A Holistic Approach to Chronic Constipation
As a holistic Pelvic Health Occupational Therapist, I often remind clients: Your gut has a rhythm—and it's smarter than your alarm clock.
If you're someone who feels sluggish, bloated, or “stuck” in the mornings, you're not alone. Constipation affects up to 27% of adults, and it's more than just uncomfortable—it impacts energy, mental clarity, mood, intimacy, and how you show up in your daily life (Schmidt & Santos, 2014).
Let's explore the science of morning bowel movements, how constipation disrupts your quality of life, and how simple, evidence-based tools—like abdominal massage—can support nervous system regulation, digestion, and daily function.
Why Morning Is Prime Time for Bowel Movements
Our gut operates on a circadian rhythm—a built-in 24-hour body clock. Between 5–8 AM, colonic motility is naturally at its peak. If you eat breakfast or drink warm fluids around this time, your gastrocolic reflex kicks in, stimulating your colon to make a move. This is your body's way of creating space for incoming food.
Pair this with a relaxed nervous system (thanks to sleep), and you’ve got a perfect window for gentle, regular elimination. But when constipation persists—especially functional chronic constipation, which is not caused by a structural issue—this rhythm can get disrupted.
Constipation Isn’t Just About "Not Going"
According to the Rome IV criteria, functional constipation includes:
Straining
Hard or lumpy stools (Bristol Stool Type 1 or 2)
Incomplete evacuation
Feeling blocked
Needing to manually assist defecation
Less than 3 spontaneous bowel movements per week
These symptoms don’t just affect your gut—they bleed into your daily functioning. They interrupt meals, work, exercise routines, intimacy, and even how comfortable you feel leaving the house. This is where occupational therapy meets gut health.
Abdominal Massage: A Powerful, Hands-On Tool
In a 2022 randomized, placebo-controlled clinical trial, researchers evaluated the impact of abdominal massage plus lifestyle advice compared to a placebo ultrasound treatment for people with functional constipation (Doğan et al., 2022). The results were powerful:
Constipation severity decreased by 70% in the massage group
Defecation frequency increased by 70%
Stool consistency improved significantly
Quality of life scores improved by 56%
This wasn’t just placebo. These participants experienced meaningful improvements in their physical and emotional well-being. The abdominal massage worked by stimulating peristalsis, softening stool, reducing abdominal tension, and activating parasympathetic responses that help us “rest and digest.”
As OTs, this aligns beautifully with how we approach the gut-brain connection: through body-based regulation, gentle input, and supporting function in real life routines.
Why Toilet Posture Matters: The Squatty Potty & the Puborectalis Muscle
Toilet posture plays a major role in how easily and effectively we can eliminate. Most Western toilets position the body at a 90-degree angle at the hips, which maintains a sharp anorectal angle—the bend between the rectum and the anal canal—due to tension in a muscle called the puborectalis.
The puborectalis acts like a sling, wrapping around the rectum to help maintain continence. While this is helpful when you're walking around, it becomes a barrier when you're trying to poop. Sitting at a 90-degree angle keeps this muscle partially contracted, creating a kink in the rectum that you have to strain against to eliminate stool.
Using a footstool like a Squatty Potty elevates your knees above your hips (closer to a 35-degree angle), which helps put the puborectalis on slack. This reduces straining, improves the ease of evacuation, and protects your pelvic floor from unnecessary downward pressure. For clients with pelvic organ prolapse, hemorrhoids, or pelvic pain, this posture can be a game-changer.
Pelvic Floor & Breath: Partners in Healthy Elimination
When it comes to constipation, the pelvic floor muscles often play a silent but significant role. These muscles form a supportive hammock at the base of the pelvis and help regulate bowel, bladder, and sexual function. Ideally, during a bowel movement, the pelvic floor should relax and lengthen to allow stool to pass with ease. However, in many people—especially those with a history of chronic straining, trauma, anxiety, depression, or poor toileting posture—these muscles may contract instead of relax, a condition known as pelvic floor dyssynergia. This dysfunctional coordination leads to incomplete evacuation, straining, and worsening constipation. One of the most effective ways to retrain this is through breath awareness. Deep, diaphragmatic breathing helps down-regulate the nervous system and creates natural pelvic floor movement: on the inhale, the diaphragm and pelvic floor both descend; on the exhale, they recoil and return to rest. By practicing this rhythm consistently—especially during toileting—you encourage the pelvic floor to release fully and support natural elimination without force.
Hydration: The Unsung Hero of Gut Motility
Your colon’s job is to reabsorb water from waste before it's eliminated. When you’re dehydrated, the colon pulls more water than usual, which dries out the stool, making it harder, lumpier, and slower to pass. This leads to straining, abdominal bloating, and discomfort—especially for clients with pelvic floor overactivity or trauma-related holding patterns.
Proper hydration softens stool, promotes smoother transit, and supports the peristaltic wave-like contractions that move waste along. A general target is half your body weight in ounces of water daily, adjusting for activity and climate. Starting the day with warm water or herbal tea can activate the gastrocolic reflex and nudge your gut into movement.
Understanding Fiber: Soluble vs. Insoluble
Fiber is a non-digestible carbohydrate that promotes healthy bowel movements, but not all fiber is created equal. Understanding the difference between soluble and insoluble fiber can help tailor recommendations:
Soluble fiber dissolves in water and forms a gel-like substance in the gut. It helps soften stool and slows digestion, making it ideal for people with constipation, sensitive guts, or those prone to diarrhea or IBS.
Examples: oats, chia seeds, flaxseed, psyllium husk, apples, carrots, sweet potatoes.Insoluble fiber adds bulk and helps "sweep" the colon by increasing stool size and speeding transit time. However, in people with pelvic floor dysfunction or slow motility, too much insoluble fiber without adequate water can worsen bloating and pain.
Examples: whole wheat, bran, raw greens, nuts, seeds, and the skins of fruits and vegetables.
In practice, I often recommend starting with soluble fiber, especially when working with clients who have chronic constipation, bloating, or rectal pain. Once motility improves and hydration is adequate, you can gradually add in insoluble fiber as tolerated.
Lifestyle & Functional Tips (because as an OT, that is my specialty!!)
1. Abdominal Massage (2–3x/week)
Use clockwise strokes along the path of the colon with light-to-medium pressure. Focus on the descending, transverse, and ascending sections of the colon. This can be self-applied or I frequently teach it to family members too!
Pro tip: Pair it with deep diaphragmatic breathing to enhance vagus nerve activation.
2. Consistent Morning Routine
Create a predictable wake-eat-move rhythm:
Hydrate with warm lemon water or herbal tea
Eat breakfast to trigger the gastrocolic reflex
Sit on the toilet with feet elevated (use a squatty potty or footstool)
Pair your breath to your pelvic floor
Allow 10–15 minutes of undistracted time
When needing to push (not strain) complete an open-mouth-exhale to decrease pressure down on the pelvic floor
3. Move Your Body
Moderate movement (even a short walk or gentle yoga) supports gut motility. Bonus: movement also helps decrease pelvic floor tension, a common contributor to obstructive defecation.
4. Nervous System Regulation
Chronic constipation is often worsened by autonomic dysregulation—think chronic stress, trauma, or shutdown states. Try:
Somatic body scanning
Pelvic drop & release breathing
Gentle vagus nerve work (humming, gargling, or cold face immersion)
5. Nourish With Soluble Fiber & Fluids
Focus on softening stool with oats, chia, flax, cooked fruits, and hydration. This reduces the need to strain, which also supports pelvic floor health.
Final Thoughts
As a Pelvic Health Occupational Therapist, I recognize constipation not just as a GI issue—but a whole-person challenge affecting physical, emotional, and daily function. Incorporating tools like abdominal massage and lifestyle strategies into your care plan is simple, research-backed, and empowering.
Start small. Be consistent. Trust your body’s rhythm—and when needed, help it along with your hands and breath.
Reference
Doğan, İ. G., Gürşen, C., Akbayrak, T., Balaban, Y. H., Vahabov, C., Üzelpasacı, E., & Özgül, S. (2022). Abdominal massage in functional chronic constipation: A randomized placebo-controlled trial. Physical Therapy & Rehabilitation Journal, 102(7), 1–10. https://doi.org/10.1093/ptj/pzac058
