Research report

Using massage to ease constipation31 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

AuthorKristina Lämås is a senior lecturer in the department of nursing at

Umeå University, Sweden

ABSTRACT

Lämås 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.

AimThis 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. 

MethodThe 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 ¼ of defecations; Lumpy or hard stools in more than ¼ of defecations; Sensation of incomplete evacuation in more than ¼ of

defecations Sensation of anorectral obstruction or blockade in more

than ¼ of defecations; Manual manoeuvres needed to facilitate more than ¼ 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 sessionsThe 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.

ResultsAbdominal 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 (Lämås et al., 2009). Health-related quality

of life (HRQoL) also increased significantly in the intervention

group (Lämås 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 (Lämås et al., 2010). Results from

interviews (Lämås 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”.

DiscussionMany 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.

ConclusionThe 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

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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

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Lämås K et al (in press) Experiences of abdominal massage for

constipation – an interview study. Journal ofClinical Nursing.

Lämås K et al (2009) Effects of abdominal massage in

management of constipation - a randomized controlled

trial.International Journal of Nursing Studies; 46: 759-767.

Lämås 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

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Thompson WG et al (1999) Functional bowel disorders and

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Walter S et al (2002) A population-based study on bowel habits in

a Swedish community: prevalence of faecal incontinence and

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Van Dongen E, Elema R (2001) The art of touching: the culture

of ‘body work’ in nursing. Anthropology & Medicine; 8: 149-162.

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