Age and Ageing Advance Access published January 29, 2016

Age and Ageing 2016; 0: 1–5 © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi: 10.1093/ageing/afw005 All rights reserved. For Permissions, please email: journals.permissions@oup.com

Abdominal massage for the alleviation of

symptoms of constipation in people with
Parkinson’s: a randomised controlled pilot study
DOREEN MCCLURG1, SUZANNE HAGEN2, KATHARINE JAMIESON2, LUCY DICKINSON3, LORNA PAUL4,
ANNELOUISE CUNNINGTON5

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1
Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow G4 0BA, UK
2
Glasgow Caledonian University—NMAHP RU, Glasgow, UK
3
School of Life and Health Sciences, Stirling University, Stirling, UK
4
School of Health Sciences, Glasgow University, Glasgow, UK
5
Geriatrics, Greater Glasgow and Clyde NHS, Glasgow, UK
Address correspondence to: D. McClurg. Tel: (+44) 0 141 331 8105. Email: Doreen.mcclurg@gcu.ac.uk

Abstract
Background: constipation is one of the most common non-motor features of Parkinson’s affecting up to 90% of patients. In
severe cases, it can lead to hospitalisation and is usually managed with laxatives which in themselves can lead to side effects.
Abdominal massage has been used as adjunct in the management of constipation in various populations, but not in those with
Parkinson’s.
Objective: the primary objective was to test the recruitment, retention and the appropriateness of the intervention methods
and outcome measures.
Methods: thirty-two patients with Parkinson’s were recruited from three movement disorder clinics and were randomised to
receive either 6 weeks of daily abdominal massage plus lifestyle advice on managing constipation (Intervention Group, n = 16)
or lifestyle advice (Control Group, n = 16). Data were collected prior to group allocation (Baseline), at Week 6 (following
intervention) and 4 weeks later (Week 10). Outcome tools included the Gastrointestinal Rating Scale and a bowel diary.
Results: constipation has a negative impact on quality of life. The study recruited to target, retention was high and adherence
to the study processes was good. The massage was undertaken as recommended during the 6 weeks of intervention with 50%
continuing with the massage at 10 weeks. Participants in both groups demonstrated an improvement in symptoms, although
this was not significantly different between the groups.
Conclusion: abdominal massage, as an adjunct to management of constipation, offers an acceptable and potentially beneficial
intervention to patients with Parkinson’s.

Keywords: bowel, defaecation, abdominal massage, laxative, older people

Introduction feeling of being unwell [4] and overall negatively impacts on

One in every 500 people in the UK has Parkinson’s [1] with a
prevalence of constipation between 80 and 90% often with
an emergence before the onset of motor symptoms [2];
yet high-quality research to assess the efficacy of various
treatments is scarce [2, 3]. Constipation in people with
Parkinson’s (PWP) may be due to intrinsic gastrointestinal
disease pathology, as an adverse effect of many of the drugs
commonly taken, decreased mobility and/or poor diet.
This results in difficult and painful defaecation, a general
quality of life [5].
Abdominal massage, as an adjunct in the management
of constipation, is inexpensive, non-invasive, free from
harmful side effects and may be performed by the patient
or by a carer, with several studies reporting patient benefit
[6–8]. We aim to establish the feasibility of using abdominal
massage in PWP and refine the methods for a pragmatic
randomised controlled trial (RCT) to determine the effect-
iveness of abdominal massage as an intervention for PWP
and constipation.

1
D. McClurg et al.
Methods
Thirty-two PW were recruited from three movement dis-
orders clinics in Glasgow, UK; Ethical approval number
(10/S1001/11). Participants had a confirmed diagnosis of
Parkinson’s and were over 18 years with self-reported consti-
pation. In addition, medication had to be stable for a month
pre-randomisation, and they had to be willing to complete the
outcome measures (OCMs) and undertake the massage either
themselves or have it performed by a carer. Patients were
excluded if they had a Mini Mental State Examination score of
<25 [9] or red flag symptoms such as bleeding per rectum.
Following written consent, baseline demographic, clinical
characteristics, medication list and outcome data were col-
lected for each participant by a Data Research Assistant
(DRA). Participants were then randomised remotely to the
Control or Intervention Group. Participants in both groups
were visited weekly for 6 weeks by a Clinical Research
Assistant (CRA) during which advice on good bowel manage-
ment was discussed and an Information Booklet was provided
(http://www.parkinsons.org.uk/sites/default/files/publications/
download/english/b060_bladderandbowels.pdf). The advice in-
cluded monitoring and modifying fluid and dietary intake,
being more active and using a correct defaecation position.
In addition to the advice, the Intervention Group (n = 16)
received training in the abdominal massage technique.
During the first visit, the CRA demonstrated the massage on
the participant, watched the abdominal massage training
DVD with them and answered any questions. The partici-
pants or carers, as appropriate, were taught the technique
and given the opportunity to practice and were advised
to undertake it daily. For a description of the massage tech-
nique, see Supplementary data, Appendix 1, available in
Age and Ageing online. The control group (n = 16) received
advice only but were offered one training session and a copy
of the DVD at the end of the study.
Outcome measures
The main objectives of the study were to determine the will-
ingness of PWP to be recruited to and remain in such a
study, explore participants’ satisfaction with the programme
and determine the appropriateness of programme delivery,
resources required and the outcome assessments used.
Bowel dysfunction questionnaires were completed at base-
line, on completion of the intervention (Week 6) and 4 weeks
later (Week 10). As there was no validated OCM for PWP
and constipation, we used three tools—the Gastrointestinal
Symptom Rating Scale (GSRS) [10], the Constipation Scoring
System (CSS) [11] and the Neurogenic Bowel Dysfunction
Score (NBDS) [12] with higher scores indicating more severe
constipation. A bowel diary was also completed throughout
the intervention phase; this recorded frequency of defaecation,
time spent defaecating and laxative use.
Analysis
Since the study assessed feasibility for a main trial, many of
the results were related to the feasibility, e.g. recruitment and
2
retention. In addition, the standard deviation for the GRS,
which appeared to be most relevant to this population, was
used to undertake a sample size calculation. The SD pooled
across groups for the GRS at 10 weeks was 5.9. All study data
were analysed on an intention to treat basis using SPSS v22
statistical software. Summaries for each OCM were tabulated
with means and standard deviations at baseline, 6 weeks and
10 weeks for both groups. Effect sizes for both time points
were estimated using generalised linear models, with mean dif-
ferences between groups adjusted for baseline symptom score.
Further estimates were calculated with additional adjustments
for gender, age and baseline Hoen & Yahr score
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Results
Twenty-six participants were recruited from our primary site
which had a database of 250–300 PWP which equates to
around 10%. Originally we had thought that 50% would
have bothersome constipation and 60% of these would be
willing to be recruited. It was not possible to predict recruit-
ment from the other two centres due to delays in gaining
regulatory approvals and lack of a dedicated person to recruit
participants at clinic. Overall 63 patients completed an ex-
pression of interest form, 43 of which agreed to take part, 11
of which were ineligible. Of the 32 participants recruited
(7 female, 25 male; mean age 72.3, SD 9 years), one from
each group withdrew due to ill health (Figure 1).
Overall retention to the study was 94% (30/32), with
8/15 continuing to undertake the massage routinely at 10
weeks, and five saying they would re-commence the massage
should their symptoms get worse. The two groups were
comparable at baseline in terms of age, gender and disability,
although the control group had lower scores on all outcomes
relating to constipation. The massage was performed by a
carer in 13/16 (80%), and 12/16 (75%) of participants
reported that the massage had been performed daily, with 2
(12%) performing it 5 days per week. 13/15 patients in the
control group wanted to be taught how to undertake the
massage on completion of the study.
Demographic and baseline characteristics, with observed
scores and change scores at 6 and 10 weeks, are summarised
in Table 1. The symptoms of constipation improved in both
groups; however, there was no significance between group
difference in the GRS adjusted for baseline symptom score
(−1.81 (95% CI −7.01, 3.39) P = 0.477). Similar results were
observed for the NBDS and the CSS. The bowel diary did
not demonstrate any significant differences in the frequency
of defaecation, although there was a reduction in time spent
defaecating from 10 min (SD 2.5) to 4.5 min (SD 1.4) in the
Intervention Group and from 5 min (SD 2.4) to 4 min (SD
1.5) in the Control Group. Controlling for age, gender or
severity of disability did not affect the results.
Discussion
This is the first paper reporting on the use of abdominal
massage for the relief of constipation in PWP. The primary
 Abdominal massage for the alleviation of symptoms of constipation
Figure 1. Consort diagram.
aim was to determine the feasibility and sample size required
for a future RCT.
Several important verities have been realised from the
study. The recruitment was slower than anticipated with ap-
parently less patients than forecast complaining of constipa-
tion. In a future RCT, we would need to modify our
forecasted recruitment and have a dedicated person to
recruit participants at each site as this appeared to improve
recruitment. However, once people were recruited to the
study, the retention rates were very good (94%). The results
indicated that our preferred OCM for a full trial should be
the GRS and a sample size of 169 per group would be
required for a fully powered RCT using this tool. This is
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based on the observed absolute difference of 1.8 between
groups at 10 weeks and the SD of 5.9, at 80% power (two-
sided α = 0.05).
This population was quite elderly (72.3 years SD 9), with
moderate disability, and the intervention was largely depend-
ent on the ability and willingness of a carer, 13 out of 15
cases, to undertake the massage. Participants all reported
that they felt comfortable with the massage; only one carer, a
lady in her mid-70s with arthritis in her hands, reported
that it was ‘burdensome’ to undertake; however in a future
RCT, any additional burden on the carer needs to be moni-
tored carefully. As recorded in the diaries, adherence to the
massage during the 6 weeks of intervention was good,
3
D. McClurg et al.

.................................................................................................................
although at follow-up (Week 10) only 8 (50%) of participants

baseline symptom score, gender, age and

Between group differences (adjusted for
were continuing with the massage. Five of these participants

Hoen & Yahr) Mean (95% CI) P-value

stated that they would resume if symptoms got worse;
however, continuation/discontinuation in the long-term
would need to be monitored in the larger study. The numbers

3.94 (−4.82, 12.72) 0.361

2.03 (−1.11, 5.17) 0.194
1.09 (−1.90, 4.08) 0.455
1.00 (−0.86, 2.86) 0.279
−0.31 (−2.67, 2.04) 0.784

−0.99 (−4.71, 2.73) 0.583

are too small to determine any effect but from the results it
would appear that the symptoms of constipation were reduced
by providing supported advice and those who additionally
undertook the massage, did, in most domains report greater
improvement. Due to the nature of the intervention, it was
not possible to blind participants, and although the study was
designed that both groups were provided with the same
contact time with a clinician, a placebo effect cannot be ruled

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out. Mechanistic tests such as anorectal physiology tests
Weeks Between group differences (adjusted

could be used in a larger trial to determine whether the

for baseline symptom score only)
Table 1. Demographic and baseline characteristics, with observed scores and adjusted mean differences at 6 weeks and 10 weeks

massage decreased transit time. An important finding was

2.84 (−4.55, 10.22) 0.438
0.82 (−2.51, 4.15) 0.618
0.82 (−2.02, 3.66) 0.555
0.04 (−1.81, 1.89) 0.965
−0.22 (−2.79, 2.34) 0.859

−1.81 (−7.01, 3.39) 0.477

that both groups appeared to be less constipated which
Mean (95% CI) P-value

could indicate that additional support to implement lifestyle

changes may bring benefit. Although we did not record ad-
herence to lifestyle changes, it would also be important to
record such changes in behaviour in a larger study.
The support offered to both groups was quite intense,
and the economic cost of such an intervention requires add-
itional investigation within an RCT. However, after the third
6

6
10

10

10

visit most reported that they felt quite competent about deli-
vering the massage, and it would seem feasible to reduce the
Week 10 x ,

frequency of visits to support training and implementation.

24.4, 5.2
6.4, 5.0

3.6, 2.7

It is possible that one or two training sessions would be

SD

ample with telephone support.

Week 6 x ,

22.6, 6.2
6.9, 4.9

2.8, 2.7
SD

Conclusion
Control group

2.4 (SD 0.9)

This study suggests that a trial to investigate the effects of

Baseline x,

28.9, 12.8
72 (SD 9)
13M:3F

abdominal massage is feasible within the Parkinson’s pop-

9.1, 5.5

5.4, 4.0

ulation. To undertake such a study, the recruitment strategy

SD

requires careful consideration, and the delivery of the

Week 10 x ,

support offered to both groups needs to be reviewed.

24.3, 6.6
8.9, 4.7

4.2, 3.5
SD

Key points
Week 6 x,

26.9, 12.7
9.2, 4.8

3.6, 2.7

• Constipation has a significant effect on the quality of life of

SD
Intervention group

Parkinson’s patients.
• There is limited efficacious research around management.
2.5 (SD 1.0)
Baseline x,

• Abdominal massage is non-invasive and has no side effects.

34.4, 11.0
72 (SD 8)

12.2, 4.1
12M:4F

8.1, 4.7
SD

Supplementary data
Gastrointestinal rating scale (GRS)
Constipation Score System (CSS)

Neurogenic Bowel Dysfunction

Supplementary data mentioned in the text are available to

subscribers in Age and Ageing online.
Score (NBDS)
Hoen & Yahr
Age (years)
Male/Female

Acknowledgements
We thank the staff at the three recruitment sites Dr
AnneLouise Cunnington, Dr Gilchrist and Dr Burns; PD

4
 Abdominal massage for the alleviation of symptoms of constipation
nurses Kay hood, Lesley White, Paul Lochrin and Jacqui
Kerr and the participants for taking part.
Conflicts of interest
None declared.
Funding
This study was funded by Parkinson’s UK. The authors have
no affiliations to declare
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Received 18 July 2015; accepted in revised form
17 December 2015