The Effect of Abdominal Massage on Constipation and Quality of Life

Abstract

This study was a randomized controlled trial aimed to find the impact of abdominal massage application on constipation and quality of life among patients. The sample included 30 intervention (abdominal massage) and 30 control subjects. To collect data, the following were utilized: Patient Information Form, Gastrointestinal Symptom Rating Scale, Constipation Severity Instrument, Bristol Scale Stool Form, Patient Assessment of Constipation Quality of Life (PAC-QOL) Scale, and European Quality of Life Instrument (EQ-5D). The data were collected from among patients in the morning and evening on the fourth, fi fth, and sixth days postoperatively. No signifi cant fi ndings were discovered between experimental and control groups in terms of individual characteristics and characteristics that might influence constipation (p >.05). It was found that patients who received abdominal massage application defecated more often following their surgery than patients in the control group, which led to a statistically high level of signifi cant difference between the groups (p ≤.001). It was also found that the experimental group displayed higher average PAC-QOL and EQ-5D scores on discharge. Findings indicated that abdominal massage applied to patients diagnosed with postoperative constipation reduced symptoms of constipation, decreased time intervals between defecation, and increased quality of life.

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48 Copyright © 2016 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
massage is used in patients with constipation by nurses,
patients defecate early, less pharmacological agents are
used, and the quality of life improves ( Richards, 1998 ).
Background
The frequency of constipation ranging from 2% to
28% is a problem peculiar to the gastrointestinal (GI)
system. Women compared with men and elderly com-
pared with young experience more frequent complaints
of constipation ( Kaya, Kaya, Turan, S¸irin, & Gülog˘lu,
2013 ; Lamas et al., 2010; Turan et al., 2011 ; Yurdakul,
2004 ). The symptoms include scybalum (hard stool
mass) and defecation less than three times a week,
abdominal and rectal pain, decrease in intestinal noise,
rectal fullness, pressure in rectum, stress and pain
while defecation, feeling full, loss of appetite, head-
ache, fatigue, and hemorrhoid ( Kaya, 2011 ; H. Kaya,
2012 ; Yurdakul, 2004 ).
Constipation may be brought on by a change in
diet, medication, daily routine, exercise patterns, acute
emotional stress, surgery, medication, or disease pro-
cesses ( H. Kaya, 2012 ; McClurg, Hagen, Hawkins, &
Lowe-Strong, 2011 ; Sinclair, 2011 ). Constipation also
has a significant impact on the person’s quality of life
and well-being and can range from a headache and
Constipation is a common problem that often
has a profound effect on patients’ well-being
and quality of life ( Lamas, Lindholm,
Stenlund, Engstrom, & Jacobsson, 2009 ;
Preece, 2002 ). The use of abdominal massage to help
relieve constipation has been an effective therapy for
several hundred years ( Preece, 2002 ). More recently,
interest in abdominal massage as an effective interven-
tion for constipation without known side effects has
resurfaced ( Harrington & Haskvitz, 2006 ). Abdominal
massage has been widely used by nurses recently ( Ayas¸,
Leblebici, Sözay, Bayramog˘ lu, & Niron, 2006 ; Emly,
Cooper, & Vail, 1998 ; Ernst, 1999 ). When abdominal
The Effect of Abdominal Massage on
Constipation and Quality of Life
ABSTRACT
This study was a randomized controlled trial aimed to fi nd the impact of abdominal massage application on consti-
pation and quality of life among patients. The sample included 30 intervention (abdominal massage) and 30 control
subjects. To collect data, the following were utilized: Patient Information Form, Gastrointestinal Symptom Rating
Scale, Constipation Severity Instrument, Bristol Scale Stool Form, Patient Assessment of Constipation Quality of Life
(PAC-QOL) Scale, and European Quality of Life Instrument (EQ-5D). The data were collected from among patients in
the morning and evening on the fourth, fi fth, and sixth days postoperatively. No signifi cant fi ndings were discovered
between experimental and control groups in terms of individual characteristics and characteristics that might infl uence
constipation ( p > .05). It was found that patients who received abdominal massage application defecated more often
following their surgery than patients in the control group, which led to a statistically high level of signifi cant difference
between the groups ( p ≤ .001). It was also found that the experimental group displayed higher average PAC-QOL
and EQ-5D scores on discharge. Findings indicated that abdominal massage applied to patients diagnosed with
postoperative constipation reduced symptoms of constipation, decreased time intervals between defecation, and
increased quality of life.
Nuray Turan , PhD, BSN
Türkinaz Atabek As¸tı , PhD, BSN
Received March 27, 2014; accepted May 21, 2014.
About the authors: Nuray Turan, PhD, BSN, is Assistant Professor,
Department of Fundamentals of Nursing, Florence Nightingale Faculty
of Nursing, Istanbul University, Istanbul, Turkey.
Türkinaz Atabek As¸tı, PhD, BSN, is Professor, Department of Nursing,
Faculty of Health Sciences, Bezmialem Vakıf University, Istanbul, Turkey .
The authors declare no conflicts of interest.
Correspondence to : Nuray Turan, PhD, BSN, Department of Fundamentals
of Nursing, Florence Nightingale Faculty of Nursing, Istanbul University,
Abide-i Hürriyet Cad, 34381, Istanbul/Turkey ( nkaraman@istanbul.edu.tr ).
DOI: 10.1097/SGA.0000000000000202
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The Effect of Abdominal Massage on Constipation and Quality of Life
VOLUME 39 | NUMBER 1 | JANUARY/FEBRUARY 2016 49
fatigue to feelings of being bloated; experiencing loss
of appetite, nausea, and vomiting; and can exacerbate
other symptoms such as limb spasticity or bladder dys-
function ( Preece, 2002 ). Several studies have found
correlation between constipation and decreased health-
related quality of life ( Dedeli, Turan, Fadılog˘ lu, & Bor,
2007 ; Glia & Lindberg, 1997 ; O’Keefe, Talley,
Zinsmeister, & Jacobsen, 1995 ; Wald et al., 2007 ).
Constipation is also commonly known to be a prob-
lem for a range of orthopedic patients. Orthopedic
patients with reduced mobility and who have reduced
food or fluid intake, use opioid analgesic medications,
use a bedpan in the early postoperative period, and are
older than the average surgical patients are prone to
constipation ( Atabek, 1994 ; S¸ endir, Büyükyılmaz, As¸tı,
Gürpınar, & Yazgan, 2012 ).
Nurses have an important role in care and treatment
of constipation ( Kaya et al., 2013 ). However, constipa-
tion management in nursing care is problematic
because of the individual variability of bowel habits
( Kaçmaz & Kas¸ıkçı, 2007 ; Lamas et al., 2009 ).
Abdominal massage, which is an efficient way to man-
age constipation, is widely used by nurses, especially
recently ( Ayas¸ et al., 2006 ; Ernst, 1999 ; Resedence,
Brocklehurst, & O’Neil, 1993 ). Abdominal massage is
a noninvasive intervention stimulating peristalsis as a
result of administering patting, kneading, and vibra-
tion clockwise to the abdomen ( Sinclair, 2011 ; Tuna,
2011 ; Uysal, Es¸er, & Akpınar, 2012 ). Abdominal mas-
sage of the ascending, transverse, and descending
colons may be effective in regulating bowel movements
and decreasing medication used for constipation
through improvements in intestinal motility when per-
formed on a daily basis ( Harrington & Haskvitz,
2006 ; Kanbir, 1998 ; Kyle, 2011 ; Preece, 2002 ;
Richards, 1998 ).
When abdominal massage is used, less pharmacologi-
cal agents are used and quality of life improves ( Kyle,
2011 ; Sinclair, 2011 ). A review of the literature in
Turkey shows that there were few studies about nursing
interventions related to the effect of abdominal massage
on constipation. This study therefore investigates, the
effect of abdominal massage on individuals with consti-
pation in regards to GI functions, quality of life, and the
use of laxatives.
Methods
The purpose of this experimental study is to identify
the effect of abdominal massage on constipation and
the quality of life of patients attending orthopedic and
trauma clinics who have undergone surgery. The
research hypotheses are as follows:
Hypothesis 1 (H1): The use of pharmacological agents is
less in patients with a constipation nursing diagnosis
who use abdominal massage than in patients who do
not use abdominal massage.
Hypothesis 2 (H2): Gastrointestinal functions are bet-
ter in patients with a constipation nursing diagnosis
who use abdominal massage than in patients who do
not use abdominal massage.
Hypothesis 3 (H3): The quality of life is better in pa-
tients with a constipation nursing diagnosis who use
abdominal massage than in patients who do not use
abdominal massage.
Ethical Permissions
Written consent was obtained from the Department of
Orthopedics and Traumatology in hospitals where
this research was conducted. Ethical approval was
obtained from the hospital ethics committee and nec-
essary permissions were taken from the local health
authority. The participant patients in experimental
and control groups were informed on the fourth day
following their surgery about the purpose of their
research, the duration and what would be expected
from them, and how and where the data obtained
would be used via a “volunteer information leaflet.”
Written permission was obtained from the patients
who chose to participate in the research.
Setting and Sample
This randomized controlled study was conducted
between March 2010 and June 2012 in Orthopedics
and Traumatology Clinics of university training and
research hospitals that are located in Istanbul. The
target population includes patients in orthopedics and
trauma clinics of training and research hospitals who
have not defecated in the first 3 days after their sur-
gery. The sample consisted of experimental and control
groups that were randomly chosen among those
patients who met the sample criteria. To do this, the
researcher wrote down “test” or “control” on pieces
of paper that were cut similarly, folded, and placed
into a nontransparent bag. For every patient who met
the sample criteria and agreed to participate in the
study, the researcher blindly chose a piece of paper
from the bag and determined the subject’s assignment
to the “experimental group” or “control group”.
Sample criteria for the patient included: (1) aged 18
years or older; (2) had no problem that hindered cogni-
tive, emotional, or verbal communication; (3) had
undergone a surgery in orthopedics and traumatology
clinics and was hospitalized for treatment; (4) had no
history of psychiatric disease, abdominal hernia, intes-
tinal cancer, or laparotomy; (5) had been unable to
defecate for the first 3 days following the surgery; (6)
had not used any pharmacological and nonpharmaco-
logical agents involving laxatives; and (7) was able to
have a treatment for at least 7 days.
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The Effect of Abdominal Massage on Constipation and Quality of Life
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The study was conducted with 60 subjects, 30 in the
experimental group and 30 in the control group. The
power of the research was calculated using the GPower
3.1 software program. For the Gastrointestinal
Symptom Rating Scale total score, the effect was found
to be 0.52. In this framework, when 30 observations
were made in a group, the power of the test was found
as (1- β ) 0.63 within a p = .05 level of significance. For
the Gastrointestinal Symptom Rating Scale Abdominal
Pain subdimension, the effect was found as 0.65. In this
framework, when 30 observations were made in group,
the power of the test was found as (1- β ) 0.80 within a
p = .05 level of significance. For the Gastrointestinal
Symptom Rating Scale Reflux subdimension, the effect
was found as 0.94. In this framework, when 30 obser-
vations were made in group, the power of the test was
found as (1- β ) 0.97 within a p = .05 level of
significance.
Data Collection Instruments
When collecting data, the Patient Information Form,
Gastrointestinal Symptom Rating Scale (GSRS),
Constipation Severity Instrument (CSI), Bristol Stool
Scale, Patient Assessment of Constipation Quality of
Life (PAC-QOL) Scale, and EuroQol European Quality
of Life Instrument (EQ-5D) were used.
Patient Information Form
The Patient Information Form was created in accord-
ance with existing literature ( Kaya & Turan, 2011 ; N.
Kaya, 2012 ; Kaya et al., 2013 ; Turan et al., 2011 ) and
involved questions regarding the patients’ age, gender,
body mass index, marital status, educational back-
ground, income status, and his/her hospital duration.
Gastrointestinal Symptom Rating Scale
The validity and reliability of the scale created by
Revicki, Wood, Wiklund, and Crawley (1998), which
aims to evaluate the common symptoms in patients
with GI system disorders, was translated to Turkish by
Turan and As¸tı (2011) . The GSRS a 5-score Likert scale
with 15 questions and options starting with “no prob-
lem” and ends with “severe discomfort.” In the GSRS,
the patient is questioned about how he or she felt
regarding any GI problems in the last week. The GSRS
has five dimensions: “diarrhea,” “indigestion,” “con-
stipation,” “abdominal pain,” and “reflux.” A high
score indicates that the symptoms were severe ( Kaya &
Turan, 2011 ; Revicki et al., 1998 ; Turan & As¸tı, 2011 ).
Constipation Severity Instrument
Turkish validity and reliability of the scale created by
Varma et al. (2008) was established by Kaya and
Turan (2011) . The Constipation Severity Instrument
aims to determine how often the patients defecate, the
volume of defecation, and how hard it is to defecate
for the patient. The Constipation Severity Instrument
has three dimensions: “obstructive defecation,”
“colonic inertia,” and “pain.” High scores indicate
that the symptoms were severe ( Kaya & Turan, 2011 ;
Turan et al., 2011 ; Varma et al., 2008 ).
Patient Assessment of Constipation Quality of Life
Developed by Marquis et al. (2005) to determine the
effect of constipation on the quality of life, the Patient
Assessment of Constipation Quality of Life scale has
established validity and reliability by Dedeli et al.
(2007) in Turkish. The scale consists of four dimen-
sions: “anxiety,” “physical discomfort,” “psychosocial
discomfort,” and “satisfaction.” As the scores from the
scale increase, it is assumed that the quality of life is
low ( Kaya & Turan, 2011 ; Turan et al., 2011 ).
EuroQol-General Health Scale
The EuroQol-General Health Scale consists of a system
that defines five different dimensions including “move-
ment,” “self-care,” “routine work,” “pain/discomfort,”
and “anxiety/depression.” Each dimension is rated as
follows: “no problem” = 1, “some problems” = 2,
“severe problems” = 3; subjects can choose only one.
The score received is indicated as EQ-5
DSKOR ( Bolol,
Ülgen, Turan, Kaya, & Kaya, 2010 ; Brooks, 1996 ).
Because the scale can be used in other countries, a
visual analog scale, which enables patients to express
their subjective health perceptions and is shaped like a
calibrated and vertical thermometer, is included in the
scale. This part of the scale is reflected as EuroQol
VAS
( Brooks, 1996 ).
Bristol Stool Form Scale
Developed by a group of gastroenterologists at Bristol
University in England, the Bristol Stool Form Scale is
used to evaluate the shape of stool, indicate changes in
bowel habits, and collect information about potential
pathological entities. This scale is designed to classify
the bowel movements of an individual in seven differ-
ent categories. Type 1 and Type 2 indicate “constipa-
tion”; Type 3 and Type 4 indicate “normal defeca-
tion”; and Type 5, Type 6, and Type 7 indicate “diar-
rhea.” It is accepted that there is a direct correlation
between the form of stool and the period of time it
stays in the bowel ( Lewis & Heaton, 1997 ).
Procedure
Experimental Group
The patients hospitalized in Orthopedics and
Traumatology Clinics who had undergone a surgery
and met the sample criteria were identified. An experi-
mental group was randomly chosen among these
patients. Four days after surgery and in the morning,
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The Effect of Abdominal Massage on Constipation and Quality of Life
VOLUME 39 | NUMBER 1 | JANUARY/FEBRUARY 2016 51
the massage be undertaken daily with each session last-
ing 15 minutes ( McClurg et al., 2011 ; Richards, 1998 ).
Liquid petrolatum is used during the application in
order to enable the researcher to move his hands on the
skin of the patient easily and not cause any disturbance
to the patient. During massage application, the subject
was placed in a supine position with the head-of-bed
angle elevated at 30 ° –45 ° ( Emly, 2007 ; Preece, 2002 ;
Uysal et al., 2012 ).
The abdominal massage was applied in a clockwise
direction over the intestines on the abdominal wall.
Four basic strokes are typically used in abdominal
massage: stroking, effleurage, kneading, and vibration.
Stroking was applied over the dermatome of the vagus
nerve, iliac crests, and down both sides of the pelvis
toward the groin. This was repeated several times and
followed by effleurage. Effleurage strokes followed the
direction of the ascending colon, across the transverse
colon and down the descending colon. Kneading was
applied down the descending colon, up the ascending
the subjects were given the Patient Information Form,
GSRS, CSI, PAC-QOL, and EuroQol European Quality
of Life Instrument. Four days after surgery, consenting
subjects received abdominal massage for 3 days in the
morning and evening for 15 minutes and totaling
6 times. After the intervention, the subjects who defe-
cated in this period were administered the Bristol Stool
Form Scale and the stool was evaluated. Six days after
surgery, the GSRS was given to the subjects to evaluate
the effect of abdominal massage. At discharge from the
hospital, the PAC-QOL and EuroQol were adminis-
tered to the subjects ( Figure 1 ).
Abdominal Massage Application
According to “Abdominal Massage Application
Guideline” developed by Uysal et al. (2012), abdomi-
nal massage was applied to subjects who had not def-
ecated after surgery, and these subjects were given
abdominal massage 4 days after surgery for 3 days,
lasting 15 minutes twice a day. It is recommended that
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FIGURE 1. The research protocol.
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The Effect of Abdominal Massage on Constipation and Quality of Life
52 Copyright © 2016 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
colon, and down the descending colon. The massage
was concluded with vibration over the abdominal wall
( Preece, 2002 ; Uysal et al., 2012 ).
Control Group
Data from the subjects in the control group were col-
lected as in the experimental group. Four days after the
surgery, subjects were started on medication appropri-
ate for routine clinical treatment such as laxative sup-
pository and enema. Data were collected from both
groups in the same way ( Figure 1 ).
Data Analysis
When evaluating data, Statistical Package for the
Social Sciences (SPSS) for Windows 16 software was
used. Descriptive statistical methods (frequency, per-
centage, average, and standard deviation) were used.
To examine normal distribution, the Kolmogorov-
Smirnov distribution test was applied. To compare
qualitative data, Pearson Ki-Kare test was used. When
two groups were compared for quantitative data,
Whitney U test was used to compare parameters that
did not show normal distribution. For more than two
groups when quantitative data was compared, the
Kruskal-Wallis test was used for parameters that did
not show normal distribution and Mann-Whitney U
test was applied to find which group caused the differ-
ence. The results were evaluated with a 95% trust
confidence interval and alpha set at .05.alpha set at
.05.
RESULTS
Individual Characteristics of Patients
Facts regarding the individual characteristics of sub-
jects are shown in Table 1 .
Postoperative Day Four
Four days after the surgery, the experimental group
was determined to have a higher GSRS abdominal pain
dimension score scale (9.46 ± 2.64), the control group
was above (7.73 ± 2.67) score average, and both find-
ings were statistically significant ( p < .05). On the
GSRS Reflux dimension score scale, the dimension
score average (5.60 ± 3.32) of the experimental group
was higher than the control group score (3.16 ± 1.53)
( p ≤ .001) ( Table 2 ). At four days after surgery, there
was no meaningful statistical difference found between
the total score averages of the GSRS diarrhea, indiges-
tion, constipation dimensions, and nor GSRS total
score averages for the experimental and control groups
( p > .05).
Four days after the surgery, there was no statisti-
cally meaningful difference between experimental and
control groups regarding CSI, PAC-QOL, and EQ-5D
total scores and dimension score averages ( p > 05)
( Table 2 ).
Postoperative Day Six
Seventy percent of the subjects in the experimental
group ( n = 21) defecated on post-operative day four
while 46.7% of the subjects in the control group
defecated on the fifth day after surgery ( n = 14) for
the first time ( Figure 2 ). According to the Bristol
Stool Form Scale, the characteristics of stool in 40%
of the experimental group ( n = 12) was ( n = 12)
Type 2, while 43.3% of the control group ( n = 13)
was Type 1. A statistically meaningful difference was
detected between groups for this measure ( p < .05)
( Table 3 ).
Six days after the surgery, the total score average of
the GSRS in the experimental group was 42.36 ±
12.66; in the control group, the total score was deter-
mined as 37.20 ± 11.50. When GSRS dimensions were
compared, only the experimental group GSRS indiges-
tion dimension score average (8.00 ± 2.84) was lower
than the control group score average (11.00 ± 2.76)
and statistically significant ( p ≤ .001) ( Table 4 ).
When discharged from the hospital, the PAC-QOL
physical disturbance dimension score average in the
experimental group (7.20 ± 3.14) was lower than the
control group score average (9.60 ± 3.59) and statisti-
cally meaningful ( p < .01). The PAC-QOL psychoso-
cial disturbance dimension score average was lower
(13.33 ± 5.22) than the control group score average
(15.70 ± 6.15) and statistically meaningful ( p < .05)
( Table 5 ). According to the EQ-5D, when EQ-5D
SKOR
and EQ
VAS score averages were compared, no statisti-
cally significant difference was found between these
score averages ( p > .05) ( Table 5 ).
Four days after the surgery and after discharge, the
total score average of the PAC-QOL total score aver-
age was higher than at discharge and statistically sig-
nificant ( p ≤ .001). The average dimension scores for
the PAC-QOL physical discomfort and anxiety were
higher 4 days after the surgery in the experimental
group than the average scores at discharge, and this
difference was statistically significant ( p ≤ .001)
( Table 5 ).
Four days after the surgery and at discharge, the
EQ5D
SKOR score average was low compared with the
discharge score average. The increase in EQ-5D
SKOR
score was statistically significant ( p ≤ .001). Similarly,
in the control group, 4 days after the surgery, the
EQ-5D
SKOR score average was lower than the dis-
charge score average, and the difference was statisti-
cally significant ( p ≤ .001). Four days after the surgery,
the average score of the EQ
VAS in the experimental
group was determined to be lower than the discharge
score average. The increase in EQ
VAS scores was
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The Effect of Abdominal Massage on Constipation and Quality of Life
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Copyright © 2016 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
TABLE 1. Individual Characteristics of Subjects ( N = 60)
Experimental ( n  30) Control ( n  30)
χ
2 , MW, p n % n %
Age groups, y
19-34 2 6.7 3 10 χ
2 = 2.097
35-50 5 16.7 9 30 p = .553
51-66 14 46.7 12 40
≥ 67 930 620
Average age ( ± SD)
(minimum–maximum)
57.26 ± 14.05
(minimum = 19, maximum = 79)
54.00 ± 13.69
(minimum = 25, maximum = 77)
MW = 383
p = .322
Gender
Female 25 83.3 25 83.3 –
Male 5 16.7 5 16.7
BMI
Thin 1 3.3 0 0 χ
2 = 1.077
Normal 6 20 7 23.3 p = .783
Overweight 9 30 9 30
Obese 14 46.7 14 46.7
BMI average ( ± SD)
(minimum–maximum)
29.10 ± 5.73
(minimum = 18, maximum = 42)
29.23 ± 5.85
(minimum = 19, maximum = 40)
MW = 445
p = .941
Marital status
Single 4 13.3 5 16.7 χ
2 = 0.131
Married 26 86.7 25 83.3 p = .718
Level of education
Illiterate 7 23.3 3 10 χ
2 = 2.473
Literate 3 10 2 6.7 p = .781
Primary school 15 50 18 60
Secondary school 2 6.7 3 10
High school 2 6.7 3 10
College 1 3.3 1 3.3
Level of income
Able to meet the
expenses 8 26.7 9 30 χ
2 = 0.082
Unable to meet the
expenses 22 73.3 21 70 p = .774
Duration of hospital stay
7-9 d 6 20.7 7 23.3 χ
2 = 0.287
10-12 d 13 43.3 11 36.7 p = .866
≥ 13 d 11 36.7 12 40.0
Type of surgery
Major 28 93.3 27 90 χ
2 = 0.218
Minor 2 6.7 3 10 p = .640
Note . χ
2 = Chi-squared test; BMI = body mass index; MW = Mann-Whitney U test; SD = standard deviation.
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The Effect of Abdominal Massage on Constipation and Quality of Life
54 Copyright © 2016 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
statistically significant ( p ≤ .001); however, the control
group’s EQ
VAS score average was found than the dis-
charge score average on the fourth day after surgery,
and this difference was statistically significant ( p ≤
.001) ( Table 5 ).
DISCUSSION
This study was conducted to determine the effect of
abdominal massage on constipation and quality of life
for hospitalized patients who have undergone orthope-
dic or trauma surgery. Nurses play a pivotal role in
management of constipation. There are few studies
about the efficiency of abdominal massage in prevent-
ing constipation, despite the benefits as an alternative
method in constipation treatment ( Lamas et al., 2009 ;
Uysal et al., 2012 ).
This study suggests that abdominal massage, com-
pared with laxative, suppository, and enema, decreases
the symptoms of constipation in patients who are diag-
nosed with postoperative constipation and shortens
the defecation period and improves the quality of life.
To evaluate the efficiency of abdominal massage and
medicine appropriate for clinic routine (such as laxa-
tive, suppository, or enema), the GI symptoms in
experimental and control groups; seriousness of consti-
pation; and the characteristics of the quality of life and
general health should be similar. For this purpose, 4
days after the surgery, data obtained from the GSRS,
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TABLE 2. Comparison of GSRS, CSI, PAC-QOL, and EQ-5D Points of Subjects in Experimental
and Control Groups on the Fourth Day of Surgery
Experimental ( n  30) Control ( n  30)
MW p X
–  SD X
–  SD
GSRS
Abdominal pain 9.46 ± 2.64 7.73 ± 2.67 288 .015
Reflux 5.60 ± 3.32 3.16 ± 1.53 224 .001
a
Diarrhea 4.80 ± 2.17 4.16 ± 2.00 368 .183
Indigestion 12.46 ± 6.43 12.96 ± 5.63 410 .548
Constipation 10.03 ± 5.36 9.16 ± 4.99 417 .618
GSRS total 30.20 ± 9.87 34.36 ± 5.67 331 .077
CSI
Obstructive defecation 9.66 ± 8.22 9.83 ± 7.18 424 .698
Colonic inertia 9.06 ± 7.06 8.73 ± 6.56 437 .841
Pain 0.33 ± 1.49 0.33 ± 1.64 450 .999
CSI total 19.06 ± 14.79 18.90 ± 13.14 430 .761
PAC-QOL
Physical disturbance 10.70 ± 3.68 9.60 ± 4.90 360 .178
Psychosocial disturbance 16.86 ± 6.38 16.60 ± 6.95 432 .784
Anxiety 27.00 ± 10.80 24.40 ± 11.61 381 .297
Satisfaction 21.90 ± 3.29 19.96 ± 5.86 398 .431
PAC-QOL total 76.46. ± 15.53 70.56 ± 21.68 323 .060
EQ-5D
EQ-5D
SKOR 0.03 ± 0.28 0.05 ± 0.29 449 .982
EQ
VAS 61.50 ± 15.76 59.83 ± 16.73 416 .601
Note . CSI = Constipation Severity Instrument; EQ-5D = EuroQol European Quality of Life Instrument; GSRS = Gastrointestinal
Symptom Rating Scale; MW = Mann-Whitney U test; PAC-QOL = Patient Assessment of Constipation Quality of Life.
a Correlation is significant at the .01 level (two-tailed).
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CSI, PAC-QOL, and EuroQol scales applied to the
comparison groups show that the experimental and
control groups correlate.
The fact that most of the subjects in the experimen-
tal group first defecated on the fourth day of surgery
and the subjects in the control group defecated on the
fifth day after surgery indicates that the application of
abdominal massage had more effects on the patients
than routine medications such as laxatives, supposito-
ry, and enema. Abdominal massage increases peristal-
sis and thus could be helpful for increasing bowel
function and decreasing constipation ( Lamas et al.,
2009 ). Jeon and Jung (2005) conducted an experimen-
tal survey with a group of paralyzed patients, and the
period of defecation was shortened in those in the
experimental group who received abdominal massage
( n = 15) compared with a control group ( n = 15). On
the contrary, laxatives are the most common strategy
for managing constipation. However, long-term use of
some laxatives may be associated with harmful side
effects including increased constipation and fecal
impaction ( Sinclair, 2011 ).
When the characteristics of stool from the experi-
mental and control groups were compared, it was
found that most of the subjects in the experimental
group have Type 2 and the subjects in the control group
have Type 1 stools according to the Bristol Stool Form
Scale. The Bristol Stool Form Scale is an easy to use and
dependable tool when identifying stool ( Lane,
Czyzewski, Chumpitazi, & Shulman, 2011 ). According
Copyright © 2016 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
FIGURE 2. The first day of defecation for comparison groups after the surgery.
TABLE 3. The Characteristics of Stool in Test and Control Groups According to Bristol Stool Scale
Experimental ( n  30) Control ( n  30) Total ( n  60)

2 , p n % n % n %
Characteristics of stool
Type 1 4 13.3 13 43.3 17 28.3 χ
2 = 11.837
Type 2 12 40 8 26.7 20 33.4 p = .019
a
Type 3 4 13.3 7 23.3 11 18.3
Type 4 9 30 2 6.7 11 18.3
Type 5 1 3.4 0 0.0 1 1.7
a Correlation is significant at the .05 level (two-tailed).
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The Effect of Abdominal Massage on Constipation and Quality of Life
56 Copyright © 2016 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
to the scale, classification of Type 1 and Type 2 is
defined as “constipation” ( Lewis & Heaton, 1997 ).
Stool aspect was correlated to intestinal transit time and
not to the frequency of bowel movements. The form
and frequency of stool give important indications about
many important diseases ranging from GI symptoms to
infections ( Chumpitazi et al., 2010 ). In Rasmussen’s
study (2010), most patients were also detected as hav-
ing Type 1 or Type 2 stool characteristics.
When GI symptoms were compared on the sixth
day of after surgery, symptoms such as abdominal
pain, reflux, diarrhea, and constipation (but not indi-
gestion) decreased compared with the fourth day, sug-
gesting that both abdominal massage and routine
medications were effective on patients. The facts
obtained from this study are parallel to the findings of
the research by Lamas et al. (2009) . There is only a
difference between comparison groups for indigestion.
This fact from the study suggests the application of
abdominal massage is as effective as the use of phar-
macological agents and has no other side effects. In
addition, when the principle of maximizing benefit and
doing no harm is taken into consideration, it is widely
known that each pharmacological agent certainly has
a side effect.
The fact that the quality of life in the experimental
group related to constipation is lower on the physical
discomfort and psychosocial discomfort dimensions
than the control group suggests the positive effects of
abdominal massage on constipation and its symptoms.
Abdominal massage affects the abdominal muscles and
bowels; in addition, it stimulates the abdominal neural
network and changes the tone of bowels. In this way,
the pain and discomfort caused by constipation
decreases ( Kyle, 2011 ; Sinclair, 2011 ; Tuna, 2011 ). In
the study conducted by Preece (2002) with a single
group ( n = 15), the symptoms of 11 of the patients
who received abdominal massage decreased. In another
study conducted by McClurg et al. (2011) with a
group of 30 patients, the researchers suggest that
application of abdominal massage obviously heals con-
stipation and its symptoms.
The fact that there was no difference in general
health condition between groups when they were dis-
charged suggests that the application of abdominal
massage and the other clinical treatments have a posi-
tive effect on subjects’ overall health and increases
their quality of life. Abdominal massage may signifi-
cantly improve quality of life: it decreased constipation
and associated abdominal discomfort in patients
( Harrington & Haskvitz, 2006 ; Preece, 2002 ). Since,
long-term use of some laxatives may be associated
with harmful side effects including increased constipa-
tion and fecal impaction ( Sinclair, 2011 ), abdominal
massage is a valuable intervention.
The increase in the quality of life of subjects in the
experimental group from the fourth day until they were
discharged indicates that the application of abdominal
massage has an effect on constipation and its symptoms,
and this condition has a positive effect on their health.
In the research by Albers et al. (2006) on paraplegic
patients, it was also shown that the application of
abdominal massage increases the comfort level of
patients. In research by Ayas¸ et al. (2006), 24 patients
with spinal cord injury were applied abdominal massage
for 15 minutes. For these patients, the period when stool
was in the bowel, abdominal distension, and fecal incon-
tinence decreased and the frequency of defecation
increased. For the current study’s control group, there
was no significant difference between the fourth day of
surgery and discharge, which suggests that the medicine
used in for treatment of constipation does not have the
same effect abdominal massage has on quality of life.
In the evaluation of general state of health in both
groups, the increase from the fourth day until discharge
from the hospital is similar to patients who are hospi-
talized because of orthopedic problems and can be
explained by their discharge after their problems or
discomfort regarding constipation is resolved.
CONCLUSION
This study shows that abdominal massage decreases the
symptoms of constipation compared with medication
such as laxatives, suppository, and enema; shortened the
period of defecation; and increased the quality of life.
When managing constipation, nurses have an impor-
tant role. For surgical patients experiencing constipa-
tion, nurses need to be informed about the application
of abdominal massage, one of the nonpharmacological
Copyright © 2016 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
TABLE 4. Comparison of GSRS Scores
Between Groups at 6 Days After Surgery
Experimental
( n  30)
Control
( n  30)
MW p X
–  SD X
–  SD
Abdominal
pain 5.40 ± 2.74 6.16 ± 2.30 341 .103
Reflux 3.60 ± 2.09 3.13 ± 1.57 423 .665
Diarrhea 4.66 ± 1.64 4.60 ± 1.90 417 .613
Indigestion 8.00 ± 2.84 11.00 ± 2.76 190 .000
a
Constipation 8.53 ± 4.13 9.46 ± 2.96 358 .168
GSRS total 42.36 ± 12.66 37.20 ± 11.50 340 .102
Note . GSRS = Gastrointestinal Symptom Rating Scale;
MW = Mann-Whitney U test.
a Correlation is significant at the .01 level (two-tailed).
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The Effect of Abdominal Massage on Constipation and Quality of Life
VOLUME 39 | NUMBER 1 | JANUARY/FEBRUARY 2016 57
methods used effectively for nursing treatment of con-
stipation. In-service training programs should be
organized to educate nurses about this technique and
its use for treating constipation. Patients with a diag-
nosis of constipation and their families should be
encouraged to cooperate with a dietician and physical
therapist to create a nutrition and exercise program
useful for managing postoperative constipation. We
also suggest that different experimental studies includ-
ing nonpharmacological methods that can ease or
Copyright © 2016 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
TABLE 5. Comparison of PAC-QOL and EQ-5D Scores Between Comparison Groups 4 Days
After Surgery and at Discharge From the Hospital
Experimental ( n  30) Control ( n  30)
MW p X
–  SD X
–  SD
PAC-QOL
Physical disturbance (before
abdominal massage)
10.70 ± 3.68 9.60 ± 4.90 360 .178
Physical disturbance
(at discharge)
7.20 ± 3.14 9.60 ± 3.59 270 .007
a
p = .000
b p = .999
Psychosocial disturbance
(before abdominal massage)
16.86 ± 6.38 16.60 ± 6.95 432 .784
Psychosocial disturbance
(at discharge)
13.33 ± 5.22 15.70 ± 6.15 311 .038
a
p = .000
b p = .134
Anxiety (before abdominal
massage)
27.00 ± 10.80 24.40 ± 11.61 381 .297
Anxiety (at discharge) 21.56 ± 7.38 24.03 ± 9.47 399 .447
p = .002
a p = .508
Satisfaction (before abdominal
massage)
21.90 ± 3.29 19.96 ± 5.86 398 .431
Satisfaction (at discharge) 21.73 ± 2.82 20.00 ± 3.90 335 .087
p = .591 p = .968
PAC-QOL total (before
abdominal massage)
76.46 ± 15.53 70.56 ± 21.68 323 .060
PAC-QOL total (at discharge) 63.83 ± 13.99 69.33 ± 16.53 362 .190
p = .000
b p = .891
EQ-5D
EQ-5D
SKOR (before abdominal
massage)
003 ± 0.28 0.05 ± 0.29 449 .982
EQ-5D
SKOR (at discharge) 0.48 ± 0.27 0.51 ± 0.26 411 .552
p = .000
b p = .000
b
EQ
VAS (before abdominal
massage)
61.50 ± 15.76 59.83 ± 16.73 416 .601
EQ
VAS (at discharge) 82.16 ± 10.96 79.96 ± 11.53 379 .283
p = .000
b p = .000
b
Note . EQ-5D = EuroQol European Quality of Life Instrument; MW = Mann-Whitney U test; PAC-QOL = Patient Assessment of
Constipation Quality of Life.
a Correlation is significant at the .05 level (two-tailed).
b Correlation is significant at the .01 level (two-tailed).
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The Effect of Abdominal Massage on Constipation and Quality of Life
58 Copyright © 2016 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
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ACKNOWLEDGMENTS
The authors are grateful to the Scientifi c Research Project
Unit at Istanbul University and Associate Professor
Nurten Kaya, PhD, BSN, for their contributions
(Project No: 9631).
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