Journal of Bodywork & Movement Therapies (2011) 15, 436e445

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

REVIEW

The use of abdominal massage to treat chronic

constipation
Marybetts Sinclair, LMT*

c/o Maren, PO Box 582 Philomath, OR 97370, USA

Received 26 August 2009; received in revised form 28 June 2010; accepted 19 July 2010

KEYWORDS Summary Constipation is a disorder of gastrointestinal motility characterized by difficult or

Bowel stasis; decreased bowel movements, and is a common condition in Western countries. Laxatives are
Peristalsis; the most common strategy for managing constipation. However, long-term use of some laxa-
Ileus; tives may be associated with harmful side-effects including increased constipation and fecal
Self-massage; impaction. Abdominal massage, once an accepted method of treating constipation, is no
Transit-time longer standard of care, but may be a desirable therapy for this condition because it is inex-
pensive, non-invasive, free of harmful side-effects, and can be performed by patients them-
selves. However, until recently, evidence for its effectiveness was not strong enough to
make a recommendation for its use in constipated patients.
In 1999, Ernst reviewed all available controlled clinical trials, and found that there was no
sound evidence for the effectiveness of abdominal massage in the treatment of chronic con-
stipation. This article reviews scientific evidence from 1999 to the present, regarding abdom-
inal massage as an intervention for chronic constipation. Since that time, studies have
demonstrated that abdominal massage can stimulate peristalsis, decrease colonic transit time,
increase the frequency of bowel movements in constipated patients, and decrease the feelings
of discomfort and pain that accompany it. There is also good evidence that massage can stim-
ulate peristalsis in patients with post-surgical ileus. Individual case reports show that massage
has been effective for patients with constipation due to a variety of diagnosed physiologic
abnormalities, as well as in patients with long-term functional constipation.
ª 2010 Elsevier Ltd. All rights reserved.

* Tel.: þ1 541 753 8374.

E-mail address: maryb@peak.org.

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2010.07.007
Use of abdominal massage to treat chronic constipation 437

Introduction than-normal pace, until by the time it reaches the end of

the large intestine it has lost a great deal of water and has
Constipation is a disorder of gastrointestinal motility char- become hard, dry, and difficult to eliminate (Leung, 2007;
acterized by difficult or decreased bowel movements (less Locke et al., 2000).
than three times a week). When the digestive system is Constipation affects about 9% of children, and between
functioning optimally, food is eaten and digested, and then 12 and 19 percent of all adults. (Shan et al., 2008; Van de
the residue is excreted, usually within 20e56 h (see Figures Berg et al., 2006; Wald et al., 2008).
1 and 2) (Liu et al.,, 2005; Southwell et al., 2009) Con- In the United Kingdom 10% of the general population,
stipation may be brought on by a change in diet, medica- 20% of elderly living at home, 49% of those in long-term
tion, a change in daily routine, abdominal surgery or acute care, and 70% of persons with learning disabilities have
emotional stress. Longer-lasting constipation, however, chronic constipation. English citizens spend 67 million
generally occurs when disease, poor diet, muscle spasticity, pounds on laxatives each year (Johanson et al., 2007;
physical obstructions, sluggish contractions, or other Emly and Rochester, 2006; Addison et al., 2003). In the
factors cause stool to move through the colon at a slower- United States and Canada, chronic constipation affects

Figure 1 “Structures of the Digestive System”, reprinted with permission from Stedman’s Medical Dictionary, 27th edition,
Baltimore: Lippincott, Williams and Wilkins, 2000.
438 M. Sinclair

From the late 1800’s through the 1950’s, in both Europe

and the United States, Swedish massage, using petrissage,
effleurage, vibration and tapotement strokes applied to the
anterior abdominal wall, was a widely used treatment for
constipation (Kleen, 1921; Kellogg, 1923; Starr, 1903;
Whorton, 2000) (Oriental styles of bodywork have long
used abdominal techniques to reduce constipation) (Chia,
1991; Matsumoto and Birch, 1998; Marin, 1999). Practi-
tioners believed that by applying pressure to the anterior
abdominal wall, they were compressing the digestive
organs between the massaging fingers and the posterior
wall of the abdominal cavity and stimulating peristalsis.
Some, but not all, believed massage also propelled feces
through the intestines towards the rectum (Kellogg, 1923).
Some practitioners targeted massage to the large intestine
so specifically, that one prominent physician recommended
the abdomen of the constipated patient be X-Rayed prior to
massage to identify the colon’s exact location (Kellogg,
1923). Abdominal massage may have inadvertently
treated scar tissue or trigger points in the muscles of the
midabdomen, either of which can cause excess gas and
sensations of abdominal swelling and fullness, and some
Figure 2 “Retained Feces in Colon of Patient with Functional patients may have confused relief of their symptoms with
Constipation”, reprinted with permission from Federle, M., a reduction in constipation (Travell et al., 1999). Profes-
Diagnostic Imaging Abdomen, AMIRSYS Inc., Salt Lake City sionals in the field of massage therapy continue to recom-
Utah, 2007. mend abdominal massage for constipation (Fernandez,
2006; Sinclair, 2004).

about 15% of the population, and American citizens spend

725 million dollars on laxatives each year (Higgins, 2004; Literature search
Shan et al., 2008). In a survey of 13,879 adults from 7
countries, an average of 12.3% of adults were consti- Observational studies and case reports comprise most of
pated, with a higher percentage occurring in women and the evidence for the effectiveness of abdominal massage
seniors (Wald, 2008). Women are especially likely to as a treatment for constipation. In 1999, a systematic
become chronically constipated (Rao, 2008, 2009, Davies review of evidence by Ernst examined observational
et al., 2009; Higgins, 2004; Talley, 2004; Van de Berg studies, case reports and four controlled clinical trials.
et al., 2006; Wald, 2008; Johnson, 1989). Even those Ernst concluded that all four clinical trials had methodo-
who have a bowel movement every day may have hidden logical flaws. Only one was randomized, and one trial
constipation, that is, feces remaining in any of the three consisted of only one patient. In addition, they were not
divisions of the colon or in the rectum itself (Raahave consistent in terms of the trial design, the type of
et al., 2004). massage that was given, or the type of patients that were
Current allopathic treatment of constipation includes in the trials. Therefore, he found that there was no sound
dietary changes (especially an increase in the consumption scientific evidence regarding the effectiveness of
of fiber and water), attention to habits/urge to defecate, abdominal massage in the treatment of chronic con-
physical exercise, enemas, bulk-forming, osmotic or stim- stipation. Looked at collectively, however, the trials
ulant laxatives, and stool softeners. Biofeedback training showed enough positive results, such as decreased con-
may be used for patients with constipation caused by poor stipation and improved patient well-being, that more
rectoanal coordination (Rao, 2008). Surgical treatment may rigorous trials e randomized, controlled, and with larger
be used as a last resort. numbers of patients e were warranted (Ernst, 1999).
Naturopathic medicine views constipation as having one Since the appearance of Ernst’s paper, there have been
of three primary causes, atonic (due to dilated or ptosed further observational studies with specific populations: two
intestines, loose rectal muscles, or inactivity), spastic (due with spinal cord injured patients (Albers et al., 2006; Ayas
to irritation caused by food, medicines, parasites or et al., 2006) and one each with groups of post-stroke
emotional stress) or obstructive (due to adhesions from patients (Jeon and Jung, 2005), elderly patients (Kim
surgery or infection). Treatment includes nutrition et al., 2005), hospice patients (Preece, 2002) and
(including dietary changes, probiotics, digestive enzymes profoundly disabled group-home residents (Emly, 2001). In
and dietary supplements), internal and external hydro- each case, abdominal massage decreased constipation and
therapy, botanical and homeopathic medicines and manual associated abdominal discomfort. For example, Ayas et al
therapies such as massage and visceral manipulation found that 15 min of abdominal massage per day decreased
(Mariotti, 2009). Colon hydrotherapy may be employed as colonic transit time, abdominal distention, and fecal
a method of stretching the muscles and fascia of the colon incontinence, and increased frequency of defecation in 24
from within (Dorman, 2006). spinal cord injured patients (Ayas et al., 2006). Emly’s
Use of abdominal massage to treat chronic constipation 439

study took place at a group home for profoundly disabled Anatomy and pathophysiology
adults, all of whom had been taking laxatives for extended
periods of time. At the beginning of the study, all laxatives The abdominal viscera lie directly beneath the muscles of
were withdrawn and daily abdominal massage using the anterior abdominal wall. Longitudinal and circularly
moderate-pressure effleurage, kneading and vibration was arranged smooth muscle, with sensory neurons and nerve
given instead. Subjects were assessed after eighteen endings lying within it, make up the walls of the stomach,
months and not only were they no more constipated than small intestine and colon. The vagus nerve innervates
when using laxatives, in some cases there was marked most of the digestive tract, and parts not innervated by
improvement in digestive function (Emly, 2001). the vagus are innervated by pelvic nerves from the sacral
Four individual case reports have also appeared since region of the spinal cord. The vagus can be impinged as it
1999, where abdominal massage effectively decreased passes through the jugular foramen or at the cranial
constipation. These individuals were a 64 year-old woman base, possibly affecting visceral function (Joyce and
with myelopathy (HAM/TSP, a spinal cord inflammation Clark, 1996).
with effects similar to those of a traumatic spinal cord There may be trigger points in the intestinal muscles
injury), an 8-year-old boy with lifelong constipation, themselves: when stimulated with an inflatable balloon
a severely constipated female patient in her mid-eighties trigger areas in the esophagus, small intestine and colon can
with abdominal muscle weakness, and a 31-year-old male in reproduce patients’ abdominal pain (Moriarty and Dawson,
the acute phase of Guillan-Barre syndrome (Liu et al., 2005; 1982; Travell et al., 1999). It is unknown if there is a rela-
Quist, 2007; Harrington and Haskvitz, 2006, and Shirreffs, tionship between these trigger points and constipation.
2001) (footnote: Acute Guillain-Barre presents with poly- Digestion is a complex process requiring the co-ordi-
neuritis, which leads to weakness of the muscles of the nated interaction of mechanical, chemical, neurological
digestive tract, sluggish contractions and constipation). and hormonal elements. Except at the mouth and anus,
There were many variations in the observational studies digestion is performed entirely by smooth muscles, whose
and case reports, such as the specific massage technique, actions include churning, kneading and propulsion of
how it was applied, and for how long. None were random- chyme, reflex emptying of the colon (the gastrocolic
ized, controlled trials. reflex), and rectal compliance. Efficient movement of
In 2009 Lamas carried out a randomized, controlled trial contents through the system has a great deal to do with the
on the use of abdominal massage with sixty elderly sensory neurons and nerve endings that sense distortion,
patients. All subjects had functional constipation which had pinching, contraction and distention of the gut wall. When
been treated with laxatives for several years. Patients were a segment of smooth muscle is distended with approxi-
divided into a control and an intervention group, both of mately 2 mm Hg of pressure, stretch receptors of the
which continued to take laxatives during the study period. afferent neurons located in the lumen wall are activated
The intervention group received 32 massages over a period and contraction occurs of both longitudinal and circular
of 8 weeks. Each session began with 8 min of hand massage muscles. The circular muscles create a ring around the
to help patients relax, followed by 7 min of abdominal lumen. At the same time, a few centimeters above the
massage. The massage technique was based upon the higher pressure area, intestinal wall muscles contract,
Tactile Stimulation Method of Birkestad which consists while below the point of stimulus, the muscles relax. Thus
primarily of palm-to-skin stroking, gentle pressing, and pressure is created on chyme, pushing it forward and
static touch, all using very light pressure (Birkestad, 1999). bulging or stretching the next segment of intestinal wall
For Lamas’ study, it consisted of light-pressure longitudinal muscle in turn, which stimulates yet another contraction
and transverse strokes over the abdomen, and clockwise and creates a peristaltic wave. Most contractions involve
circular movements over the presumed course of the colon. only 1e4 cm of bowel before they die out, thus peristaltic
Using a gastrointestinal function questionnaire, subjects contractions move the contents of the intestines along at
were assessed before the study began, after the fourth about 1 cm per minute. Not only large amounts of chyme,
week, and then after the eighth week, the end of the study. but lumps of food, artificial objects, intestinal parasites
No significant differences were found after 4 weeks. At 8 and tension in the muscles themselves can stimulate
weeks, however, the massage group had significantly less contractions, while very small stools (typical of patients on
constipation, less abdominal pain, and more bowel move- low-fiber diets) fail to distend the lumen sufficiently to
ments than the control group. Researchers also found that stimulate peristalsis. Artificial distention or stimulation of
the more constipated the patients were at the beginning of the intestinal walls by enemas, digital stimulation, medical
the study, the greater the improvement in their symptoms procedures and temperature extremes can also stimulate
(Lamas et al., 2009). muscle contractions (Lippincott’s, 2008; King et al., 1986).
Another randomized controlled study investigated the In anesthesized dogs, gentle stroking or touching of the
effectiveness of mechanical abdominal “massage” upon the mucosal (or inner) surface of the small intestines stimu-
peristalsis of patients who had had colon surgery one day lated contractions which lasted 30 s to 1 min (Neya, 1993).
before. Peristalsis normally slows or stops altogether after Mechanical stretch of segments of isolated guinea pig
colon surgery, but use of a machine which applied inter- intestine causes a contraction of the intestinal muscle
mittent pressure to the abdomen significantly decreased (Brookes et al., 2004).
the time to first passage of flatus after surgery for the When the intestinal wall just proximal to a sphincter
mechanical massage group versus a control group (Le Blanc- becomes distended, the sphincter relaxes briefly, during
Louvry et al., 2002). which time chyme is propelled through it. Simultaneously,
440 M. Sinclair

the muscles just distal to the chyme relax: chyme is thus high as 100 mg Hg, moves part of the contents in the
moved forward, while sphincters contract again to prevent cecum up the ascending colon, into the transverse colon
backflow. and then down into the descending colon and rectum. The
In the colon, muscle contractions squeeze, compact and contraction lasts 1e4 min before it decreases and then
propel chyme, squeezing out water in the process and finally stops altogether. Finally, more contractions move
forming the remaining paste into stool. Slow transit of the now-formed stool into the rectum (These muscle
stool may occur at any point throughout the colon, and in contractions can empty the bowel as high up as the splenic
only one or two segments rather than all three (van der flexure). The peristaltic action of the sigmoid colon and
Sijp et al., 1993). Spasm of colonic muscles may occur distention of its distal end stimulate contraction of the
with some illnesses such as pneumonia or myocardial large muscles of the rectum, thereby increasing rectal
infarction (Barral, 2005) Most of the actual propulsion of pressure and stimulating relaxation of the internal and
stool happens when mass movements (large waves of external sphincters. Abdominal wall muscles, which nor-
peristaltic action) occur, 1e4 times daily, generally just mally are voluntarily contracted to increase intra-abdom-
after eating a meal (see Figure 3). At this time, a massive inal pressure during a bowel movement, also enhance
contraction of the cecum and colon, creating pressures as defecation by applying inward and downward pressure on

Text box 1. Factors that interfere with the timely movement of abdominal contents through
the digestive system
More than one factor may be present in the same patient.

))) Lifestyle-related factors such as a diet that is low in fiber, regularly ignoring the urge to defecate, and chronic
dehydration (Older people may drink less in an attempt to control incontinence). Another factor, low muscle tone
due to inactivity, slows gastrointestinal transit time (Cordain, 1986; Oettle, 1991; Peters et al., 2001; Petticrew
et al., 2001; Davies et al., 2009; De Oliveira and Burrini, 2009).
))) Aging-related changes including the loss of enteric neurons and increased susceptibility to the adverse effects of
medications.
))) Long-term use of stimulant laxatives, which can result in decreased bowel contractions and increased con-
stipation (Petticrew et al., 2001).
))) Dysfunction in the pelvic floor muscles secondary to childbirth or hysterectomy, resulting in an immobile peri-
neum and decreased descent of the pelvic floor during defecation (Rao, 1998) The longitudinal coat of muscle of
the distal colon, which becomes complete in the sigmoid colon and rectum, is continuous with perineal muscle
and fascia.
))) Medical conditions such as hypothyroidism, multiple sclerosis, Parkinson’s disease, Crohn’s disease, diabetes,
celiac disease, irritable bowel syndrome, stroke, diverticulosis, cerebral palsy, and spinal cord injury, which can
cause either sluggish intestinal contractions or chronic colonic spasm, both of which can slow down the movement
of stool (Talley et al., 2003).
))) Use of constipating medications, including opiates, diuretics, antidepressants, antacids, antihistamines, iron
preparations and anticonvulsants. Opiates, for example, decrease peristaltic contractions as well as the urge to
defecate. Use of aspirin, acetominaphen and non-steroidal anti-inflammatory medications is also associated with
chronic constipation (Chang et al., 2007).
))) Mechanical obstruction: The small or large intestines may compressed by tumors, hernias, prolapsed internal
organs, chronic colonic spasm, the weight of a fetus during pregnancy or an accumulation of hard, dry feces.
Intestinal adhesions which can narrow the lumen of the bowel may result from previous abdominal infections,
blunt abdominal trauma, endometriosis, radiation treatment of the pelvis, and abdominal surgery, especially that
of the large intestine, appendix or uterus (Barral, 2005; Dondelinger, 2004; Klingele, 2005; McKay and Hirano,
1998; Opoien et al., 2007) (see Figures 4 and 5).
)) Emotional stress. The gastrointestinal tract contains both sympathetic and parasympathetic nerve fibers, and
under emotional stress, sympathetic function predominates, contracting sphincters, constricting digestive system
blood vessels and inhibiting both motility and secretion. Stimulation of the parasympathetic nerve supply of the
colon increases its motor activity, while sympathetic stimulation decreases it. Conditions such as anxiety,
depression and cognitive impairment may contribute to constipation ((Stam et al., 1997, Petticrew et al., 2001))
Victims of physical and/or sexual abuse during childhood are more likely to suffer from chronic constipation than
control subjects who did not experience abuse. (Walling et al., 1994) Numerous case reports are available of
successful treatment of constipation when the sole intervention was psychiatric (Clarke, 2007; Devroede et al.,
1989; Drossman et al., 1990; Jarrell, 2003; Latimer, 1983; McMahon and Koltenburg, 2006; Mayer, 1993; Shorter,
1993).
Use of abdominal massage to treat chronic constipation 441

Figure 3 “Stages of a Mass Movement of the Colon”, adapted from Hertz, A. F., Am J Physiolo 47: 57e65, 1913 A. The subject (an
adult male with no gastrointestinal pathology) took 2 ounces of barium sulfate suspension along with breakfast. Five hours later,
fecal material (the shadows at the end of the ileum, the caecum and the ascending colon) was visible. B. The subject then ate
a lunch of meat, vegetables and pudding. The end of his ileum emptied rapidly during the meal, while his caecum and ascending
colon filled. Towards the end of the meal, a large round mass at his hepatic flexure became cut off from the rest of his ascending
colon. C. Immediately after the meal was finished, some of the mass moved slowly around his hepatic flexure. D. The diameter of
the separated portion suddenly became much smaller and the large round shape changed into a long narrow one which extended
from his hepatic flexure almost to his splenic flexure. E. After a few seconds, the long narrow shape developed haustral
segmentation. F. Five minutes later, the long narrow shape suddenly become more elongated and passed around his splenic flexure.
G. The long narrow shape immediately passed down his descending colon H. The long narrow shape immediately passed into the
beginning of his sigmoid colon

stool. In one case, moderate hand pressure to the lower Symptoms

abdomen elicited measurable waves of rectal muscle
contractions in a patient within 10 s (Sakakibara, R., In addition to a reduced number of bowel movements,
personal communication, Dec 20, 2009, sakakibara@ symptoms of constipation also include straining during
sakura.med.toho-u.ak.jp). defecation, slower colonic transit time, hard lumpy stools,
abdominal distention and pain, sensations of incomplete
defecation, decreased mood, decreased enjoyment of life,
and sometimes limitations in recreation and work (Clarke
et al., 2008; Dennison et al., 2005; Johanson et al.,
2007). Chronic straining to pass stool can lead to physical
changes, including hemorrhoids, hernias, anal fissures,
laxity of colonic muscle fibers, thickening of the colonic
wall as a result of the high pressure needed to push hard
stool along, and activation of myofascial trigger points
(Travell et al., 1999). During a bowel movement, a bolus of
hard feces pressing against the left iliopsoas muscle can
cause referred pain in that muscle’s pain referral area
(Travell et al., 1999). Increased intra-colonic pressure
secondary to constipation can lead to weakness in the colon
walls, particularly in the sigmoid colon, predisposing
patients to diverticulosis (ADA, 2008). Long-term use of
laxatives may be a risk factor for the development of
colonrectal cancer, possibly because toxicants have more
Figure 4 “Small bowel obstruction secondary to adhesion time to be absorbed by the lining of the colon (Brocklehurst
from abdominal surgery” reprinted from Ros, P., “CT and MRI of et al., 1998; Jacobs, 1998; Roberts et al., 2003; Watanabe
the Abdomen and Pelvis: a Teaching File, second edition”, et al., 2004). Other complications that can develop from
Baltimore: Lippincott, Williams and Wilkins, 2007. chronic constipation include decreased rectal sensitivity,
442 M. Sinclair

massage is performed by parents, and during massage

sessions, constipated older children and adults having to visit
the bathroom immediately after abdominal massage.
The mechanisms behind abdominal massage’s con-
stipation-reducing effect are not fully understood, but are
most likely are a combination of stimulation and relaxation.
Direct pressure over the abdominal wall alternately
compresses and then releases sections of the digestive
tract, briefly distorting lumen size and activating stretch
receptors that can reinforce the gastrocolic reflex and
trigger intestinal and rectal contraction (Brookes et al.,
2004). Liu found that pressure on the lower abdomen eli-
cited measurable waves of rectal muscle contraction in
a spinal cord injured patient with viral myelopathy,
a condition similar in outcome to a spinal cord injury. The
patient typically had no ability to strain when attempting to
defecate, with only small, infrequent, rectal muscle
contraction. When her abdomen became distended
with feces, the patient applied moderate pressure to her
lower abdomen, using a rolling motion of her hand which
elicited the waves of rectal muscle contraction and
intermittent defecation through her anal sphincter. (Saka-
kibara, R., personal communication, Dec 20, 2009) Case
reports by Harrington, Shirreffs and Preece found abdom-
Figure 5 “Constipation due to pelvic organ prolapse: anterior
inal massage was helpful for constipation due to muscle
rectocele (herniation of posterior vaginal wall) caused by vaginal
weakness or slowed colonic motility induced by medica-
childbirth”, reprinted with permission from Ros, P., “CT and MRI
tions (Harrington and Haskvitz, 2006; Preece, 2002;
of the Abdomen and Pelvis: a Teaching File, second edition”,
Shirreffs, 2001).
Baltimore: Lippincott, Williams and Wilkins, 2007.
Liu concluded that the massage might trigger defeca-
tion not only through activation of intestinal stretch
receptors, but also by stimulating somato-autonomic
fecal impaction, incontinence, and even bowel perforations
reflexes (Liu et al., 2005) Colonic transit time may be
(Kamm and Lennard-Jones, 1990).
decreased by this mechanism (Ayas et al., 2006).
Abdominal massage may affect also constipation by a very
Discussion different mechanism, that of stimulating the para-
sympathetic nervous system, thus decreasing abdominal
The two randomized controlled trials performed since 1999 muscle tension, increasing motility of digestive tract
indicate that abdominal pressure or massage increases muscles, increasing digestive secretions, and relaxing
peristalsis, and thus could be helpful for increasing bowel sphincters in the digestive tract. In Lamas’s study, the
function and decreasing chronic constipation (Lamas et al., massage employed was a light rhythmic touch, performed
2009, and Le Blanc-Louvry et al., 2002). in an environment designed to enhance relaxation (Lamas
In addition, the 6 observational studies and 4 case reports et al., 2009). Diego et al found that abdominal massage in
that have appeared since Ernst’s call for further research add premature infants could measurably increase vagal
weight to the evidence for the effectiveness of abdominal activity and gastric motility (Diego, 2005). An earlier case
massage. Despite the fact that there were many variations in report of abdominal massage for a chronically constipated
the massage technique, amount of pressure applied, whether patient with abdominal spasticity due to cerebral palsy
a patient or a healthcare professional performed it, how it was reported that 30 min after abdominal massage, the
applied (even pressure from a machine stimulated peri- patient typically had a bowel movement without an
stalsis), the number of sessions and the duration of the enema: the author concluded that the release of abdom-
studies, in each case massage was still effective in reducing inal muscle tension through massage increased peristalsis.
constipation. In most, massage was performed by a health- (Emly, 1998). Given the current evidence, it is unlikely
care professional, but in 2, massage was self-administered. that stool is manually propelled along the digestive tract
Sometimes other interventions were combined with abdom- towards the rectum during abdominal massage, as some
inal massage, such as aromatherapy, chiropractic manipula- early practitioners believed.
tions or dietary changes. (In Lamas’s 2009 and Liu’s 2005
studies, however, neither fluid, fiber intake or exercise was
altered). Participants’ health status also varied widely. Conclusion
Professional massage practitioners have often noted that
manual pressure over the abdomen can stimulate bowel Abdominal massage has measurable effects upon con-
sounds, passage of flatus, and/or bowel movements. For over stipation, either low muscle tone through stimulation, or
25 years, the author has witnessed bowel movements spasmodic muscle states through relaxation. However,
occurring during infant massage classes when abdominal neither of these effects would result in stool being
Use of abdominal massage to treat chronic constipation 443

manually propelled along the digestive tract towards the effectiveness of abdominal massage depend upon the
rectum. cause of the constipation? For example, is abdominal
Abdominal massage can stimulate peristalsis, decrease massage more or less effective when the constipation
colonic transit time, increase the frequency of bowel stems from an underactive thyroid or a diet lacking in
movements in constipated patients, and decrease the fiber, than if it is caused by a spinal cord injury? And what
feelings of discomfort and pain that accompany it. Indi- if the functional constipation stems from pelvic floor
vidual case reports show that massage has been effective dysfunction rather than slow-transit constipation or con-
for patients with chronic constipation due to a variety of stipation-predominant irritable bowel syndrome? Further
diagnosed physiologic abnormalities and in patients with research is required to identify sub-groups of patients that
long-term functional constipation. There is also sound might benefit from abdominal massage. Fruitful research
scientific evidence that massage can stimulate peristalsis in might also be performed to identify the types of patients
patients with post-surgical ilieus. Its effectiveness, lack of who would be the best candidates to learn self-massage.
side-effects, and low-cost (especially if self-administered), Abdominal massage techniques are not complex, and in
make abdominal massage an attractive option in bowel two of the case studies, self-massage effectively relieved
management programs for persons with chronic con- constipation. Many laypeople could be taught to perform
stipation. One set of guidelines for holistic management of this technique on a regular basis, much as they brush their
chronic constipation in primary care has been developed by teeth regularly.
a multi-professional group of healthcare practitioners in How long abdominal massage should be administered is
the United Kingdom. These guidelines combine abdominal also an important question investigation. One study which
massage with education of patients regarding toileting was conducted with elderly patients found constipation
habits, exercise and diet, monitoring use of possibly was decreased after only ten days of abdominal massage,
constipating medications and prescribing laxatives if other and that the effect lasted for 7e10 days after massage
methods have not been successful (Emly and Rochester, was stopped, while Lama’s massage found no effect until
2006). In cases where patients must receive constipating 8 weeks of treatment (Kim et al., 2005; Lamas et al.,
medications, such as the 87% of late-stage cancer patients 2009).
who become constipated as a direct result of their opioid A study investigating different pressure techniques
medication, the condition may add greatly to suffering could also be enlightening. Varying amounts have been
from the patient’s actual disease (Petticrew et al., 2001; used, from the light-pressure technique of Lamas to the
Riechelmann et al., 2007). Here, abdominal massage may moderate-pressure technique used by Preece (Kim
significantly improve quality of life: it decreased con- et al., 2005; Jeon and Jung, 2005; Emly, 2001; Preece,
stipation and associated abdominal discomfort in hospice 2002).
patients (Preece, 2002). A further question of interest is which techniques are
Drawbacks of abdominal massage include the need to the most effective in treating constipation. Some investi-
perform massage repeatedly to see results, and to gators found that Swedish massage was effective,
continue the massage for extended periods of time. There however, mechanical massage has been effective as well.
are a number of important questions on this topic that These techniques are far more alike than they are
future research could address: for example, might the different.

Text box 2. A Typical Swedish Massage of the Abdomen for Constipation

Contraindications include abdominal obstruction, abdominal mass, intestinal bleeding, abdominal radiation therapy,
strangulated hernia and less than 6 weeks post-abdominal surgery.

1. Effleurage of the entire abdomen-10 times.

2. Effleurage of the rectus abdominis, external and internal obliques and transverse abdominis muscles-10 times
each.
3. Kneading of the abdomen-3 times.
4. Clockwise effleurage over the presumed path of the colon-10 times.
5. Vibration of the small and large intestines-one minute, or more.
6. Repeat step 4.
7. Kneading over the presumed path of the colon, with the fist, heel of the hand or thumbs-one minute or more.
8. Petrissage over the presumed path of the colon-one time.
9. Vibration over the presumed path of the colon.
10. Repeat Step 4.

Techniques used in different studies varied to some extent: for example, Lamas et al. (2009) used primarily light-
pressure effleurage of the abdomen for a total of 7 min, while Emly (2001, 2006) used moderate-pressure effleur-
age, kneading and vibration, for a total of 15e20 min, while Preece (2002) used propulsive massage, for a total of
10 min.
444 M. Sinclair

References Ernst, E., 1999. Abdominal massage for chronic constipation:

a systematic review of controlled clinical trials. Research in
Complementary Medicine 6 (3), 149e151.
American Dietetic Association, 2008. Health Implications of dietary
Fernandez, E., 2006. Deep Tissue Massage Treatment: a Handbook
fiber. Journal of the American Dietetic Association 108,
of Neuromuscular Therapy. Mosby Elsevier, St. Louis, Missouri.
1716e1731.
Harrington, K.L., Haskvitz, E.M., Nov 2006. Managing a patient’s
Addison, R., et al., 18 March 2003. A national audit of chronic
constipation with physical therapy. Physical Therapy 86 (11),
constipation in the community. Nursing Times 99 (11), 34e35.
1511e1519.
Albers, B., et al., March 2006. Abdominal massage as intervention
Higgins, P.D., 2004. Epidemiology of constipation in North America:
for patients with paraplegia caused by spinal cord injury-a pilot
a systematic review. Am Journal of Gastroenterology 99 (4),
study. Pflege Z. 59 (3), 2e8.
750e759.
Ayas, S., et al., Dec 2006. The effect of abdominal massage
Jacobs, E.J., Jul 1998. Constipation, laxative use, and colon cancer
on bowel function in patients with spinal cord injury.
among middle aged adults. Epidemiology 9 (4), 385e391.
American Journal of Physical Medicine Rehabilation 85
Jarrell, J., Feb, 2003. Myofascial dysfunction and pelvic pain.
(12), 951e955.
Canadian Journal of CME, 107e116.
Barral, J., 2005. Visceral Manipulation. Eastland Press, Seattle,
Jeon, S., Jung, H.M., Feb 2005. The effects of abdominal meridian
Washington.
massage on constipation among CVA patients. Taehan Kanho
Birkestad, G., 1999. Beroring i vard och omsorg. Ofeigur forlag, Solna.
Hakhow Chi 35 (1), 135e142.
Brocklehurst, J., et al., 1998. Laxatives and fecal incontinence in
Johanson, J., et al., 2007. Review of the treatment options for
long-term care. Nursing Standards 13 (52), 32e36.
chronic constipation. Medscape General Medicine 9 (2), 25.
Brookes, S.J.H., et al., 2004. Initiation of peristalsis by circum-
Johnson, J.F., 1989. Clinical Epidemiology of chronic constipation.
ferential stretch of flat sheets of guinea pig ileum. Journal of
Journal of Clinical Gatroenterology 11, 516e536.
Physiology 516 (2), 525e538.
Joyce, P., Clark, C., 1996. The use of Craniosacral therapy to Treat
Chang, J.Y., et al., 2007. Risk factors for chronic constipation and
Gastroesophageal Reflux in infants. Infants and Young Children
a possible role of analgesics. Neurogastroenterological Motility
9 (2), 51e57.
19, 905e911.
Kamm, M.A., Lennard-Jones, J.E., 1990. Rectal muscosal electro-
Chia, Mantak, 1991. Chi Nei Tsang: Internal Organ Chi Massage.
sensory testing: evidence for a rectal sensory neuropathy in idio-
Thailand Healing Tao Center, Chiang Mai.
pathic constipation. Diseases of the Colon and Rectum 33, 419e423.
Clarke, D., 2007. They Can’t Find Anything Wrong: 7 Keys to
Kellogg, J.K., 1923. The Art of Massage: A Practical Manual for the
Understanding, Treating and Healing Stress Illness. Sentient
Nurse, the Student, and the Practitioner. Modern Medicine
Publications, Boulder, Colorado.
Publishing Co, Battle Creek, Michigan.
Clarke, M.C., et al., Feb 2008. Quality of life in children with slow-
Kim, M.A., et al., Feb 2005. Effect of aromatherapy massage for
transit constipation. Journal of Pediatric Surgery 43 (2),
the relief of constipation in the elderly. Taehan Kanho Hakhoe
320e324.
Chi 35 (1), 56e64.
Cordain, L., Mar 1986. The effects of an aerobic running program
King, E., WEick, L., Dyer, M., 1986. Illustrated Manual of Nursing
on bowel transit time. Journal of Sports Medicine Physical
Techniques, third ed. JB Lippincott, Williams and Wilkins, ,
Fitness 26 (1), 101e104.
Philadelphia.
Davies, E.C., et al., Sept 2009. The use of opioids and laxatives and
Kleen, E., 1921. Massage and Medical Gymnastics. J.A. Churchill,
the incidence of constipation in patients requiring neck of the
London.
femur surgery: a pilot study. Journal of Clinical Pharmacology
Klingele, C.J., Aug 2005. Pelvic organ prolapse in defecatory
and Therapeutics 33 (5), 561e566.
disorders. Obstetrics and Gynecology 106 (2), 315e320.
De Oliveira, E.P., Burrini, R.C., Sept 2009. The impact of physical
Lamas, K., et al., 2009. Effects of Abdominal Massage in manage-
exercise on the gastrointestinal tract. Current Opinion in Clinical
ment of constipation. International Journal of Nursing Studies.
Nutrition and Metabolic Care 12 (5), 533e538.
Latimer, P., 1983. Functional Gastrointestinal Disorders, a Behav-
Dennison, C., et al., 2005. The health-related quality of life and
ioral Medicine Approach. Springer Publishing, New York.
Economic Burden of constipation. Pharmacoeconomics 23 (5),
Le Blanc-Louvry, I., et al., Feb 2002. Does mechanical massage of
461e476.
the abdominal wall after colectomy reduce post-operative pain
Devroede, G., et al., 1989. Idiopathic constipation by colonic
and shorten the duration of ileus: results of a randomized study.
dysfunction: relationship between personality and anxiety.
Journal of Gastrointestinal Surgery 6 (1), 43e49.
Digestive Diseases and Sciences 34 (9), 1428e1433.
Leung, F.W., 2007. Etiologic factors of chronic constipation: review
Diego, M.A., 2005. Vagal activity, gastric motility, and weight gain
of the scientific evidence. Digestive Diseases and Sciences 52
in massaged preterm neonates. Journal of Pediatrics 147 (1),
(2), 313e316.
50e55.
Lippincott’s, 2008. Nursing Procedures. Lippincott Williams and
Dondelinger, R.F., 2004. Imaging and Intervention in Abdominal
Wilkins, Baltimore, MD.
Trauma. Springer, New York.
Liu, Z., et al., 2005. Mechanism of abdominal massage for difficult
Dorman, T., 2006. Colonics, Townsend Letter: the Examiner of
defecation in a patient with myelopathy. Journal of Neurology
Alternative Medicine, July, pp. 77e81.
252, 1280e1282.
Drossman, et al., 1990. Sexual and physical abuse in women with
Locke, G.R., Pemberton, J.H., Phillips, S.F., 2000. American
functional or organic gastrointestinal disorders. Annals of
Gastroenterological Association medical Position Statement:
Internal Medicine 113, 701e708.
guidelines on constipation. Gastroenterology 119 (6), 1761e1766.
Emly, M., 1998. Colonic motility in profoundly disabled people:
Marin, Gilles, 1999. Healing from Within with Chi Nei Tsang: Applied
a comparison of massage and laxative therapy in the manage-
Chi Kung in Internal Organs Treatment. North Atlantic Books,
ment of constipation. Physiotherapy 84 (4), 178e183.
Berkeley, Ca.
Emly, M., Jul 26eAug 1 2001. Abdominal massage for adults with
Mariotti, R., 2009. A Naturopathic Approach to Visceral Manipula-
learning disabilities. Nursing Times 97 (30), 61e62.
tion. Healing Mountain Publishing, Seattle, WA.
Emly, M., Rochester, P., 11 Aug 2006. A new look at constipation
Matsumoto, K., Birch, S., 1998. Hara Diagnosis: Reflections on the
management in the community. British Journal of Community
Sea. Paradigm Pub, Taos, New Mexico.
Nursing 11 (8), 328e332. 326.
Use of abdominal massage to treat chronic constipation 445

Mayer, E. (Ed.), 1993. Basic and Clinical Aspects of Chronic Shan, N., et al., June 2008. Ambulatory care for constipation in the
Abdominal Pain. Elselvier, New York. United States, 1993e2004. American Journal of Gastroenter-
McKay, J., Hirano, N., 1998. The Chemotherapy and Radiation ology 103 (7), 1746e1753.
Therapy Survival Guide. New Harbinger Publications, Oakland, Shirreffs, C.M., May 2001. Aromatherapy massage for joint pain and
California, 33 pp. constipation in a patient with Guillian Barre. Complementary
Mcmahon, S., Koltenburg, M. (Eds.), 2006. Wall and Melzak’s Therapies in Nursing and Midwifery 2 87e83.
Textbook of Pain, fifth ed. Elselvier, Churchill Livingstone Shorter, E., 1993. From Paralysis to Fatigue: A History of Psycho-
p. 764. somatic Illness in the Modern Era. Free Press, New York.
Moriarty, J.K., Dawson, A.M., 1982. Functional abdominal pain Sinclair, M., 2004. Pediatric Massage Therapy. Lippincott, Williams
further evidence that the whole gut is affected. British Journal and Wilkins, Baltimore.
of Medicine 284, 1670e1672. Southwell, B.R., et al., Jul 2009. Colonic transit studies: normal
Neya, T., 1993. Role of 5HT3 Receptors in peristaltic reflex elicited values for adults and children with comparison of radiological
by stroking the mucosa in the canine jejunum. Jornal of Phys- and scintigraphic methods. Pediatric Surgery International 25
iology 471, 159e173. (7), 559e572.
Oettle, G.J., 1991. Effect of moderate exercise on bowel habit. Stam, R., et al., June 1997. Trauma and the gut: interaction
Gut 32, 941e944. between stressful life experiences and intestinal function. Gut
Opoien, H.K., et al., 2007. Al, Post-Caesarean surgical site infections 40 (6), 704e709.
according to CDC standards: rates and risk factors. A prospective Starr, L., 1903. Hygiene of the Nursery: Including the General
cohort study. Acta Obstetrics and Gynecology Scandinavia 86 (9), Regimen and Feeding of Infants and Children; Massage and the
1097e1102. Domestic Management of the Ordinary Emergencies of Early
Peters, H.P., et al., Mar 2001. Potential benefits and hazards of Life. P Bakiston’s Son and Co, Philadelphia.
physical activity and exercise in the gastrointestinal tract. Gut Talley, N., et al., 2003. Risk factors for chronic constipation based
48 (3), 435e439. on a general Practice Sample. American Journal of Gastroen-
Petticrew, M., et al., Dec 2001. Effectiveness of laxatives in adults. terology 98, 1107e1111.
Quality and Safety in Health Care 10 (4), 268e273. Talley, N., 2004. Definitions, Epidemiology, and Impact of chronic
Preece, J., May 2002. Introducing abdominal massage in palliative constipation. Reviews in Gastroenterological Disorders 4 (Suppl.
care for the relief of Constipation. Complementary Therapies in 2), S3eS10.
Nursing and Midwifery 8 (2), 101e105. Travell, J., Simons, D., Travell, J., 1999. Travell and Simon’s
Quist, D., 2007. Resolution of symptoms of chronic constipation in an 8 Myofascial Pain and Dysfunction: The Triggerpoint Manual. In:
year old male after chiropractic treatment. Journal of Manipulative Upper Body, second ed., vol. 1. Lippincott, Williams and Wil-
and Physiological Therapeutics 30 (1), 65e68. kins, Baltimore, Maryland, pp. 953e959.
Raahave, D., et al., Nov 2004. Additional faecal reservoirs Van de Berg, M.M., et al., Oct 2006. Epidemiology of childhood
or hidden constipation: a link between functional and organ- constipation. American Journal of Gastroenterology 101 (10),
ic bowel disease. Danish Medical Bulletin 51 (4), 422e425. 2401e2409.
Rao, S.S., Jul 1998. Obstructive Defecation: a failure of rectoanal van der Sijp, J.R., et al., March 1993. Radioisotope determination
coordination. American Journal of Gastroenerology 93 (7), of regional colonic transit in severe constipation: comparison
1042e1050. with radio opaque markers. Gut 34 (3), 402e408.
Rao, S.S., Sept 2008. Dyssynergic defecation and Biofeedback therapy. Wald, A., et al., 2008. A Multinational survey of Prevalence and Patterns
Gastroenterology Clinics of NorthAmerica 37 (3), 569e581. of laxative use among adults with self-Defined constipation.
Rao, S.S., et al., May 2009. Investigation of colonic and whole-gut Alimentary Pharmacology and Therapeutics 28 (7), 917e930.
transit with wireless motility capsule and radiopaque markers in Walling, Mary, et al., 1994. Abuse history and chronic pain in
constipation. Clinical Gastroenterology and Hepatology 7 (5), women: II. A multivariate analysis of abuse and psychological
537e544. morbidity. Obstetrics and Gynecology 84 (2).
Riechelmann, R.P., et al., Dec 2007. Symptom and medication Watanabe, T., et al., 2004. Constipation, laxative use, and risk of
profiles among cancer patients attending a palliative care colorectal cancer: the Miyagi Cohort Study. European Journal of
clinic. Support Care Cancer 15 (12), 1407e1412. Cancer 40 (14), 2109e2115.
Roberts, M.C., et al., April 2003. Constipation, laxative use, and Whorton, J., 2000. Inner Hygiene: Constipation and the Pursuit of
colon cancer in a North Carolina population. American Journal Health in Modern Society. Oxford University Press, New York,
of Gastroenterology 98 (4), 857e864. 149 pp.