., 2007). An enrolled nurse educated in gentle massage gave the massage in a secluded room for privacy, with soft light and relaxing music to create a calm atmosphere. Participants could choose whether sessions took place in the clinic, at home or at work; massage oil was used to reduce friction against the skin, and the hands were massaged in addition to the abdomen as they have many receptors that are stimulated by touch.

Hand massage
Massage sessions began with the hand, enabling the therapist to lead into the abdominal massage gradually when participants had relaxed. The back of the hands, fingers and palms were massaged for about eight minutes using longitudinal strokes and circular movements.

Abdominal massage
The abdomen was massaged lightly for about seven minutes, using lateral and downward strokes and circular movements in the

direction of the large intestine. A systematic massage pattern enables the recipient to recognise the strokes, promoting a feeling of security and making it easier to relax in future sessions.

Results
Abdominal massage significantly reduced gastrointestinal symptoms with regard to constipation and abdominal pain, and resulted in an increased number of bowel movements compared with the control group (Lms et al., 2009). Health-related quality of life (HRQoL) also increased significantly in the intervention group (Lms et al., 2010). However, abdominal massage did not have an immediate effect and it took up to two weeks for participants to experience any increase in bowel function. Bowel function then increased gradually during the eight-week study period. There were no differences in the use of laxatives between the two groups of participants. Around 40% of participants who received abdominal massage had a greatly improved HRQoL after eight weeks. HRQoL was used to calculate cost effectiveness and when given to those who had a greatly improved HRQoL, abdominal massage was found to be a cost effective treatment (Lms et al., 2010). Results from interviews (Lms et al., accepted) indicated they felt comfortable receiving abdominal massage, and believed their bowel function had improved. A reduction in problems with bloating, headaches and disturbed sleep was also reported and participants became less concerned about the complexity of bowel function during the massage, describing it as a feeling of freedom.

Discussion
Many participants said they felt neglected by healthcare workers despite reporting symptoms of pain, cramps, nausea, difficulty eating, disturbed sleep and fainting associated with bowel movements. One thought she may be to blame for this, that she had not been clear enough or told her story with enough emphasis. This communication breakdown warrants further discussion. Perhaps the condition is neglected because it is accorded low status compared with other medical problems? Alternatively healthcare workers may find it difficult to appreciate that the condition can cause significant suffering.

Even if earlier studies have been small, and with methodological flaws the results have been promising. The results from our study support those promising findings and hopefully future studies will continue to strengthen the evidence of abdominal massage. However, previous studies have indicated that abdominal massage does not have a lasting effect and should therefore be seen as an ongoing treatment rather than something that cures constipation alone(Holey and Lawler, 1995). Additionally, not everyone is comfortable receiving massage, especially around the abdomen. One criterion for giving massage is that both the massage therapist and the recipient feel comfortable with the situation. Touching another person is an intimate form of communication - if the therapist does not feel comfortable it is likely to affect the quality of the massage and the recipient will notice this. When educating nurses in massage therapy it is important to emphasise the need to be present and open with the person receiving the massage; absence or distraction on the part of the therapist could adversely affect the quality of the massage. Abdominal massage requires a relationship of trust between the therapist and the patient. Potential obstacles to the patient feeling comfortable with the situation should be explored. According to (van Dongen and Elema, 2001), touch is affected by power in relationships, as well as culture, gender, age, status and roles. Massage therapists should consider a number of factors before proceeding with abdominal massage:

Are there cultural factors that make massage of the abdomen inappropriate? Does the patient have a past bad experience of massage that makes it inappropriate? How does gender or age affect therapists relationships with patient in terms of giving abdominal massage? Are they in a position of power or status, or do they have a role that stops patients expressing an opinion?
Limited knowledge about how massage affects the spread of cancer must also be considered. If a treatable, active abdominal tumor is suspected abdominal massage may be inappropriate. Caution should also be observed if there is inflammation of the

abdomen, signs of infection, or if the person has recently undergone abdominal surgery.

Conclusion
The study participants considered abdominal massage to be a pleasant treatment compared with using laxatives, which often have negative side-effects. It is uncertain if abdominal massage can replace laxatives but it can be used as a complementary therapy or as a first-line treatment. Negative side-effects associated with abdominal massage are rare but not everybody will benefit from it. The crucial thing is to find patients whose constipation will be relieved by abdominal massage. It is unknown at present which patients will benefit the greatest and this needs further study. Abdominal massage can easily be learned by enrolled or registered nurses, and if a patient with constipation feels comfortable with abdominal massage it may well be worth trying.

References:
Annells M, Koch T (2002) Older people seeking solutions to constipation: the laxative mire. Journal of Clinical Nursing; 11: 603-612. Diego M et al (2007) Preterm infant massage elicits consistent increases in vagal activity and gastric motility that are associated with greater weight gain. Acta Paediatrica;96: 1588-91. Ernst E (1999) Abdominal massage therapy for chronic constipation: a systematic review of controlled clinical trials.Research in Complementary Medicine; 6: 149-151. Friedrichsen M, Erichsen E (2004) The lived experience of constipation in cancer patients in palliative hospital-based home care. International Journal of Palliative Nursing; 10: 321-5. Garry G (1889) Abdominal massage in constipation and allied conditions. The Lancet; 133: 422-423. Holey LA, Lawler H (1995) The effects of classical massage and connective tissue manipulation on bowel function.British Journal of Therapy and Rehabilitation, 2, 627-631. Lms K et al (in press) Experiences of abdominal massage for constipation an interview study. Journal ofClinical Nursing. Lms K et al (2009) Effects of abdominal massage in management of constipation - a randomized controlled trial.International Journal of Nursing Studies; 46: 759-767.

Lms K et al (2010) Abdominal massage for people with constipation - a cost utility analysis. Journal of Advanced Nursing; 66: 1719-1729. Purves D et al (2007) Neuroscience. Sunderland, MA: Sinauer Associates. Thompson WG et al (1999) Functional bowel disorders and functional abdominal pain. Gut; 45: II43-II47. Walter S et al (2002) A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation. Scandinavian Journal of Gastroenterology; 37: 9116. Van Dongen E, Elema R (2001) The art of touching: the culture of body work in nursing. Anthropology & Medicine; 8: 149-162. HAVE YOUR SAY You must sign in to make a comment

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