Constipation, which includes rectal evacuation disorders, slow transit constipation, and IBS to name a few is one of the most common gastrointestinal disorders worldwide (1,2). The complexity of constipation and its impact on a person’s health and quality of life is often misunderstood and common treatment strategies such as diet, exercise, hydration, and stress management can be an oversimplification of what is necessary to effectively manage the disorder (1). From a rehabilitation lens, it is pivotal to prioritize the function of the nervous system when developing a treatment strategy for constipation, considering the nervous system is the central control mechanism of all functions and processes in the human body.

Dry needling, specifically, dry needling with electrical stimulation, is one of the most impactful tools we have in rehabilitation to improve the health and function of the nervous system. Dry needling has evolved from a procedure that utilizes a monofilament needle to deliver mechanical input into “trigger points” in muscle tissue to include the use of a monofilament needle for the delivery of electrical stimulation, which is often described as percutaneous electrical stimulation or neuromodulation. The use of electrical stimulation with dry needling can have a profound effect on improving the healing capacity of tissues and the overall functional recovery of the human body primarily due to the impact it has on the nervous system. Therefore, we must have a sound understanding of the neuroanatomy and physiology of any region of the body and the associated dysfunction to effectively develop and implement a treatment plan.

The gastrointestinal system is considered the most complicated system in our body in terms of the number of structures involved in function and regulation and the enormity of neurons that innervate the gastrointestinal tract, and it is yet to be fully understood (3). The enteric nervous system, which is commonly considered the third branch of the autonomic nervous system, is at the center of regulatory control of the gastrointestinal (GI) tract and precisely coordinates the function of GI neurons, glial cells, macrophages, interstitial cells, and enteroendocrine cells which drives gut motility and secretions (3). It is interesting to note that the sophistication of the enteric nervous system allows the GI tract to be able to function independently of any neural inputs from the central nervous system (3,4). However, normal physiologic functioning of the GI tract is influenced by bidirectional neuronal connections between the enteric and central nervous systems which is known as the “brain-gut-axis” (3).

Embedded in the walls of the GI tract are the myenteric and submucosal plexuses of the enteric nervous system, which innervate the GI tract and uniquely provide both excitatory and inhibitory motor neurons (4). The myenteric plexus lies between the longitudinal and circular muscle layers of the GI tract and coordinates smooth muscle movements or gut propulsions (“motility”) while the submucosal plexus is found within the connective tissues of the submucosa and regulates secretion, absorption, and blood flow in the GI tract (3,4).

The sympathetic and parasympathetic nervous systems influence the function of the GI tract primarily through integrated neuronal activity with the enteric nervous system versus direct innervation to the wall of the gut, with the exception of blood vessels and sphincters which receive direct sympathetic innervation (3).

Sympathetic inputs to the GI tract regulate secretion and motility and parasympathetic inputs to the distal colon are important for colonic motility and defecation (3).

The function of the somatic nervous system innervating key structures involved with defecation should be equally prioritized to comprehensively evaluate factors contributing to constipation. This may include spinal nerves from the thoracolumbar and sacral vertebral segments, the iliohypogastric and ilioinguinal nerves, the pudendal nerve, the levator ani nerve, and even the phrenic nerve if we are considering the innervation and function of the diaphragm and the importance of breathing mechanics and control of intraabdominal pressure during voiding.

From a treatment perspective, the most impactful window of access to modulate activity in the gastrointestinal tract using dry needling with electrical stimulation is targeting spinal nerves and associated peripheral nerves and their target organs (primarily muscle tissue) that converge with our autonomic nervous system innervating the gut (5). Additionally, electrical stimulation applied directly over the involved target tissue in the GI tract can help facilitate changes in GI function because the enteric nervous system is embedded in the wall of the GI lumen. The rationale for the use of neuromodulation to impact the function of the gastrointestinal tract is that our system is a bioelectric system, therefore, the application of electrical stimulation can have a profound impact on neuromuscular function which is interrelated with neurovascular, neuroimmune function, neuroinflammatory function, neuroendocrine function and so on (5, 6, 7). There is even evidence that electrical stimulation can impact the concentration of bacterial populations in the GI tract which can influence the overall function of the gut. Lastly, ongoing dysfunction in gastrointestinal tissue or any visceral tissue can create neuromotor dysfunction in associated somatic tissues that may include pain, tissue sensitization, abnormal muscle tone, and abnormal motor control strategies which can be effectively and efficiently treated with dry needling and electrical stimulation.

In conclusion, dry needling with electrical stimulation is one the best tools used in conjunction with traditional rehabilitation strategies to create meaningful, sustainable improvements in the function of the human body. If you want to learn more about the implementation of dry needling into your practice as it relates to constipation or gastrointestinal disorders, join us on an upcoming course!

Dry Needling and Pelvic Health: Foundational Concepts and Techniques 

• Galloway NJ - March 21 - 23 2025
  
• Atlanta GA - June 21-22, 2025
• Dayton OH - September 13-14, 2025

Dry Needling and Pelvic Health 2: Advanced Concepts and Neuromodulation

• Seattle WA - May 17-18, 2025

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations

References

1. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018;97(20):e10631. doi:10.1097/MD.0000000000010631
2. Black CJ, Ford AC. Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. Med J Aust. 2018;209(2):86-91. doi:10.5694/mja18.00241
3. Sharkey KA, Mawe GM. The enteric nervous system. Physiol Rev. 2023;103(2):1487-1564. doi:10.1152/physrev.00018.2022
4. Spencer NJ, Hu H. Enteric nervous system: sensory transduction, neural circuits and gastrointestinal motility. Nat Rev Gastroenterol Hepatol. 2020;17(6):338-351. doi:10.1038/s41575-020-0271-2
5. Larauche M, Wang Y, Wang PM, et al. The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs. Neurogastroenterol Motil. 2020;32(11):e13925. doi:10.1111/nmo.13925
6. Zhang C, Chen T, Fan M, et al. Electroacupuncture improves gastrointestinal motility through a central-cholinergic pathway-mediated GDNF releasing from intestinal glial cells to protect intestinal neurons in Parkinson's disease rats. Neurotherapeutics. 2024;21(4):e00369.
7. Jacobson A, Yang D, Vella M, Chiu IM. The intestinal neuro-immune axis: crosstalk between neurons, immune cells, and microbes. Mucosal Immunol. 2021;14(3):555-565. doi:10.1038/s41385-020-00368-1

AUTHOR BIO:
Tina Anderson, MS PT

Tina Anderson (she/her) received her Master of Science in Physical Therapy in 2001 from Grand Valley State University located in Grand Rapids, Michigan. She graduated from Michigan State University in 1996 with a Bachelor of Science in Kinesiology. Tina specializes in treating patients with complex neuromusculoskeletal dysfunction including dysfunctions of the pelvic floor. Tina earned her dry-needling certification in 2006 and has been teaching dry-needling nationwide since 2008. Tina was integral in pioneering dry-needling techniques for the pelvic floor and surrounding neuroanatomical structures. She currently owns and operates a private physical therapy practice in Aspen, Colorado. Tina and her family, including their new “fur” child Beatrice, love living and playing in the Rocky Mountains!

For over 25 years my practice has had a focus on children suffering from bloating, gas, abdominal pain, fecal incontinence and constipation. Functional Gastrointestinal Disorders (FGID) are disorders of the brain -gut interaction causing motility disturbance, visceral hypersensitivity, altered immune function, gut microbiota and CNS processing. (Hyams et al 2016). Did you know that children who experience chronic constipation that do not get treated have a 50% chance of having issues for life?

The entire GI system is as amazing as it is and complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. In her book GUT, Giulia Enders talks about Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great (Chase et el 2018). Last year an 18-year-old patient of mine had to decline a scholarship to an Ivy League University because she needed to live at home due to her bowel management problem.

Unfortunately, FGID conditions can lead to suicide and death. Over 15 years ago my children’s pediatrician told me about an 11-year-old boy who hung himself because he had encopresis. In 2016 a 16-year-old girl suffered a cardiac arrest and died because of constipation.

The problems with children are different than for adults and need to be addressed with a unique approach.

How do physical therapists treat pediatric FGID?

• Have a solid foundation in the gastrointestinal system
• Coordinate muscle functions from top to bottom!
• Identify common childhood patterns
• Learn treatment techniques and strategies to address the issues specifically

Study and understand gastrointestinal anatomy, physiology, function and examination techniques. The entire GI system is as amazing as it is complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great.

What do the Pelvic Floor Muscles (PFM) have to do with it?

Encopresis leads to a weak internal/external anal sphincter and pelvic floor muscles and constipation leads to pelvic floor muscles that can’t relax. Confused? When the Rectal Anal Inhibitory Reflex or RAIR fails from bypass diarrhea the sphincter muscles relax, and feces leaks out. This constant leakage leads to weak sphincter and pelvic floor muscles. When it happens on a regular basis most children don’t feel it, however their peers smell it and life changes.

My course, Pediatric Functional Gastrointestinal Disorders, teaches how to coordinate the muscle function based on the tasks required.

How did this start?

One painful bowel movement can lead to withholding for the next due to fear of the pain happening again. The muscles of the pelvic floor then tighten to hold the poop in. This actually does not make the muscle strong but instead makes it confused. The muscle then is controlled by the consistency of poop being too hard and painful to let out or too loose and not able to hold in.

Managing functional GI disorders is a process. It takes the bowel a long time to re-train and it requires patience and skill to know how to do it. Many therapists and patients themselves get frustrated and compliance fails. This is mostly due to lack of knowing how to titrate medications and give the bowel what it needs (other than proper nutrition that is!) It's like retraining a person to walk after a stroke, the brain needs to relearn normal bowel sensations.

Most families don’t realize how severe constipation can be. It is an insidious problem that gets ignored until it is too late.

Typically, what I hear from parents is their child was diagnosed with constipation and was advised to take a daily laxative. So, which one is the best one? How do they all work? Once leakage occurs again the laxative is discontinued as we think the bowel must be empty and this medication is causing the leaks which is counterproductive. Now the frustrating cycle of backing up or being constipated begins again. The constipation returns, the laxative is restarted, the loose stool leaks out and the laxative is stopped and that is the REVOLVING DOOR or what I refer to as children riding the “Constipation Carousel”. The bowel is an amazingly beautiful, smart but also sensitive organ that does not like this back and forth and therefore will not learn how to be normal. In the meantime, they experience distended abdomens and dysmorphia ending up in eating disorder clinics. I had an 11-year-old girl taking Amitriptyline for abdominal pain all because of a pressure problem in the gut not knowing how to work the pelvic floor with the diaphragm and her core.

No two children are the same and no two colons are the same. Laxatives need to be titrated to the specific needs of your child’s colon and motility of their colon not their age or body weight.

The success in getting children to have regular bowel movements of normal consistency without any fecal leaks is based not only teaching how to titrate laxatives but also how to sense urge, become aware of the pelvic floor muscles and learn how NOT to strain to defecate, retrain the core and diaphragm with the ribcage and integrate developmental strategies for function. Teaching Interoception- what my body feels like when I have an urge- is an important part of this course. This is especially important for those children born with anorectal malformations or congenital problems such as imperforate anus or Hirschsprung’s Disease.

In this class we use visceral techniques, manual therapy techniques, sensory techniques and neuromuscular reeducation and coordination to retrain the entire system.

Come and explore the amazing gut with me and learn how to improve the health and well-being of your patients, in Pediatric Functional Gastrointestinal Disorders!

1. Hyams, JS, et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology volume 150, 2016;1456-1468.
2. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and rome IV. Gastroenterology 2016;150:1262-1279
3. Robin SG, Keller C, Zwiener R, et al. Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria. J Pediatr 2018; 195:134.
4. Koppen IJN, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, Di Lorenzo C, Benninga MA, Tabbers MM. Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr. 2018 Jul;198:121-130.e6. doi: 10.1016/j.jpeds.2018.02.029. Epub 2018 Apr 12.
5. Zar-Kessler C, Kuo B, Cole E, Benedix A, Belkind-Gerson, J. Benefit of pelvic floor physical therapy in pediatric patients with dyssynergic defecation constipation. 2019 Dig Dis https://doi.org/10.1159/000500121/
6. Chase J, Bower W, Susan Gibb S. et al. Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children’s Continence Society. J Ped Urol (2018) 14, 98e107