Physiotherapeutic Intervention in Children With Chronic Functional Constipation

1. INTRODUCTION

Chronic functional constipation (CFC) is a common problem in the pediatric population, affecting approximately 25% of those seeking specialized medical care. The complaint is multifactorial, involving environmental, psychological and physiological factors, which interact with the brain-gut axis, but the retention of stools secondary to the pain-restraint cycle, associated to the fear and anxiety of the resulting bowel movement, is important in the development and management of CFC.

Difficulties involved in the management of CFC are common. Conventional treatment includes educational measures, disimpaction, laxatives and an increased fiber intake. However, these measures have not necessarily been beneficial for all cases, with a cure ratio of between 50 and 60%, and around one third of all patients become long-term sufferers of constipation.

The muscles of the intestine contribute to atonic constipation - sluggish or flaccid muscles in the bowel or rectum, or spasticity - increased muscle tone due to emotional stress. These two factors are both present in patients with CFC. Bowel movement depends on the interlinked functions of abdominal muscles, the pelvic floor and diaphragmatic breathing: contraction of the diaphragm, abdominal distention resulting from the voluntary relaxation of the abdominal wall and the pelvic floor lead to increased intra-abdominal and peristaltic pressure and relaxation of the external anal sphincter (EAS), thus culminating in bowel movement. Added to which, activity of the parasympathetic autonomic nervous system causes an increase in gastrointestinal motility and relaxation of the sphincters. The superficial and deep abdominal muscles, in addition to the diaphragm and muscles of the pelvic floor, form a single muscle unit that assists regular bowel movement, and should all be worked together in order to stimulate peristalsis. Therefore, a combination of exercises that stimulate and relax the abdominal muscles, indirectly acting on the pelvic floor, coordinated with diaphragmatic breathing, may trigger contraction of the intestinal and rectal muscles, therefore bringing relief to patients with CFC.

Multidisciplinary treatment can complement the conventional treatment of CFC. Physiotherapy exercises for the abdominal muscles and diaphragm plus abdominal massage may reverse any changes brought on by CFC. Retraining the intestinal functions is brought about due to two main effects: