Abdominal Massage For The Relief Of Constipation In People With Parkinsons: A Qualitative Study
1Nursing, Midwifery, and Allied Health Professions, Research Unit, Glasgow Caledonian University, Glasgow G4 0BA, UK
2Nursing, Midwifery and Allied Health Professions, Research Unit, Stirling University, Stirling, UK
3School of Medicine, Dentistry & Nursing, Nursing & Health Care School, 59 Oakfield Avenue, Gilmorehill Campus, Glasgow University, Glasgow, UK
4Care of Elderly Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
Constipation is a common nonmotor symptom of neurological conditions including Parkinson’s . Constipation is the most common gastrointestinal complaint reported in people with Parkinson’s and is estimated to impact 27–67% of all sufferers . Furthermore, constipation in Parkinson’s has been shown to occur to varying degrees at any time point during disease progression, with epidemiological data indicating that bowel dysfunction can even precede typical Parkinsonian motor symptoms by as much as 20 years .
Abdominal massage has been shown to be a safe, effective, and noninvasive form of bowel management in the general population , as well as people with multiple sclerosis and stroke . It is therefore plausible that PwP who suffer from constipation may also benefit from using abdominal massage as a form of constipation management and this was explored in our feasibility studies .
2.1. Study Design and Sample
2.2. Ethical Approval
2.3. Data Collection
2.4. Data Analysis
These Daily Adjustments Can Help Improve Quality Of Life After A Parkinsons Diagnosis
For people with Parkinson’s disease, taking steps to improve quality of life is important and this involves changes in your daily routine.
Planning activities for times you’ll feel your best, leaving plenty of time to complete tasks and taking breaks when you need them are all simple steps that can add up to make life more manageable for anyone diagnosed with Parkinson’s disease.
“Along with considering the adjustments below, it’s also important to know when to ask for help,” said Dr. Fenna Phibbs of Vanderbilt Neurology. “As Parkinson’s progresses, your health-care provider can refer you to an occupational therapist, who can help practice tasks of daily living.”
Until then, making these changes can improve quality of life:
Constipation Linked To Increased Risk Of Developing Parkinsons Disease
The American Academy of Neurology is the world’s largest association of neurologists and neuroscience professionals, with 36,000 members. The AAN is dedicated to promoting the highest quality patient-centered neurologic care. A neurologist is a doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system such as Alzheimer’s disease, stroke, migraine, multiple sclerosis, concussion, Parkinson’s disease and epilepsy.
What Causes Constipation In People With Parkinson’s Disease
In some people with Parkinson’s disease, constipation may occur due to the improper functioning of the autonomic nervous system. The autonomic nervous system is responsible for regulating smooth muscle activity. If this system is not working properly, the intestinal tract may operate slowly, causing constipation.
Also, medications used to treat Parkinson’s disease can cause constipation.
When Parkinsons Interferes With Gastrointestinal Function
This 63-minute audio with slides by Dr. Peter A. LeWitt discusses the effect of Parkinson’s disease on the gastrointestinal system, with particular focus on constipation. Improving GI function can have a positive impact on the consistency of benefit from Parkinson’s disease medications. Highlights of recent research into Parkinson’s disease originating in the GI tract, developing biomarkers for early diagnosis, and others.
Parkinsons Disease: Dr Chris On How To Spot Early Signs
We use your sign-up to provide content in ways you’ve consented to and to improve our understanding of you. This may include adverts from us and 3rd parties based on our understanding. You can unsubscribe at any time. More info
Parkinson’s disease is a condition that causes the brain to become progressively more damaged over time, said the NHS. You could lower your risk of the neurodegenerative condition’s symptoms by avoiding certain fruits, it’s been revealed.
Dietary Fibre For Constipation In Parkinsons Disease
Be guided by your doctor, but general suggestions include:
- Choose easy-to-eat fibrous foods such as soft fruits. Consider mashing or pureeing fruits to make them easier to eat. Make sure to include the skin, where most of the fibre is found.
- Eat at least two pieces of fruit and five serves of vegetables every day.
- Eat homemade vegetable soups.
- Sprinkle a tablespoon of bran, psyllium husks or chia seeds on your breakfast cereal or add the bran to baked products such as cakes. However, avoid bran if you have swallowing problems.
- Fibre supplements may be helpful, but you must drink enough fluids for these to work properly. Avoid fibre supplements if you have problems swallowing.
- Don’t increase dietary fibre too quickly or you’ll risk bloating and abdominal cramps. If discomfort occurs, cut back your fibre intake, increase your fluid intake, apply a hot water bottle to your abdomen and see your doctor.
Toilet Habits And Constipation In Parkinsons Disease
Suggestions for good toilet habits include:
- Go to the toilet as soon as you feel the urge to pass a bowel motion. Hanging on can contribute to constipation.
- Use the correct posture on the toilet to help you pass a bowel motion – place your elbows on your knees, bulge out your stomach, straighten your spine and put your feet on a footstool.
- Avoid holding your breath and don’t strain when you are on the toilet. Allow yourself plenty of time.
- Use a warm washcloth pressed against your back passage or gently massage with one or two fingers to help to relax the muscles.
- Talk to your doctor or pharmacist about medicines to help soften your bowel motions.
Addressing Practical Aspects Of Eating And Drinking
Some people with Parkinson’s have problems chewing and swallowing. This can make it difficult to eat a diet with plenty of fibre. A speech and language therapist can give advice about this. Ask your GP, specialist or Parkinson’s nurse for a referral. If it takes a long time to eat and your meal goes cold, eat smaller portions and go back for seconds that have been kept warm. You can also get special plates that keep your meals hot – the Disabled Living Foundation has more information.
An occupational therapist will also be able to give you some tips and practical advice.
How About Using Supplements In Parkinsons Disease
Some patients prefer using food supplements. Nutrition supplements like coenzyme Q10, fish oil, and vitamin D have been linked to reducing disease progression and some studies suggest that taking these supplements may benefit the patients. However, research in this direction is still limited and we can’t advise you to take any supplements at this stage. We recommend you discuss it with your healthcare provider first before considering any supplements.
Treatment For Constipation In Parkinsons Disease
Your doctor may suggest various treatments to help combat constipation, including:
- dietary changes, including more fibre rather than refined or highly processed foods, and water
- moderate exercise
- good toilet habits
- avoidance of unnecessary medicines that contain substances known to cause constipation
- laxatives, particularly agents that bulk and lubricate the stools
- treatment for any other medical problem that may be contributing to your constipation, such as haemorrhoids .
Background: The Stomach Parkinson’s And Levodopa
Levodopa is not absorbed from the stomach, but the stomach plays an important role in controlling how levodopa reaches the parts of the small intestine where it is absorbed. Some medicines, including dopamine agonists and anticholinergics, can also delay gastric emptying, as can severe stomach acidity, although over-treatment of this problem can also prevent the break-down of levodopa tablets, leading to incomplete absorption.
Unfortunately, gastric emptying can be delayed by Parkinson’s itself or by constipation caused by the colon-gastric reflex. Levodopa tablets may remain in the stomach for a long time, leading to delayed absorption in the small intestine and a delayed response to the treatment.
An enzyme called dopa-decarboxylase that is present in the stomach lining can convert levodopa trapped in the stomach into dopamine, making it unavailable to the central nervous system. Also, dopamine formed in the stomach may stimulate gastric dopamine receptors, leading to stomach relaxation and reduced gastric motility, and this can worsen the problem.
Liquid levodopa may improve motor fluctuations by ensuring better absorption than standard preparations, especially when taken after meals. Subcutaneous infusion of the dopamine agonist apomorphine is effective in controlling motor fluctuations by bypassing the gastrointestinal tract.
Dressing Tips For Anyone With Parkinsons Disease
To make dressing easier:
- Sit down to dress. This helps prevent falls.
- Choose clothes that are easy to put on and take off. Elastic waistbands and clothes that close in the front are good choices.
- Add paper clips to zipper pulls. This makes them easier to grasp.
- Choose shoes that are easy to wear. Wear shoes with hook and loop straps. Women should not wear high heels and men should avoid cowboy boots, Phibbs said.
Diagnosis Of Constipation In Parkinsons Disease
Diagnosis of constipation may include:
- medical history
- detailed description of symptoms
- physical examination.
Medical problems other than Parkinson’s disease can also cause constipation. Your doctor may wish to do tests to rule out other possible causes. The tests depend on the medical condition under investigation.
Exercise For Constipation In Parkinsons Disease
Be guided by your doctor, but general suggestions include:
- Talk with your doctor, physiotherapist, exercise physiologist or healthcare professional when planning your exercise program.
- Aim for at least 30 minutes of exercise every day.
- Spend a few minutes warming up and cooling down. This could include marching in place or stretching.
- Start with the easiest exercises first. Slowly introduce the more difficult exercises as your fitness increases.
- Only exercise when other people are at home who can help if necessary.
- Remember: too little exercise and fluid intake with an increase in dietary fibre can worsen constipation for some people.
Why Might Constipation Be A Parkinson’s Symptom
This 62-minute audio with slides is presented as an interview of two neurologists and explains how the gastrointestinal musculature is well enervated and, therefore, affected by the loss of dopamine and deposits of alpha synuclein, just as the brain is. Management options are discussed, and recent research into the microbiome and the gut/brain connection in Parkinson’s disease.
What Are Those Common Triggers Of Constipation
Fluids For Constipation In Parkinsons Disease
Be guided by your doctor, but general suggestions include:
- Try to drink six to eight glasses of fluid every day. Water is best, but you can also include fluid in the form of soup, juice, tea and coffee.
- Limit drinks that cause dehydration such as alcohol, tea and coffee.
- Spread your drinks throughout the day.
Causes Of Constipation In Parkinsons Disease
The ways in which Parkinson’s disease can increase the risk of constipation include:
- lack of dopamine in the brain – impairs control of muscle movement throughout the body. Bowel muscles can become slow and rigid
- uncoordinated bowel motions – the bowel muscles may be weak and unable to contract, or they may clench instead of relaxing when trying to pass a motion
- eating problems – dietary fibre containing insoluble fibre adds bulk to your bowel motions and can help prevent constipation. However, if a person with Parkinson’s disease finds it difficult to chew or swallow, they may avoid eating fibrous foods
- drinking problems – you need water to plump up the dietary fibre in your bowel motions. Swallowing difficulties may discourage a person with Parkinson’s disease from drinking enough fluids
- sedentary lifestyle – lack of exercise slows the passage of food through your intestines. Parkinson’s disease reduces muscle control, so lack of exercise is common
- medications – many different medications can cause constipation. Medications used in the treatment of Parkinson’s disease may slow bowel movements or cause a decrease in appetite.
Follow A Squatty Potty Posture In The Toilet
A proper posture while sitting on the commode in the toilet is very important for controlling constipation. But this is ignored by most people.
We usually follow a slump posture while sitting in the toilet. This position is not good for proper elimination as it makes a kink in the rectum and restrains the outward movement of bowel which makes the constipation more worsen.
To avoid this, researchers recommend following a squatty potty posture. In this posture, your sitting position makes an angle in a way where your knees are above your hips, the same like you do squats. This position makes the rectum like a shoot that allows the bowel to eliminate out the stool more easily.
Using a western toilet commode can make it very hard to get into squatty potty position. However, a toilet stool can make it easier for you. So use a small stool available in your house that allows to raise your knees above your hips and make it to a squatty position when sitting in the toilet. You can also buy a , which is especially designed for squatty potty position.
What Is Constipation And Why Is It Important
Constipation is the most common gastrointestinal complaint affecting approximately 15 % of the North American population. Certain subgroups have an even higher risk . It is remarkable that for such a common disorder there is great debate on the definition of constipation. A committee of experts in the field include in the definition 2 or more of the following: abnormalities of stool frequency , abnormal stool form, straining at stool, sense of incomplete evacuation or obstruction to passage of stool, and the use of manual maneuvers to aid in passage of stool .
Parkinsons Disease: Combating Constipation
In Part 2 of this 3-part blog series we discuss constipation related to Parkinson’s disease and the gut-brain connection.
In patients with Parkinson’s disease, the major cause of constipation is that the nervous system control of the gut slows down due to the effects of the disease, resulting in the slowing down of gut movement and leading to constipation.
Alpha-synuclein refers to the abnormal protein that is also seen in the brains of patients with PD. These same protein deposits have been observed in the gut prior to development of motor symptoms, up to 20 years prior to diagnosis. These abnormalities have also been found in the parasympathetic neurons of the vagus and sacral nerves that connect the brain to the visceral organs and are involved in the autonomic nervous system. The term parasympathetic refers to the side of the autonomic nervous system that allows the gut to move . Basically as the nervous system control of the gut slows, gut function slows and constipation results.
Interestingly, patients’ self-reports of constipation may not paint the full picture of the severity of constipation. One study found that objective measurements of colon transit time revealed higher rates of constipation than subjectively reported by patients. This is known as slow transit constipation.
Patients with PD should be aware of their bowel movements and remain vigilant to the development of constipation and should do the following to improve bowel regularity:
Managing Motor Complications Of Parkinsons
The motor complications discussed so far—from tremor to balance problems—may all be managed with different Parkinson’s medications, says Jennifer S. Hui, M.D., a neurologist with Keck Medicine of University of Southern California in Los Angeles. “The gold standard medication is levodopa, which is a medication that basically gets converted to dopamine, which is the missing neurotransmitter in the brain in Parkinson’s,” she explains. “It’s very effective at treating the motor symptoms.” Other medications may be used as well, such as dopamine agonists or different delivery methods , she says.
Staying Hydrated Can Improve Constipation
More fiber requires more fluids! Inadequate fluid intake is a cause for constipation, resulting in frequent recommendations to treat with increased fluids.9 However, research shows that this is only useful for those who are under hydrating rather than meeting their hydration needs.
So, if you’re getting enough water now, adding more won’t help. Consuming natural mineral water may also help with constipation.12
Water has been shown to promote gut motility to prevent and treat constipation in practice.10 There are several ways to check if you’re meeting your fluid needs. First, do you experience significant daily weight fluctuations? What color is your pee? Urine color ranges typically from dark orange to clear.
For adequate hydration, aim for a light yellow or lemonade color. To promote maximal fluid absorption, sip, don’t chug. Remember, you can also eat your fluids by incorporating foods with high water content such as cucumbers, watermelon, tomatoes, and more!
How Can It Affect People With Parkinsons
- Constipation can impact the absorption and effectiveness of levodopa .
- Constipation can disturb bladder function. An over-full bowel due to constipation can press on your bladder, reducing the amount of urine it can hold.
- Straining due to constipation can weaken your pelvic floor muscles. Pelvic floor muscle strength is important for both bladder and bowel control.
- Severe constipation is the most common cause of bowel incontinence. Bowel incontinence is the inability to control your bowel motions. It can range from soiling your underwear to the loss of a full bowel motion.
Impact Of Diet On Parkinsons Medications
Taking certain foods may interfere with the efficacy of drugs used in Parkinson’s disease. This is especially true for high-protein foods. Their consumption may affect the body’s ability to absorb levodopa, which is the most prescribed drug in Parkinson’s disease. It’s therefore good to take levodopa 30 – 60 minutes before eating the high-protein foods.
However, for some patients it causes nausea, and taking levodopa on an empty stomach might not be a good idea. In that case, taking levodopa with a small snack can enhance the absorption of the drug in the blood.
Avoid Eating White Rice And White Bread
While brown rice may help relieve constipation, white rice may have the opposite effect. Unlike brown rice, white rice lacks fibers and nutrients. It’s rather rich in starch content, which is slowly digested and cause significant bloating.
Similar is the case with white bread. It is made of wheat that lacks most of its fiber content. This caused the stool hard and makes it difficult for the colon to remove it from the body. Therefore, try to avoid using white bread or anything made from white floor like cakes, cookies, donuts, and bagels.
How Might Parkinson’s Affect The Bowels
Bowel problems can occur in anyone, but some problems, especially reduced bowel movement or constipation, are particularly common in Parkinson’s. This tends to be as a result of slowness of movement and muscle rigidity, both of which are visible symptoms of the condition. But Parkinson’s also muscles we cannot see – including the bowel muscles – which in turn causes a reduction or slowness of bowel movements.
Poor bowel function may be exacerbated if chewing and swallowing food is difficult, which is quite common in Parkinson’s. This may make it harder to eat a diet that is rich in fibre – for example fruit, vegetables and whole grains – which helps form soft, bulky stools and aids bowel function.
Exercise is also thought to play a role in efficient bowel function, but if Parkinson’s makes activities more difficult, the bowel may be less stimulated and the intestines can become sluggish.
Constipation is thought to affect up to 65% of people with Parkinson’s – the bowel symptoms may predate the neurological ones . Tremor and a fear of spilling drinks can mean some people unintentionally reduce their fluid intake which can make stools hard and more difficult to pass. When stools remain unpassed for a long time, they become harder as the body absorbs more water from them. If stools build up in the rectum they can become impacted and block the rectum. They may also overflow as lumps of stool or watery mucus.
Final Thoughts: What Has Worked For Me
Some of the prescription medications that have helped me include: Amitiza, Linzess, Movantik, Relistor, Symproic, and Trulance. Plus I made sure to exercise, massage my stomach in a circular motion at least once a day, drink warm/hot water in the morning before eating, and use probiotics. I also tried to do things that helped make me feel more relaxed. In my experience, a combination of these things is what truly helps maintain a healthy bowel, which results in better PD symptom control by allowing medication to be maximally absorbed.
Want More Practical Articles Like This
Much more can be found in?our?Every Victory Counts®?manual.?It’s packed with up-to-date information about everything Parkinson’s, plus an expanded worksheets and resources section to help you put what you’ve learned into action.?Request your free copy of the?Every Victory Counts?manual by clicking the button below.
Thank you to our 2021 Peak Partners,? Adamas, Amneal, Kyowa Kirin, and Sunovion, for helping us make printing, distribution, and shipping of the Every Victory Counts manual possible.
Treating And Managing Bowel Problems
The first step in dealing with bowel disorders is to talk to your doctor. He or she will probably review your medication to see if this is a contributory factor. Whilst it is usually possible to control any difficulties with diet, fluid intake and exercise, your doctor, or Parkinson’s nurse specialist if you have one, will be able to advise further, and may, for example, prescribe laxatives in severe cases of constipation. If you have any “alarm features” such as unintentional weight loss or rectal bleeding, then you may need to be referred for specialist assessment.
The following healthcare professionals can also advise on aspects of bowel care:
- A dietician will be able to advise on diet and fluid.
- A physiotherapist may be able to help with advice and abdominal exercises which will help in passing stools.
- A speech and language therapist can help with swallowing problems. They may be able to advise on ways of relaxing your throat, and give guidance on posture and exercises to help overcome any difficulties you have.
- An occupational therapist may also be able to suggest practical ways to overcome any difficulties you have with eating and drinking.
What Examinations May I Need To Have
Your GP or specialist will probably ask a series of questions to find out what the problem is. These may include:
- When did the trouble start?
- How often does it happen?
- Can you feel when your bladder or bowel is full?
- Are you having difficulty emptying your bladder or bowel?
- How often are you using the toilet?
Parkinson’s symptoms, such as slowness of movement and rigid muscles, affect the muscles in the bowel wall. This can make it harder to push stools out of the body. You may be asked to keep a chart for several days of how often you use the toilet and how much you drink.
Bladder or bowel problems can be complex in Parkinson’s, so sometimes specialist tests or X-rays may be needed. All of these can usually be done in an outpatient department or clinic.
How Can I Avoid Getting Constipated
- Eat a well-balanced diet with plenty of fiber. Good sources of fiber are fruits, vegetables, legumes, and whole grain bread and cereal. Most of the fiber in fruits is found in the skins. Fruits with edible seeds, such as strawberries, have the most fiber. Eat bran cereal or add bran cereal to other foods, such as soup.
- Drink 1½ to 2 quarts of water and other fluids a day. Liquids that contain caffeine, such as coffee and soft drinks, seem to have a dehydrating effect and may need to be avoided until your bowel habits return to normal.
- Move your bowels when you feel the urge.
Search Strategy And Study Selection
Three electronic databases were searched until May 2017 using a combination of title/abstract keywords . No time restrictions were applied while only publications in English were considered. A.P. and D.P. selected eligible studies after independently screening titles and abstracts. Full text was retrieved if any uncertainty about eligibility remained.
Problems Caused By Limited Mobility
Some people with Parkinson’s might soil their underwear. This is because mobility problems can make it difficult to wipe after using the toilet. If this is the case, it might help to use wet wipes, a bidet, or an adapted bottom wiper. An occupational therapist or the Disabled Living Foundation can offer further advice.
Bowel problems are common. But you should tell your GP if there are any changes in your bowel habits, particularly if you see blood in your stool. Some problems are difficult to avoid, but there are things you can do to make them less likely to happen.
Bladder And Constipation Problems
Parkinson’s commonly leads to problems with constipation and bladder control, including urinary urgency, frequency, retention and nocturia.
These problems add to the challenge of living with Parkinson’s and can have a negative effect on a person’s quality of life. It is important to seek help in managing these problems, as both issues can be effectively managed.
Constipation Needs To Be Treated
- For healthy bowel function a diet containing an adequate amount of fibre and fluid is recommended. Healthy diet and bowels from the Continence Foundation of Australia is a great resource to help you consume an adequate amount of fibre and fluid.
- Aim to eat at least 25-30 grams of fibre each day. to see the amount of fibre in a selection of foods.
- As a general rule, aim to drink 1.5-2.0 litres of fluid per day unless advised otherwise by your doctor. More fluid may be required in hot weather and when exercising.
Constipation is common and can significantly impact your quality of life. If you or your loved one is experiencing this non-motor symptom consider dietary changes, an increase in appropriate exercise and discussion with your treating doctor or Neurologist.
A New Toilet Or An Alternative
If you have real difficulties getting to the toilet, it may be possible to get a grant to build a new one, perhaps downstairs. An occupational therapist can advise you on this.
Not all homes are suitable for building new toilets, so a commode might be needed. A commode is a moveable toilet that doesn’t use running water. It looks like a chair, with a container underneath that can be removed and cleaned after someone has used it. They can be very discreet.
How Is Constipation Evaluated
The evaluation of constipation typically starts with a thorough history and physical exam to look for medications or other conditions that may contribute to constipation. Testing may initially include checking the stool for blood or testing the blood for anemia that may indicate gastrointestinal bleeding. Blood tests to evaluate for diabetes or thyroid disorders may be indicated if not performed recently. Typically a colonoscopy would be recommended for any patient who is due for colon cancer screening according to current guidelines. Other tests may require referral to a gastroenterologist.
Depression Anxiety And Apathy
Mental health and emotional changes may also be complications of Parkinson’s disease, according to the NIH. “Depression and anxiety can actually precede the motor symptoms before diagnosis,” says Dr. Hui. In fact, up to half of people with Parkinson’s may deal with depression or anxiety at some point during their disease, says the Michael J. Fox Foundation for Parkinson’s Research. Antidepressants can help, Dr. Hui says. Apathy—a lack of motivation and interest—may also occur, affecting up to 40% of people with Parkinson’s, per the Foundation. Exercise and a regular sleep/wake schedule can be helpful here too, they say.
Do Abdominal Massage Therapy
Abdominal massage is becoming a very popular treatment option for people with constipation. It helps to activate normal motion of your bowels and relieve the symptoms of constipation.
A study published in the Journal of Clinical Nursing found abdominal massage an effective treatment approach for constipation. In this study, nine adults with constipation were participated in abdominal massage sessions. The participants found the massage pleasant and began to feel embraced and in safe hands. They described that not only their bowel habits were improved but also their agony was gone and they felt relieved.
Parkinson’s patients are recommended to do abdominal massage therapy at least once a day, either yourself or with the help of your healthcare provider.