Abdominal massage to treat chronic constipation: for people with learning and physical disabilities

Karen Moore, i7942911@bournemouth.ac.uk Bournemouth University - School of Health and Social Care: Physiotherapy

Acknowledgements: Would like to thank Marian Emly, Alison Lindley and Jackie Plant for sharing information about their available abdominal massage services, research and training programmes.

Linda Rieder for her professional support throughout this project

Case Scenario

Example:

Spastic Quadriplegia

26 yrs old Distorted body shape

Anti- Convulsant for Epilepsy

Chronic constipation-

long term laxative use

24 care staff.

Dependant for all

mobility

Non verbal

Communication

Background to constipation: • One of the most common gastrointestinal disorders worldwide (Kyle 2010). • Causes debilitating symptoms = Reduced quality of life (Lamas et al. 2009). Symptoms of constipation: 9 Abdominal pain 9 Abdominal distension 9 Incomplete and infrequent defecation 9 Difficulty when passing stools 9 Anal fissures 9 Haemorrhoids 9 Flatulence 9 Behaviour changes (Lamas et al. 2009). • 70% of patients with learning disabilities have chronic constipation. • With an average colonic transit time of 180 hrs = 7.5 days ! • Healthy population colonic transit time is approximately 35 hrs. • The are approximately 1,191,000 people in U.K. with learning disabilities. (Coggrave et al. 2014; Emerson et al. 2011; Emly at al. 1998; Lamas at al. 2009).

Present conservative treatment for constipation: Alteration of diet - increase fibre intake. Increase fluid intake. Increase exercise More effective toileting routines. Laxatives Suppositories Enema (Kyle 2011; Sinclair 2010).

!! SIDE EFFECTS OF LONG TERM LAXATIVE USE !!

Distension of abdomen Abdominal Pain Flatulence Medication interaction Possible dependency Cramping Possible damage to smooth muscles and the enteric nerve system. (Emly and Rochester 2006; Ford and Talley 2012; Sinclair 2010).

Proposed Intervention is Defined as: “Technique  using  effleurage,  kneading  and  vibration  applied  to  the  abdominal  wall  following  

the presumed course of the large intestine to reinforce the gastro-colic  reflex”.        (Emly    et    al.  2001).

� Shortens colonic transit time. � More frequent defecation. � Reduces abdominal pain. � Reduces abdominal distension. � Relaxes the mind & body. � Stimulates parasympathetic Nervous system which aids digestion.

(Lamas et al 2009; National Clinical Guideline Centre (NCGC) 2012; Sinclair 2010).

9Patient centred care

(NCGC 2012)

Physiotherapy role in abdominal massage:

References:

Coggrave,M.,Norton,C.,Cody,J.D.,2014. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Reviews. United States of America: John Wiley & Sons. Issue 1. Art No.:CD0025115. DOI:10.1002/14651858.CD002115.pub5. Emerson, E., Baines, S., Allerton, L. and Welch, V., 2011. Health inequalities and people with learning disabilities in the UK. Improving health and lives: Learning disabilities observatory. Available from : http://www.arcuk.org.uk/membersarea/wp-content/uploads/2012/05/IHAL-PWLD-England-2011.pdf [Accessed 20 April 2014]. Emly, M., Cooper, S. and Vail, A., 1998. Colonic Motility in Profoundly Disabled People. Physiotherapy, 84 (4), 178 – 183. Emly, M., Wilson, L. and Darby,J., 2001. Abdominal massage to adults with leanring disabilities. Nursing Times Plus, 97 (30 ) , 61 -62. Emly, M. and Rochester, P., 2006. A new look at constipation management in the community. British Journal of Community Nursing, 11 (8), 326 – 332. Emly,M.,Bell,S. and Howard,J., 2008. Training module on abdominal massage : Project 6. Leeds PCT. Ford, A.C. and Talley, N.J., 2012. Laxatives for chronic constipation in adults. British Medical Journal, 345, 44-47. Harris,D. and Fineberg,I.C.,  2011.  Multidisciplinary  palliative  care  teams’  understanding  of  mental  Capacity  Act  2005  ‘best  interest’  determinations.  International Journal of Palliative Nursing,17 (1), 20 -25. Kyle, G., 2011. Managing constipation in adult patients. Nurse Prescribing, 9 (10), 481 -490. Lamas, K., Lindholm, L., Stenlund, H., Engstrom, B.aAnd Jacobsson, C., 2009. Effects of abdominal massage in management of constipation – a randomized controlled trial. International Journal of Nursing Studies , 46, 759 -767. Lamas, K., Graneheim, U.H. and Jacobsson,C., 2010. Experiences of abdominal massage for constipation. Journal of Clinical Nursing, 21, 757-765 Lewis, S.J. and Heaton, K.W., 1997. Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32, 920-924. Mental Capacity Act, 2005 National Clinical Guideline Centre (NCGC), 2012. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. United Kingdom: National Institute for Health and Clinical Excellence (NICE). Guideline number: CG138. Pigram,J., Simpson,R., Hopkins,S., Brown,J., Caulfield,H., Smith,C., Hayward Giles,S., Nancarrow, S., 2006. Supervision, accountability and delegation of activities to support workers. London: The Chartered Society of physiotherapy. Available from: file:///C:/Users/Karen/Documents/ABSTRACT%20-%20POSTER/supporting_support_workers_0.pdf [Accessed 13 May 2014]. Sinclair,M.,2010. The use of abdominal massage to treat chronic constipation. Journal of Bodywork & Movement Therapies, 15, 436-445. Williams,V., Boyle,G., Jepson,M., Swift,P., Williamson,T. and Heslop,P., 2014. Best interests decisions: professional practices in health and social care. Health and Social Care in the Community, 22 (1), 78-86.

Ethical Considerations for Clients with Learning Disabilities

1. Consent: If informed consent cannot be obtained for abdominal massage treatment then an assessment of Mental Capacity has to be carried out by MDT qualified professionals. 2. Mental Capacity Act 2005 : Protects vulnerable adults. Balances : Autonomy and wisdom. Protection and empowerment. ( Mental Capacity Act 2005; Williams et al. 2014)

3. Best interest decision: If it is established that the client does not have the mental capacity to make an informed decision, then best interest decisions can be made. (Harris and Fineberg 2011; Williams et al.2014) 4. Best interest decisions involve : The client, multidisciplinary Healthcare Professional Team, our  client’s  General  Practitioner  (GP),  and  family    members.   GP to give a full medical prior to commencing any abdominal massage programme

Lamas et al : A study of how a client may experience abdominal massage – PT and carer awareness of possible emotions by client. Our client cannot verbally express these emotions or feelings (2010). Aware of non-verbal communication !

GP to advise on weaning off laxatives as effectiveness of abdominal massage increases.

In Summary: Abdominal massage to be utilised alongside conventional treatment to enhance quality of life and reduce distressing symptoms of chronic constipation. Evidence supports abdominal massage to be part of a bowel management programme specific to our individual client . This includes education and advice on : Diet, fluid, toileting habits, mobility, full bowel assessments and ongoing quality of life assessment by carer and PT - Careful consideration of client experience and Best Interest is vital ! (Emly and Rochester 2006; Kyle 2011)

Effectives of an abdominal massage programme is evaluated by: assessing bowel patterns, stool assessments, physical assessments, functional mobility, medication, lifestyle (diet and fluid intake) – records are maintained by care staff as part the massage programme. PT should then review at each follow-up session. (Emly and Rochester 2006; Kyle 2011;Lewis and Heaton 1997)

1. PT core foundational skills : Able to assess through palpation Massage Techniques are a core skill for Physiotherapists (Emly et al. 2008).

2. Training required by PT : Abdominal massage competency at University level. If abdominal massage is not covered in a University unit then to complete a recognised quality UK based course. (for example: those offered by Marian Emly or Alison Lindley –refer to acknowledgements: permission given to share course information)

3. PT is able to then : -Train Care staff for care agency or Trust. -Individual client specific care staff training -Teach client self- abdominal massage. (Emly et al. 2008).

4. Ongoing assessment & monitoring:

PT and carer to follow a set procedure of training, supervised practice sessions,

assessments and strict record keeping . When carer is safe and competent ,then PT will

re- assess every 6 months. (Example: Emly et al.2008).

PT training and monitoring of care staff

competence and safety will follow the Chartered Society of Physiotherapy standards of delegating

tasks. (Pigram et al. 2006).

Causes of constipation:

Stress

~ Low fibre

intake ~

Low fluid Intake

~ Certain medications

~ Polypharmacy

~ Inactivity

~ Distorted body

shapes ~

High tone (Sinclair 2010)

Laxative use costs the

NHS approximately £ 60 Million

Per year!

Diagram showing direction of abdominal massage along large intestine: Permission granted to used image from Emly et al. (2008).