Mary Ferreira. Clinical Case Report Competition. Utopia Academy. First Place Winner. December 2011

Transcription

1 Massage Therapists Association of British Columbia Clinical Case Report Competition Utopia Academy December 2011 First Place Winner Mary Ferreira Myofascial release and visceral manipulation techniques for the treatment of chronic constipation: A case study P: F: research@massagetherapy.bc.ca massagetherapy.bc.ca MTABC 2011

2 Myofascial release and visceral manipulation techniques for the treatment of chronic constipation: A case study. Acknowledgements I would like to thank my case advisor, Rosanna Durante for her support and guidance in creating this case study. I would like to thank my instructor Annette Ruitenbeek for her assistance with massage techniques, loaning me text books and her overall enthusiasm about this case study. Lastly, and most importantly, I would like to thank the individual that donated hours of her time to be my subject in this case study. Abstract Objective: This study explores the effectiveness of myofascial release techniques and visceral manipulation techniques in a single case of chronic constipation. Methods: A protocol of ten 60 minute massage treatments dispersed over a 36 day period of time was completed. Techniques applied during treatments focused on myofascial release and visceral manipulation. Homecare involved education on defecation ergonomics. The Rome III questionnaire was completed prior to treatment to ensure the client met the diagnostic criteria for functional constipation and to rule out Irritable Bowel Syndrome. A bowel diary incorporating the Bristol Stool Chart was completed before, during and after the intervention time period to quantify and qualify any changes in bowel movements. Results: Prior to the massage intervention the client experienced 0-2 bowel movements per week on average. During the 5 weeks of massage intervention the client experienced (in chronological order), 5, 2, 2, 4, and 3 bowel movements per week; an overall increase in bowel movements. The Bristol Stool Form Scale numbers indicated mixed results, initially showing an increase in healthy stool bowel movements, followed by an increase in constipation type stool bowel movements. Conclusion: The results, though inconsistent, indicate that myofascial release and visceral manipulation

3 techniques can have a positive effect in cases of chronic constipation. More case studies are needed to evaluate consistency of results. Keywords Myofascial release; visceral manipulation; constipation; massage Introduction Constipation is a defecation disorder that affects 2-28% of adults in the general population 1, negatively affecting their quality of life 2. Constipation is a multi-factorial disorder that can be caused by low fibre intake, lack of physical activity, medications, Irritable Bowel Syndrome(IBS), abuse of laxatives, changes in life or routines, ignoring the urge to have a bowel movement, dehydration, problems with intestinal functioning and certain systemic conditions and disorders. In 2004, in the US alone, there were over 6.3 million patient visits to medical centres with constipation as their primary complaint 3. These visits resulted in a total cost of 1.7 billion dollars 2. One study calculated the mean annual cost for chronic constipation as $7522 per person 4. The cost of treating this common defecation disorder is huge, so there is always a demand to find new and more effective treatment methods. The most common methods of treatment involve medication and supplementation of polyethylene glycol, tegaserod, psyllium, lactulose, magnesium hydroxide, bisacodyl, senna, and stool softeners 5. Unfortunately many individuals do not respond favourably to these treatments or worry about their body becoming reliant on laxatives. There have also been several case studies and research studies with positive results utilizing 1 Stewart WF, Liberman JN, Sandler RS, et al. Epidemiology of Constipation (EPOC) Study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenerol 1999; 94: Glia A, Lindberg G. Quality of life in patients with different types of functional constipation. Scand J Gastroenterol 1997;32: Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part 1: overall and upper gastrointestinal diseases. Gastroenterology 2009;136: Nyrop KA, Palsson OS, Levy RL et al. Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain. Ailment Pharmacol Ther 2007;26: Ramkumar, Davendra MD and Satish SC Rao MD, PhD. Efficacy and Safety of Traditional Medical Therapies for Chronic Constipation: Systematic Review. The Americal Journal of Gastroenterology 2005; 100:

4 Swedish massage techniques in the treatment of constipation 6. After a lengthy search, conducted after reading Visceral Manipulation (Barral & Mercier 2005) 7, this author was unable to find research or case studies pertaining to visceral manipulation techniques being used for the treatment of chronic constipation in otherwise healthy adults. This gap in research and case studies led this author to take on the responsibility of creating a case study for this specific demographic. Visceral manipulation is a technique used to reduce visceral restrictions and restore healthy functional mobility and motility of the viscera. Mobility is a term that is used to describe movements of organs that are produced by external forces, such as active muscular contractions or passive movements that occur at an articulation or attachment 8. Motility describes the slow, low amplitude, intrinsic and inherent movement of the organs that cycles between two phases termed inspir and expir 6, 7. Inspir describes the active motion, and expir refers to the movement back to neutral 7. This movement is often thought of as being similar to the cranial motion of flexion and extension 7. The purpose of this case study is to see if visceral manipulation techniques combined with myofascial release of surrounding and associated structures will have an effect on the frequency and quality of Bowel Movements (BM) in an individual with chronic constipation. Case History The client is a 25year old female who suffers from lifelong chronic constipation. She has an athletic build with a moderate hyperlordosis. She is a full time student with a long daily commute to school. She rates her stress level as being high. She suffers from what she describes as severe dysmenorrhea. She has been unable 6 Ernst E. Abdominal massage therapy for chronic constipation: A systematic review of controlled trials. Forsch Komplementärmed 1999;6: Barral, Mercier (2005). Visceral Manipulation. Seattle: Eastland Press. 8 Chaitow (2007). Palpation and Assessment Skills, Assessment through touch. Philidelphia: Elsevier Limied.

5 to have consistent regular BM s without the aid of laxatives or enemas. She averages 0-2 BM per week without the use of laxatives. On more than one occasion she has been hospitalized to receive treatment after going more than 7 days without a BM. She feels considerable discomfort, bloating, and stress related to this condition. Stress from several days without a BM often causes her significant anxiety towards eating and usually results in a considerable decrease in the amount of food consumed. Physicians and a specialist have recommended fibre supplements and laxatives. Fibre supplements and an increase in dietary fibre have had no noticeable effect on her constipation. Laxatives are often effective, but she worries about her body s reliance on the medication so she often goes without. Assessment The American College of Gastroenterology Chronic Constipation Task Force defines chronic constipation as unsatisfactory defecation that results from infrequent stool, difficult stool passage, or both 9. However, there are often differing definitions of constipation among clinical investigators, patients and physicians, so for clarity of this case study the standardized Rome III diagnostic criteria 10 for constipation (TABLE 2) will be used. In order to ensure the client met the criteria for constipation she was first given the Rome III constipation questionnaire 11 (TABLE 1). She met all the diagnostic criteria (TABLE 2) for functional constipation and we were able to rule out IBS with the questionnaire. For one week prior to the commencement of treatment, during the length of the case study, and for one week after the last treatment, the client was asked to fill out a bowel diary (TABLE 3) that utilized the Bristol Stool Form Scale (TABLE 4). The Bristol Stool Form Scale 12 (BSFS) was developed at the Bristol Royal Infirmary in England to classify stools types. It identifies constipation stool as types 1 and 2 and diarrhoea stool as types 6 and 7, with numbers 3-5 representing 9 Americal College of Gastroenterology Chronic Constipation Task Force. An evidence- based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005; 100(suppl 1): Heaton, K W & Lewis, S J 1997, 'Stool form scale as a useful guide to intestinal transit time'. Scandinavian Journal of Gastroenterology, vol.32, no.9, pp

6 normal healthy stool. A palpation assessment of the abdominal cavity revealed a decrease in mobility and motility of the subgastric digestive tract. TABLE 1 ROME III CONSTIPATION MODULE (SCREENING QUESTIONNAIRE) Questions: Client s multiple choice answer selections: 1. In the last 3 months, how often did you have Two or three days a month discomfort or pain anywhere in your abdomen? 2. For women: Did this discomfort or pain occur Yes only during your menstrual bleeding and not at other times? 3. Have you had this discomfort or pain 6 months or Yes longer? 4. How often did this discomfort or pain get better Sometimes or stop after you had a bowel movement? 5. When this discomfort or pain started, did you Sometimes have more frequent bowel movements? 6. When this discomfort or pain started, did you Often have less frequent bowel movements? 7. When this discomfort or pain started, were your Never or rarely stools (bowel movements) looser? 8. When this discomfort or pain started, how often Most of the time did you have harder stools? 9. In the last 3 months, how often did you have Most of the time fewer than three bowel movements (0-2) a week? 10. In the last 3 months, how often did you have hard Always or lumpy stools? 11. In the last 3 months, how often did you strain Most of the time during bowel movements? 12. In the last 3 months, how often did you have a Most of the time feeling of incomplete emptying after bowel movements? 13. In the last 3 months, how often did you have a Often sensation that the stool could not be passed, when having a bowel movement? 14. In the last 3 months, how often did you press on Often or around your bottom or remove stool in order to complete a bowel movement? 15. In the last 3 months, how often did you have Sometimes difficulty relaxing or letting go to allow the stool to come out during a bowel movement?

7 16. Did any of the symptoms of constipation listed in questions 9-15 above begin more than 6 months ago? 17. In the last 3 months, how often did you have loose, mushy or watery stools? Source: Yes Never or rarely TABLE 2- ROME III DIAGNOSTIC CRITERIA FOR FUNCTIONAL CONSTIPATION 1. Must include two or more of the following: a. Straining during at least 25% of defecations b. Lumpy or hard stools at least 25% of defecations c. Sensation of incomplete evacuation at least 25% of defecations d. Sensation of anorectal obstruction/blockage at least 25% of defecations e. Manual manoeuvres to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor) f. Fewer than 3 defecations per week 2. Loose stools are rarely present without the use of laxatives 3. Insufficient criteria for IBS *Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Source: TABLE 3- BOWEL DIARY Day Massage BM Quantity BSFS # Menses 27/09/2011 Yes 28/09/2011 Yes 29/09/2011 Yes Large 2 Yes 30/09/2011 Yes 1/10/2011 2/10/2011 Yes Large 3 3/10/2011 4/10/2011 Treatment 1 Yes Large 3 5/10/2011 Yes Small 1 6/10/2011 7/10/2011 8/10/2011 Treatment 2 Yes Large 3 9/10/2011 Yes Large 3 10/10/2011 Yes Large 3 11/10/2011 Treatment 3 12/10/ /10/2011 Yes Medium 2 14/10/ /10/2011 Treatment 4 16/10/ /10/2011 Yes Medium 2 18/10/2011 Treatment 5 19/10/ /10/2011 Yes Medium 2 21/10/ /10/ /10/ /10/2011 Yes Small 2 25/10/2011 Treatment 6 26/10/2011 Yes 27/10/2011 Yes Small 1 Yes 28/10/2011 Yes Small 1 Yes 29/10/2011 Treatment 7 Yes Large 3 Yes 30/10/2011 Yes 31/10/2011 Yes Small 1 1/11/2011 Treatment 8 2/11/2011 Yes Medium 2 3/11/2011

8 4/11/2011 Yes Medium 2 5/11/2011 Treatment 9 6/11/2011 Yes Medium 3 7/11/2011 8/11/2011 Treatment 10 9/11/ /11/ /11/ /11/ /11/2011 Yes Large 2 14/11/2011 Yes Large 3 15/11/2011 TABLE 4 BRISTOL STOOL FORM SCALE Treatment Protocol All treatments performed were 60minutes in duration and focussed on visceral manipulation techniques as described in Visceral Manipulation (Barral & Mercier 2005) and myofascial release techniques. These techniques were utilized to release superficial fascia of the abdomen, to assess and release visceral restrictions, and to increase mobility and motility of the lower digestive tract and associated viscera. It is

9 indicated that visceral manipulation and release of fascial structures in the abdominal cavity can have a beneficial effect on constipation and in some cases eliminate the condition all together 13. Prior to the first treatment homecare instructions were given that were to be carried out for the duration of the case study and indefinitely if the client wished to do so. Studies have shown that the squatting position is most anatomically correct and beneficial during defecation 14. In order to mimic this positioning as much as possible, while still using a standard toilet, the client was given a stool to prop the knees up higher than the waist while having a BM. Summary of Treatments Date Treatment Goals Techniques Used/Areas Treated Observations Treatment 1 4/10/2011 Treatment 2 8/10/2011 Treatment 3 11/10/2011 Release thoracolumbar fascia and superficial abdominal fascia. Assess and increase mobility of abdominal viscera. Assess and mobilize the colon. Release restrictions at flexures. Release musculature that is contributing to hyperlordosis and Myofascial release techniques applied to the thoracolumbar fascia and superficial abdominal fascia. Assessed mobility and motility of Liver, sphincter of oddi, ileocecal valve, and colon. Visceral mobilization techniques were used to release triangular ligaments to increase liver mobility and phrenicocolic ligament to release tension in the hepatic flexure. Direct manipulation of the root of the mesentery. Sphincter of Oddi, jejunoileum, and ileocecal valve direct mobilizations and inductions. Release of superficial abdominal fascia. Direct manipulation to the duodenum, cecum, ascending colon, hepatic flexure, splenic flexure and sigmoid colon. Release of superficial abdominal fascia. Myofascial release of psoas and iliacus. Stretch of Palpable restrictions in colonic mobility. Very little movement in the ileocecal valve and colon could be palpated. There were significant restrictions in the Sigmoid mesocolon, but there was an increase in mobility created during this session. There was an increase in muscle length of the iliopsoas during 13 Barral, Mercier (2005). Visceral Manipulation. Seattle: Eastland Press. 14 Sikirov. Comparison of Straining During Defecation in Three Positions: Results and Implications for Human Health. Digestive Diseases and Sciences 2003;48:7:

10 Treatment 4 15/10/2011 Treatment 5 18/10/2011 Treatment 6 25/10/2011 Treatment 7 29/10/2011 Treatment 8 1/11/2011 Treatment 9 5/11/2011 possibly contributing to constipation by compressing and/or irritating the abdominal organs. Continue to decompress abdominal contents by decreasing hyperlordosis. Assess and treat new symptom of pain under right lower ribs (physician ruled out cholelithiasis) Mobilize the colon and release the root of the mesentery. Focus on motility induction techniques to avoid causing discomfort from direct techniques while client is menstruating. Continue to increase mobility and decrease restrictions in the abdominal viscera. Continue to increase mobility and decrease restrictions in the abdominal viscera. iliopsoas. Visceral manipulation of root of the mesentery. Myofascial release of thoracolumbar fascia, lumbar erector spinae, and lateral hip rotators and quadratus lumborum. Visceral manipulation of ascending colon, descending colon and sigmoid colon. Myofascial release of diaphragm and intercostals with focus on the right side of body. Visceral manipulation of hepatic flexure, common bile duct and gall bladder milking. Visceral manipulation of ileocecal valve and ascending colon. Release of superficial abdominal fascia. Direct mobilizations of root of the mesentery, ileocecal valve, cecum, ascending colon, hepatic flexure, splenic flexure, descending colon and sigmoid colon. Assess motility of cecum, ascending colon, transverse colon, descending colon and sigmoid colon. Use gentle induction techniques to increase motility of cecum, ascending colon, descending colon and sigmoid colon. Release of superficial abdominal fascia with focus on the hypogastric and iliac regions. Visceral release of hepatic and splenic flexures. Visceral manipulation of cecum, ascending, descending and sigmoid colon. Release of superficial abdominal fascia. Direct visceral manipulation of sphincter of oddi and ileocecal valve. Visceral manipulation of root of the this session. There was a decrease in muscular tension in the lumbar region allowing for less compression of abdominal contents by the lumbar vertebral bodies. The cecum felt congested. The client felt a decrease in pain after the hepatic flexure was released. Client no longer feels pain under right side of lower ribs. There is a definite increase in colon mobility since the first treatment. There was an increase in cecum, ascending colon and sigmoid colon motility at the end of the treatment. The Sigmoid colon mobility increased during this session. There appeared to be some spasms in the ileocecal valve during the treatment today.

11 Treatment 10 8/11/2011 Continue to increase mobility and decrease restrictions in the abdominal viscera. mesentery, cecum, ascending colon, descending colon and sigmoid colon. Release of superficial abdominal fascia. Visceral manipulation of the root of the mesentery, cecum, ascending colon, hepatic flexure, splenic flexure, descending colon and sigmoid colon. There appeared to be an increase in motility and mobility of the cecum. Positioning for release of Hepatic Flexure Positioning for release of the Splenic Flexure Direct Manipulation of the Ascending Colon Direct Manipulation of the Duodenum Direct Manipulation of the root of the mesentery Direct Manipulation of the Sigmoid Colon

12 Results The first week of treatment showed an increase from the normal 0-2 BM per week to 5 BM, with 4 of those BM s being large and in the healthy stool range of #3 on the BSFS. During the second week of treatment there were 2 medium sized BM s, with both BM s #2 on the BSFS indicating constipation type stool. During the third week the results were the same as the second week with one of the BM s being sized small. During the fourth week there was an increase to 4 BM s, with 3 of the BM s being small in size and #1 on the BSFS, and the 4 th BM was a healthy large sized #3 on the BSFS. During the fifth and last week there were 3 medium sized BM s with 2 BM s at #2 on the BSFS and 1 BM a #3 on the BSFS. View TABLE 3 for a complete look at the bowel diary. Discussion The initial results of the first week were very encouraging during this case study as the client had never experienced so many successive healthy BM s without the aid of laxatives before. The following weeks showed more discouraging results with decreases in BM s, and an increase in constipation type stool. One possible explanation for these inconsistencies is hormonal imbalance. At the approximate date of ovulation (calculated by counting 14 days back from the 1 st day of menses on the 26 th ) the results started to show a decrease in BM s. The client reported that she often experiences PMS symptoms including increased bloating and discomfort in her abdomen during the two weeks prior to her menstruation and during her menstruation. Another very important factor in this case study is that the practitioner performing the treatments is a novice at visceral manipulation. It is a reasonable assumption that a more experienced practitioner may have had different results. Therefore I feel more case studies, preferably with more experienced practitioners, are needed to seek consistency of results.

13 References Stewart WF, Liberman JN, Sandler RS, et al. Epidemiology of Constipation (EPOC) Study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenerol 1999; 94: Glia A, Lindberg G. Quality of life in patients with different types of functional constipation. Scand J Gastroenterol 1997;32: Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part 1: overall and upper gastrointestinal diseases. Gastroenterology 2009;136: Nyrop KA, Palsson OS, Levy RL et al. Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain. Ailment Pharmacol Ther 2007;26: Ramkumar, Davendra MD and Satish SC Rao MD, PhD. Efficacy and Safety of Traditional Medical Therapies for Chronic Constipation: Systematic Review. The Americal Journal of Gastroenterology 2005; 100: Ernst E. Abdominal massage therapy for chronic constipation: A systematic review of controlled trials. Forsch Komplementärmed 1999;6: Barral, Mercier (2005). Visceral Manipulation. Seattle: Eastland Press. Chaitow (2007). Palpation and Assessment Skills, Assessment through touch. Philidelphia: Elsevier Limied. Americal College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005; 100(suppl 1): Heaton, K W & Lewis, S J 1997, 'Stool form scale as a useful guide to intestinal transit time'. Scandinavian Journal of Gastroenterology, vol.32, no.9, pp Sikirov. Comparison of Straining During Defecation in Three Positions: Results and Implications for Human Health. Digestive Diseases and Sciences 2003;48:7: