It’s one of the fundamentals of life. Poo jokes are among the first we learn as children. However, the longer life goes on, the more we understand there’s nothing funny about irregularities in bowel movements. From infrequency to discomfort, straining, faecal incontinence and more, there’s certainly a lot about constipation that warrants serious investigation and interventions for sufferers. Is there more to treatment than pharmacological and dietary approaches though?
This question is an important one. That’s why a recent systematic review is noteworthy: it took a look at the evidence for manual therapies in relation to the relief of functional constipation. This included analysis of chiropractic care and the high-velocity, low-amplitude thrusts commonly used in chiropractic . The result? Seven studies fulfilled the benchmark for inclusion in the systematic review of the literature – and the news is interesting indeed.
Appearing in the International Journal of Osteopathic Medicine, the article in question first found 533 studies (after duplicates were deleted). Once these were sorted for relevance and eligibility criteria, seven studies remained. These studies spanned 236 participants whose average age at the beginning of their study was 43.2 years, ranging from ages 20-94. A specific constipation scale (Rome II and Rome III) was used to diagnose constipation and assess its severity. While one study didn’t report gender, the remaining studies were heavily skewed towards females at a rate of 70.4% to 29.6%.
The latter is an interesting statistic which in itself bears further investigation as it may be reflective of constipation appearing in higher rates in women, or simply a reflection of men not seeking help for the condition at the same rates that women do.
What interventions were used?
While the study did appear in an osteopathic journal, the analysis covered physiotherapy, chiropractic, massage, soft-tissue work, direct visceral mobilisation, exercises and muscle energy techniques and more. Chiropractic specific interventions included HVLA thrusts, and passive joint mobilisation and myofascial release also featured in the battery of techniques that may also be used by chiropractors.
Of the seven studies, two had control groups and four had comparison groups so that investigators could compare sham groups with intervention groups. Researchers also ranked studies according to their quality (using the PRISMA methodology for ascertaining quality of studies). This allowed them to find one high quality randomised controlled trial, and one moderate quality randomised controlled trial. They also found “four moderate quality uncontrolled study and one low quality study.” Based on their analysis, they deemed the available evidence for manual therapies assisting in functional constipation to be moderate.
The findings of these studies including significant positive changes in bowel frequency, straining or faecal incontinence. A full breakdown of the wide range of outcome measures can be found in the full study referenced below . They were significant though, and for sufferers of functional constipation, this may indeed be the first they hear of manual therapies as another option for treatment.
What does this mean?
The scientific method is founded on several values, one of them being scepticism – that leads to the understatement of findings rather than overstatement. Thus, a finding of “moderate” strength is actually quite notable. It does not discount the need for further research, rather it shows there is evidence that suggests manual therapy could indeed have a significant impact here.
There are a plethora of factors that might contribute to functional constipation or functional gastro-intestinal disorders (FGIDs). Among these are things “changes in intestinal motility, visceral sensitivity, gut microbiota, mucosal and immune function” among other things .
However, one of the issues that should perk up the ears of proverbial chiropractor is this: researchers remarked in their discussion on the mechanism of effect that “FGIDs are likely to be linked to stress and autonomic nervous system (ANS) dysfunction, which is the intended mechanism of effect in most of the included studies. Using manual therapies of influence the ANS was proposed to influence muscle tone and motility of the gastro-intestinal tract, increase digestive secretions and relax gastro-intestinal sphincters.”
Their findings also suggested that “mechanical forces, such as those applied by a [manual therapy] practitioner can initiate a complex interaction between the peripheral and central nervous systems. This interaction can result in a chain of neurophysiological responses which may influence autonomic function, pain modulation, and inflammatory response – factors that are all associated with constipation.”
To chiropractors and the chiropractic tribe, this brings us to the heart of our practice – the nervous system. While more research is required, and certainly more chiropractic specific research, it is encouraging indeed. It’s amazing what happens when we care for the nervous system.
- Erdrich, L., Reid, D., & Mason, J., (2020). Does a manual therapy approach improve the symptoms of functional constipation? A systematic review of the literature. International Journal of Osteopathic Medicine. 36 (2020). Pp 26-35, DOI: https://doi.org/10.1016/j.ijosm.2020.05.003