Effects of abdominal massage in management of constipation—A randomized controlled trial
Introduction
In Sweden, 20% of women and 8% of men between 31 and 76 years old reported having constipation (Walter et al., 2002). This prevalence agrees with other western countries (Brandt et al., 2005, Higgins and Johanson, 2004). The condition seems to increase with age and is more prevalent in women than men (Higgins and Johanson, 2004). In nursing homes, about 50–75% of the residents had documented diagnosed constipation or routinely used laxatives (Kinnunen, 1991, Phillips et al., 2001). Because constipation is a fundamental care problem (particularly in long-term care settings), nurses have an important role in constipation management. Constipation management in nursing care is problematic because of the individual variability of bowel habits. Moreover, there is not a consistent definition for constipation and there are various causes and risk factors related to constipation (Castledine et al., 2007).
Constipation is associated with:
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hard stools and difficulties defecating (Higgins and Johanson, 2004, Locke et al., 2000, Phillips et al., 2001),
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sensations of incomplete evacuations and urge to defecate (Locke et al., 2000),
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diarrhoea caused by fecaloma, pain in the stomach and rectum, bloating, nausea and vomiting, anorexia, and depression (Ross, 1998),
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malnutrition (Suominen et al., 2005),
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residualuria and bacteriuria (Charach et al., 2001),
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urine incontinence (Higgins and Johanson, 2004).
Symptom based criteria for constipation have been outlined by experts and are known as Rome criteria (Thompson et al., 1999) (Box 1).
Several researchers have outlined recommendations for constipation management. Increase of physical activity, fibre and fluid intake are often recommended as a first choice of treatment, although the scientific evidence for such treatments is scarce (Annells and Koch, 2003, Brandt et al., 2005, Muller-Lissner et al., 2005, Petticrew et al., 1997). The strongest evidence was found for tegaserod, a treatment that stimulates the peristaltic reflex and increases colonic motility (AGA, 2005). Osmotic laxatives such as lactulose and polyethylene glycol can be effective and there is some evidence that the bulking agent psyllium provides relief. Authors did not find sufficient evidence to recommend other bulking agents, stool softeners, stimulant laxatives, or other alternative treatments (AGA, 2005).
The function of the gastrointestinal tract is influenced, among other things, by activity in the parasympathetic division in the autonomic nervous system. Stimulation of the parasympathetic division increases the motility of the muscles, increases the digestive secretions, and relaxes sphincters in the gastrointestinal canal (Allan, 2005, Purves et al., 2007). Massage might stimulate parasympathetic activity, a response that might stimulate the gastrointestinal tract (cf. Moyer et al., 2004). In one study of preterm neonates it was examined how massage influenced weight gain (Diego et al., 2007). The massage increased vagal activity and gastric motility. In a case study with a person with myelopathy, abdominal massage elicited rectal waves and defecations (Liu et al., 2005). The explanatory mechanisms behind the effects of massage, however, are not yet fully understood.
Abdominal massage, unlike laxatives, may not cause negative side effects and may positively affect constipation (Ernst, 1999). The effects of abdominal massage have been assessed in a small number of clinical studies containing small study groups or case studies. The documented effects are significantly shorter transit time, reduced abdominal distension and faecal incontinence, increased bowel movements (Ayas et al., 2006), and return of normal bowel function (Harrington and Haskvitz, 2006, Preece, 2002). In a systematic review, Ernst (1999) found only four controlled clinical trials. The studies reported increased bowel function following abdominal massage or abdominal massage was found to be equally effective as laxative treatment. The included studies were found to have methodological flaws: the studies were small (n = 1–32) and only one was a randomized trial. Some studies lacked information about change in laxative use during the study period and another study combined the massage with exercise, which made interpretation of the result difficult. Ernst (1999) concludes that published data is insufficient to give recommendations about abdominal massage and more research is needed. No further controlled clinical trials published after 1999 have been found.
This study investigates the effects of abdominal massage on gastrointestinal functions and laxative intake on persons with constipation. The hypothesis was that abdominal massage could affect the severity of gastrointestinal symptoms, number of bowel movements, time to defecate, faeces consistency, quantity of faeces, and decrease in laxative use without increased fluid and fibre intake or increased physical activity.
Section snippets
Methods
This prospective, non-blinded, and randomized controlled trial was conducted in Sweden between January 2005 and March 2007
Results
A total of 60 people were randomly assigned to the intervention or control group. Eight participants withdrew during the study period; this means that 86.6% completed the study. Two participants withdrew before baseline because of lack of time; they were excluded. Three participants in each group withdrew after baseline; one in the intervention group because of troublesome blood pressure dip with numbness in hands and feet after the first session and two in the control group where one died and
Discussion
In this study, the intervention group had significantly less severe gastrointestinal symptoms assessed with GSRS according to total score, constipation syndrome, and pain syndrome compared to control group. The intervention group also had a significant increase of bowel movements when compared to control group. There were no significant associations between massage and indigestion syndrome, diarrhoea syndrome, consistency of faeces, or stool size.
In the univariate analysis contrary to the
Conclusions
Abdominal massage was found to decrease severity of gastrointestinal symptoms, especially symptoms associated with constipation and pain syndrome. There was also an increase in bowel movements. The massage, however, did not lead to a decrease in laxative intake, which indicates that massage could be seen as a complement to laxative use rather than a replacement. There was no immediate effect after 15 min of light pressure abdominal massage. The 8-week study period was essential to finding
Conflict of interest
No one of the authors has any potential conflicting interest in this study.
Funding
This study was supported by grants from The Swedish Research Council, The Swedish Association of Health Professionals, Ekhaga Foundation, The County Council of Västerbotten, and the Senior Centre of Västerbotten. The founding source had no involvement in the accomplishment of the study.
Ethical considerations
All participants were informed both orally and in writing that they could discontinue participation at any time and informed consents were obtained. After the study period, all participants in both groups were offered lessons in abdominal massage so they could massage themselves. The study was approved by the Ethics Committee at the Medical Faculty, Umeå University (Um dnr. 04-132M).
Acknowledgements
The authors would like to thank Senior Lecturer Sofia Mattson, Pharm Dr, Umeå University, and Maine Carlsson, dietician, University Hospital, for valuable help with the preparation of variables in the statistical analysis.
Contributions: Study design: KL, CJ, BE, LL; data collection; KL; data analysis: KL, LL, HL, and manuscript preparation: KL, LL, HL, BE, CJ. All authors have read and approved the final manuscript.
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