Does a manual therapy approach improve the symptoms of functional constipation? A systematic review of the literature



      Functional constipation is highly prevalent and places a significant burden on healthcare systems around the world. Manual therapy is a commonly used intervention, however to date there has not been a systematic review that critically appraises a wide range of manual therapy disciplines.


      To systematically review the literature and analyse the methodological quality of all included studies, and to provide an overall level of evidence analysis.


      A database search was completed to identify eligible studies that were published from database creation to July 2018. The relevant characteristics of each study were extracted, and each study was assessed for methodological quality with a modified version of the Downs and Black appraisal tool.


      Seven studies fulfilled the inclusion criteria and were assessed for methodological quality. One study was found to have ‘strong’ methodological quality, five were of ‘moderate’ quality, and one was of ‘low’ quality. All studies reported consistent findings regarding their individual primary outcome measures. Overall level of evidence for the use of manual therapy as an intervention for constipation was found to be ‘moderate’.


      There is moderate quality evidence for the use of manual therapy as an intervention for constipation. The review identified several themes that can guide future research on this topic, including intervention type and frequency, reporting quality, mechanism of effect, and variability of outcome measures.


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        • Peppas G.
        • Alexiou V.G.
        • Mourtzoukou E.
        • Falagas M.E.
        Epidemiology of constipation in Europe and Oceania: a systematic review.
        BMC Gastroenterol. 2008; 8: 1-7
        • Sanchez M.I.P.
        • Bercik P.
        Epidemiology and burden of chronic constipation.
        Can J Gastroenterol. 2011; 25 (Suppl B(Suppl B):11B-15B)
        • Longstreth G.F.
        • Thompson W.G.
        • Chey W.D.
        • Houghton L.A.
        • Mearin F.
        • Spiller R.C.
        Functional bowel disorders.
        Gastroenterology. 2006; 130: 1480-1491
        • Corazziari E.
        Definition and epidemiology of functional gastrointestinal disorders.
        Best Pract Res Clin Gastroenterol. 2004; 18: 613-631
        • Lacy B.E.
        • Mearin F.
        • Chang L.
        • et al.
        Bowel disorders.
        Gastroenterology. 2016; 150: 1393-1407e5
        • Drossman D.A.
        Functional gastrointestinal disorders: history, pathophysiology, clinical features, and Rome IV.
        Gastroenterology. 2016; 150: 1262-1279e2
        • Chang J.Y.
        • Locke G.R.
        • McNally M.A.
        • et al.
        Impact of functional gastrointestinal disorders on survival in the community.
        Am J Gastroenterol. 2010; 105: 822-832
        • Irvine E.J.
        • Ferrazzi S.
        • Pare P.
        • Thompson W.G.
        • Rance L.
        Health-related quality of life in functional GI disorders: focus on constipation and resource utilization.
        Am J Gastroenterol. 2002; 97: 1986-1993
        • Sethi S.
        • Mikami S.
        • Leclair J.
        • et al.
        Inpatient burden of constipation in the United States: an analysis of national trends in the United States from 1997 to 2010.
        Am J Gastroenterol. 2014; 109: 250-256
        • Hayat U.
        • Dugum M.
        • Garg S.
        Chronic constipation : update on management.
        Cleve Clin J Med. 2017; 84: 397-408
        • Leung L.
        • Riutta T.
        • Kotecha J.
        • Rosser W.
        Chronic constipation: an evidence-based review.
        J Am Board Fam Med. 2011; 24: 436-451
        • Lindberg G.
        • Hamid S.
        • Malfertheiner P.
        • et al.
        Constipation : a global perspective.
        World Gastroenterol Organ. 2010; : 1-13
        • National Institute for Health and Care Excellence
        Constipation in children and y young oung people : diagnosis and management.
        • Ford A.C.
        • Suares N.C.
        Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis.
        Gut. 2011; 60: 209-218
        • Xing J.H.
        • Soffer E.E.
        Adverse effects of laxatives.
        Dis Colon Rectum. 2001; 44: 1201-1209
        • Wald A.
        Is chronic use of stimulant laxatives harmful to the colon?.
        J Clin Gastroenterol. 2003; 36
        • Clar C.
        • Tsertsvadze A.
        • Court R.
        • Hundt G.
        • Clarke A.
        • Sutcliffe P.
        Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report.
        Chiropr Man Ther. 2014; 22: 12
        • Barral J.P.
        • Mercier P.
        Visceral manipulation.
        Eastland Press, Seattle2005
        • Silva C.A.G.
        • Motta M.E.F.A.
        The use of abdominal muscle training, breathing exercises and abdominal massage to treat paediatric chronic functional constipation.
        Color Dis Off J Assoc Coloproctology Gt Britain Irel. 2013; 15: e250-e255
        • Sinclair M.
        The use of abdominal massage to treat chronic constipation.
        J Bodyw Mov Ther. 2011; 15: 436-445
        • Alcantara J.
        • Alcantara J.D.
        • Alcantara J.
        An integrative review of the literature on the chiropractic care of infants with constipation.
        Compl Ther Clin Pract. 2014; 20 (1): 32-36
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        1998: 377-384
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • McGowan J.
        • Reid D.A.
        • Caldwell J.
        Post-operative rehabilitation of anterior cruciate ligament reconstruction in the skeletally immature child: a systematic review of the literature.
        Phys Ther Rev. 2017; 3196: 1-16
        • van Tulder M.
        • Furlan A.
        • Bombardier C.
        Updated method guidelines for systematic reviews in the cochrane.
        Collaboration Back Review Group. 2003; 28 (12): 1290-1299
        • Furlan A.D.
        • van Tulder M.
        • Cherkin D.C.
        • et al.
        Acupuncture and dry needling for low back pain.
        • Gürsen C.
        • Kerem Günel M.
        • Kaya S.
        • Kav T.
        • Akbayrak T.
        Effect of connective tissue manipulation on symptoms and quality of life in patients with chronic constipation: a randomized controlled trial.
        J Manip Physiol Ther. 2015; 38: 335-343
        • Brugman R.
        • Fitzgerald K.
        • Fryer G.
        The effect of osteopathic treatment on chronic constipation - a pilot study.
        Int J Osteopath Med. 2010; 13: 17-23
        • Kassolik K.
        • Andrzejewski W.
        • Wilk I.
        • et al.
        The effectiveness of massage based on the tensegrity principle compared with classical abdominal massage performed on patients with constipation.
        Arch Gerontol Geriatr. 2015; 61: 202-211
        • Koo J.P.
        • Kim H.A.
        • Kim H.R.
        Effect of physical therapy intervention on the constipation assessment scale and weekly bowel frequency in patients with constipation.
        J Int Acad Phys Ther Res. 2016; 7: 1011-1017
        • Koo J.-P.
        • Choi J.-H.
        • Kim N.-J.
        The effects of maitland orthopedic manual therapy on improving constipation.
        J Phys Ther Sci. 2016; 28: 2857-2861
        • Lämås K.
        • Lindholm L.
        • Stenlund H.
        • Engström B.
        • Jacobsson C.
        Effects of abdominal massage in management of constipation -- a randomized controlled trial.
        Int J Nurs Stud. 2009; 46: 759-767
        • Belvaux A.
        • Bouchoucha M.
        • Benamouzig R.
        Osteopathic management of chronic constipation in women patients . Results of a pilot study.
        Clin Res Hepatol Gastroenterol. 2017;
        • Ernst E.
        Abdominal massage therapy for chronic constipation: a systematic review of conrolled clinical trials.
        Forschende Komplementärmed. 1999; 6: 149-151
        • Muller A.
        • Franke H.
        • Resch K.
        • Fryer G.
        Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome.
        Syst Rev. 2014; 114: 470-479
        • Cicchitti L.
        • Martelli M.
        • Cerritelli F.
        Chronic inflammatory disease and osteopathy: a systematic review.
        PloS One. 2015; 10: 1-18
        • Heneghan N.R.
        • Adab P.
        • Balanos G.M.
        • Jordan R.E.
        Manual therapy for chronic obstructive airways disease: a systematic review of current evidence.
        Man Ther. 2012; 17: 507-518
        • Gross A.R.
        • Kay T.
        • Hondras M.
        • et al.
        Manual therapy for mechanical neck disorders: a systematic review.
        Man Ther. 2002; 7: 131-149
        • Medlicott M.S.
        • Harris S.R.
        A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder.
        Phys Ther. 2006; 86: 955-973
        • Alvarez G.
        • Cerritelli F.
        • Urrutia G.
        Using the template for intervention description and replication (TIDieR) as a tool for improving the design and reporting of manual therapy interventions.
        Man Ther. 2016; 24: 85-89
        • Van Oudenhove L.
        • Aziz Q.
        Recent insights on central processing and psychological processes in functional gastrointestinal disorders.
        Dig Liver Dis. 2009; 41: 781-787
        • Bialosky J.E.
        • Bishop M.D.
        • Price D.D.
        • Robinson M.E.
        • George S.Z.
        The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.
        Man Ther. 2009; 14: 531-538
        • Guillaud A.
        • Darbois N.
        • Monvoisin R.
        • Pinsault N.
        Reliability of diagnosis and clinical efficacy of cranial osteopathy: a systematic review.
        BMC Compl Alternative Med. 2018; 18: 1-12
        • Hawk C.
        • Khorsan R.
        • Lisi A.J.
        • Ferrance R.J.
        • Evans M.W.
        Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research.
        J Alternative Compl Med. 2007; 13: 491-512
        • Talley N.J.
        Definitions, epidemiology, and impact of chronic constipation.
        Rev Gastoenterological Disord. 2004; 4: 3-10