The Role of Rehabilitation in the Treatment of Constipation in Oncological Patients

Background: Chemotherapy, as well as opioid and antiemetic drugs, can contribute to constipation in oncological patients. This systematic review aims to analyse the potential of specific rehabilitation strategies and alternative strategies for improving constipation symptoms, with the goal of incorporating these strategies into a dedicated protocol for managing cancer-related constipation. This could potentially reduce the dosages of or eliminate the need for constipation medications. Methods: A systematic search was conducted on PubMed, Scopus and Web of Science. The review included studies analysing constipation complaints in cancer patients treated with rehabilitation, acupuncture and osteopathy. Results: The review included 16 studies in line with PRISMA and PICOS criteria. Most studies showed that physical exercise, abdominal massage, TENS, acupuncture and education on the correct defecation position positively impacted the management of constipation and quality of life in oncological patients. A physiotherapy program involving massages as well as aerobic and resistance training improved constipation in oncological women, regardless of age, sex and frailty. A combination of abdominal massage, abdominal muscle stretching and education on proper defecation position alleviated the severity of constipation and related depression. However, the outcomes regarding TENS were yet inconsistent. Another technique, becoming increasingly common for constipation, and demonstrating positive results, involved stimulating trigger points through acupressure and acupuncture. Conversely, osteopathic and superficial manipulations more frequently required constipation medications than did the other alternative approaches. However, no existing studies have proposed a specific protocol to manage cancer-related constipation. Conclusions: The results of the studies confirm the positive influences of rehabilitation, osteopathy and acupuncture on constipation and pain in oncological patients. Nevertheless, further studies are required to establish the best type, timing and duration of treatment, as well as how the stage and location of the cancer and the cause of constipation (drug-induced or functional) impact the results.


Introduction
Constipation is one of the most common side effects of cancer therapy [1], negatively impacting daily living, well-being and quality of life. Furthermore, it is challenging to treat effectively. Specific drugs for constipation are not without adverse effects, necessitating additional treatment to manage this symptom.
According to the Rome Foundation criteria, functional and opioid-induced constipation is characterized by at least two of the following symptoms during 25% or more of defecations: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage, reliance on manual manoeuvres to promote defecation,

Protocol and Registration
This systematic review analysed the efficacy of various rehabilitation strategies and alternative approaches, such as osteopathy and acupuncture, for treating constipation in patients with cancer.
The review was registered in PROSPERO (CRD42023432357), and was conducted in accordance with the guidelines set out by the preferred reporting items for systematic reviews and metanalyses (PRISMA) [12], along with the population, intervention, comparison, outcome and study design (PICOS) criteria [13].

Eligibility Criteria
This systematic review adhered to the PRISMA and PICOS guidelines. It included studies that examined adults with cancer who were suffering from constipation (participants), managing the condition conservatively with rehabilitation programs and alternative approaches, either independently or in conjunction with anti-constipation drugs. Various forms of treatment were included, such as physical exercise, massage therapy, transcutaneous electrical nerve stimulation (TENS) and acupuncture (intervention). The comparators involved subjects who did not receive a specific rehabilitation treatment for constipation or who were given a conservative therapy other than drugs for constipation. The documented outcomes indicated differences in the quality of life and severity of constipation following treatments. The design of the included studies consisted of controlled studies with separate control groups.
In addition, any type of tumour, regardless of location, or stage (severity) was included. Only original articles written in English were included. Studies whose samples comprised solely subjects not affected by cancer, those not experiencing constipation and those not treated with a rehabilitation program or other alternative approaches were excluded. Grey literature and unpublished data were not considered. Case studies and articles without a separate control group were also excluded.

Information Sources and Search Strategy
The acquisition of relevant articles was accomplished using the search strategies described in Figure 1. The studies were grouped and organized according to the PICOS strategy [13], as illustrated in Table 1. The articles search was conducted in the databases PubMed, Scopus and Web of Science, up to June 2023. No restriction on publication dates (year of publication) were applied. The comprehensive search strategy was based on the Mesh keywords: "Rehabilitation" OR "Exercise" OR "Physical Therapy Modalities" AND "Constipation" OR "Opioid-Induced Constipation" AND "Neoplasm" OR "Carcinoma".
In addition, any type of tumour, regardless of location, or stage (severity) included.
Only original articles written in English were included. Studies whose sam comprised solely subjects not affected by cancer, those not experiencing constipation those not treated with a rehabilitation program or other alternative approaches w excluded. Grey literature and unpublished data were not considered. Case studies articles without a separate control group were also excluded.

Information Sources and Search Strategy
The acquisition of relevant articles was accomplished using the search strate described in Figure 1. The studies were grouped and organized according to the PI strategy [13], as illustrated in Table 1. The articles search was conducted in the datab PubMed, Scopus and Web of Science, up to June 2023. No restriction on publication d (year of publication) were applied. The comprehensive search strategy was based on Mesh keywords: "Rehabilitation" OR "Exercise" OR "Physical Therapy Modalities" A "Constipation" OR "Opioid-Induced Constipation" AND "Neoplasm" OR "Carcinom Other key searches and variations included: "Physical activity" OR "Training" "Physiotherapy" OR "Acupuncture" OR "Osteopathy" OR "Herbal medicine" A "Stypsis" AND "Cancer" OR "Tumour" OR "Tumor" OR "Malignancy".
The grading of recommendations, assessment, development and evalua (GRADE) guidelines for systematic reviews were used to assess the quality of the re An evaluation of the quality of the outcomes was conducted to signify the degree [14 of certainty (high, moderate, low, or very low) in the total effect estimates ( Table 2).  The grading of recommendations, assessment, development and evaluation (GRADE) guidelines for systematic reviews were used to assess the quality of the results An evaluation of the quality of the outcomes was conducted to signify the degree [14][15][16][17][18]. of certainty (high, moderate, low, or very low) in the total effect estimates ( Table 2).   it tended to improve nausea and appetite loss, but not constipation.

Study Selection
The selection of articles, along with the assessment of titles and abstracts, was conducted by two independent authors who were blinded to each other's work, and who strictly adhered to the inclusion and exclusion criteria. After this preliminary screening, the remaining articles were critically evaluated to determine their eligibility for inclusion in the review. Additionally, the reference lists of the included studies were scanned for any further suitable studies that the initial search might have missed. In instances of disagreement between researchers regarding the selection of studies, a third author was consulted for resolution.

Assessment of Risk of Bias
The methodological quality of clinical trials was evaluated by two independent authors using the Cochrane risk of bias tool [35] and the risk of bias in non-randomised studies of interventions (ROBINS-I), in accordance with the Cochrane methodology [36,37]. The risk of bias in the selected clinical trials was categorized as high, moderate, low, very low, or unclear. The categories for risk of bias included random sequence generation, allocation concealment, and blinding of participants and personnel, as well as outcome assessment, incomplete outcome data and other sources of bias. Clinical trials selected were considered to have a moderate risk of bias if more than two of the criteria were rated as having a high or unclear risk ( Table 2).

Data Synthesis
The systematic review identified a common theme among the studies: the roles of rehabilitation, osteopathy and other alternative approaches in managing constipation in cancer patients. A meta-analysis was not conducted due to the heterogeneous data about the type and timing of treatment, cause of constipation, location and stage of cancer and clinical condition of the patients.

Study Selection
The search yielded 12,434 articles in PubMed, 368 in Scopus, and 19,658 in Web of Science, with the search focusing on clinical trials in English, and involving adult subjects (19+ years). After excluding duplicates, ineligible studies and those outside of the topic, 1313 articles were screened by title and abstract. Consequently, a total of 41 articles were assessed for eligibility following a full text review. Out of these, seven studies were excluded because they did not report any therapeutical plan, ten did not involve oncological patients, and eight did not pertain to constipation. Therefore, 16 publications were selected for inclusion. Table 1 presents the 16 selected studies. Of these studies, 15 were clinical trials comparing rehabilitation, osteopathy intervention, or acupuncture with (a) the constipation medication alone [19,29,33], (b) no other treatment (control or sham group) [21,24,[26][27][28][30][31][32]34], (c) different therapeutic programs (traditional versus pre-and postoperative rehabilitation program [22], different abdominal massage/manipulation [23,24] and acupuncture versus electroacupuncture [26]). Only one article reported a longitudinal observational study that compared different types of patients by age and sex, while also describing cancer localization [25]. Given its highly focused theme, the large sample size (6.757 patients), and the presence of control groups, it was included (

Rehabilitation, Osteopathy and Acupuncture
Although physical exercise, abdominal massage, TENS and acupuncture have been suggested for managing constipation in oncological patients, no existing studies have proposed a specific protocol for managing cancer-related constipation. A physiotherapy pro-gram consisting of massages and aerobic and resistance training was shown to improve constipation symptoms in women, regardless of age, sex and frailty status [25]. The combination of abdominal massage, abdominal muscle stretching and education on proper defecation posture helped to alleviate constipation severity and related depression [20]. Notably, the abdominal massage appeared to reduce constipation symptoms and improve quality of life [33] by enhancing stool consistency, reducing straining during defecation, mitigating the feeling of incomplete emptying after defecation, and increasing the number of defecations. Furthermore, the number of defecations increased by 13% [33]. Another study reported an improvement in quality of life related to digestive disorders due to visceral osteopathic manipulations. In contrast, patients who underwent superficial manipulation tended to require constipation medication more frequently [23].
The outcomes regarding TENS were not consistent. According to He et al. [21], 100% of patients experienced varying degrees of improvement through TENS, and 91% of patients with poor appetite noted better appetite. Moreover, TENS, especially when applied to specific sites, namely at bilateral 'Tianshu' (ST25 located at the middle of the abdomen, 2 cm lateral to the umbilicus) and 'Zusanli' (ST36 located on the tibialis anterior muscle four finger breadths below the kneecap and one finger breadth lateral from the anterior crest of the tibia) acupoints, seemed to decrease defecation difficulty and feelings of incomplete defecation, and improve defecation satisfaction [19]. Conversely, another study indicated that TENS on both ankle joints was not effective for constipation [27], but that it was effective for pain, with TENS placed on the back at the dermatomal level corresponding to the painful part or internal organs. Therefore, a technique could be suggested to reduce the dosage of opioid drugs, with a positive impact on opioid-induced constipation.
Another increasingly common technique for constipation involves the activation/ stimulation of trigger points through acupressure and acupuncture. Acupressure appears to reduce pain, maintain patient relief, prevent nausea and constipation, and promote gastrointestinal motility and digestive juice secretion in oncological patients [29,30,34]. Similarly, electroacupuncture seems to have positive effects in facilitating rapid recovery of patients with constipation, both physically and psychologically [26,31,32]. As proposed for the application of TENS [19], the most commonly used acupuncture point was 'Tianshu' (ST25) [29][30][31][32]34]. Lastly, auricular acupressure also had a positive effect on constipation symptoms and improved quality of life [28].
There was a significant variability in the anti-constipation techniques proposed, particularly regarding the methods and timing of treatment. In terms of massage, recommendations included 1 min sessions performed 10 times per day on the abdomen [20], sessions performed twice daily for 4 weeks, 30 min after breakfast and dinner [33], or 5 days of sessions of 15-20 min each [24]. Visceral osteopathy was suggested after each cycle of chemotherapy (three sessions of 15 min each). For specific rehabilitation strategies, the progression from 3 h of mobilization and walking on the first day after surgery to 8 h on the fourth postoperative day was proposed [22]. Additionally, a 21-day program of physiotherapy featuring massages and aerobic and resistance training consisting of 2-3 h of therapeutic units per working day [25] was suggested for its anti-constipation effect. Moreover, the current literature proposes TENS on both ankle joints (10 Hz) for 5 days [27], or once daily for 14 consecutive days, 30 min time each, at acupuncture points (Tianshu' and 'Zusanli') [19] 1.5 cm away from the midline of the T8 to T12 vertebrae (belonging to acupoints of B3, BL18, BL19, BL20 and BL21 in the traditional Chinese meridian theory system), RN12, and the pain point on the abdomen for 30 min [21]. However, electro-acupuncture stimulation was suggested at the Tiensu point, once per day for 7 consecutive days [26], or at the bilateral Tianshu, Fujie, Shangjuxu points for 30 min across a 24-session treatment over 8 weeks [31], or at the bilateral Tianshu, Fujie, Shangjuxu points, for 30 min each session across a 24-session treatment over 8 weeks, three sessions per week [32]. Acupuncture was suggested at Huángqí, Ròucōngróng, Báizhú, Hòupò, Zhĭshí, Bīngláng, Láifúzĭ, Huŏmárén and Qīngpí, once per day for a total of 14 days [29]. Lastly, auricular acupressure was suggested at seven acupoints (intestine, rectum, San Jiao, spleen, lung, sympathetic and subcortex) once per week for 6 consecutive weeks [28], or at the Zhongwan, Guanyuan and Tianshu acupoints for 8 min once per day for 3 consecutive days [30], or for 4 weeks [34].

Constipation Assessment
The assessment of constipation in oncological patients encompassed the evaluation of symptoms and quality of life. Symptoms were investigated through measures such as the number of spontaneous bowel movements per week [31,32], the Bristol stool form score [28,[30][31][32][33], the constipation assessment scale (CAS) [20,24,28]. The Cleveland Clinic constipation score [26] was also used. Quality of life was examined through the Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL) [19,26,28,29,[31][32][33][34], the European Organisation for Research and Treatment of Cancer EORTC Quality of life Core Questionnaire (EORTC QLQ-C) [22,23,25,27], the health-related quality of life score (HRQoL) [22] and the McGill Quality of Life Questionnaire (MQOL) [24]. Moreover, mood was studied with generic scales such as the Hospital Anxiety and Depression Scale (HADS) Questionnaires [25], the self-rating anxiety scale, and the self-rating depression scale [26].
Despite the wide variety of strategies proposed, the current literature indicates that all treatments reduced the severity of constipation, according to the CAS through abdominal massage and auricular acupressure [20,24,28], and controlled symptoms, as reported by the defecation diary for abdominal massage and acupressure [33,34], the four-point Likert scale for electro-acupuncture [30], the Rome III Diagnostic Criteria, the Cleveland Clinic constipation score [26] and the constipation symptom score [29] for acupuncture. Moreover, electro-acupuncture increased the number of spontaneous bowel movements per week [31,32], softened the stool according to the Bristol stool form scale [30][31][32], and improved the stool-form score through auricular acupressure [28]. It also eased and reduced the feeling of incomplete bowel evacuation according to the bowel function index through TENS [19]. Furthermore, most studies showed an improvement in the quality of life according to the EORTC QLQ-C-30 after massages and aerobic and resistance training [22,25], HRQoL after mobilization and walking [22], MQOL-HK after massage [24], and PAC-QOL through TENS, auricular acupressure, acupuncture and electro-acupuncture, abdominal massage and acupressure [19,28,29,[31][32][33][34]. Only a few articles documented a lack of difference in quality of life, specifically, according to EORTC QLQ-C-30 after visceral osteopathic manipulation [23], EORTC QLQ-C-15 after TENS on both ankle joints [27], and PAC-QOL after electro-acupuncture stimulation at the Tiensu point [26]. Likewise, the reduction of constipation seemed to correlate with reductions in anxiety and depressive mood, as recorded with HADS after massages and aerobic and resistance training [25], and the self-rating anxiety scale [26] and self-rating depression scale after electro-acupuncture stimulation at the Tiensu point [26]. Lastly, patients also reported satisfaction linked to the therapy according to the Patients' Global Assessment of Treatment Effectiveness [31], Patients' Expectations Through Electro-Acupuncture [31,32], and a satisfaction survey after mobilization and walking [22].

Discussion
Oncological patients have a high risk of developing constipation due to the side effects of chemotherapy, antiemetics and, particularly, opioid drugs. This side effect adds to the other, more well-known symptoms, such as fatigue, nausea, muscle pain and neuropathic pain.
Constipation impacts the quality of life, leading to psychological and social problems related to physical discomfort, mental distress and reminders of mortality, often resulting in avoidance and social isolation [38]. Therefore, this side effect generally necessitates additional pharmacologic and rehabilitative interventions, as well as alternative strategies, like acupuncture and osteopathy. Additionally, it is crucial to implement a shared protocol that encourages a healthy lifestyle, dietary strategies such as fibre supplements, and increased water intake.
According to our research, physical exercise, abdominal massage, TENS and acupuncture have been proven to be safe and effective in managing constipation in oncological patients. However, the areas of rehabilitation, osteopathy and acupuncture have not received sufficient attention. In fact, no existing studies have proposed a specific protocol for managing cancer-related constipation.
In developing a program that combines osteopathy, acupuncture and rehabilitation, the objectives should be aimed at reducing constipation symptoms, improving quality of life, and decreasing the reliance on constipation medications laden with side effects. To achieve these outcomes, all the suggested treatments can be considered and integrated with each other, always taking into account the patient's clinical condition and fatigue levels, especially when it comes to aerobic and resistance training. With regard to this latter point, the efficacies of massages, aerobic exercises, and resistance training have been observed regardless of age, sex and frailty status [25]. However, the effectiveness of the training is significantly influenced by the patient's overall well-being. Indeed, cancer-related fatigue could reduce adherence to the program and affect its outcomes.
Furthermore, while exercise is generally beneficial, current evidence suggests that bed rest does not pose a risk factor for constipation [39]. As such, its effects on constipation in cancer patients remain unclear and relatively under-studied in the literature.
According to the research, while all the described techniques have demonstrated positive effects on constipation, the outcomes from TENS are inconsistent, yielding positive results in some studies [19,21] and insignificant results in others [19,21,27]. This discrepancy could be due to the variability in application points, as this technique is operator-dependent.
Undoubtedly, another significant factor for oncological patients and caregivers is the provision of effective counselling. Indeed, proper advice on self-care management, which may include abdominal massage, abdominal muscle stretching and education on the appropriate defecation position, should be clearly explained and implemented on a daily basis [20].
Unfortunately, the cause of constipation is not always identified in the studies [22,24,25,27,30], nor is the stage of tumour identified in all the included research. However, most of the studies focus on the opioid-induced constipation [19,29,[31][32][33][34] and analgesic-induced constipation [21]. A few studies tackle chemotherapy-related constipation [23,28]; one discusses antiemetic-induced constipation [20], and another, post-operative constipation [26]. This heterogeneity, combined with the lack of information about the tumour stage, makes it challenging to stratify the results in order to better comprehend how treatment outcomes may depend on the various causes of constipation.
High heterogeneity was also found for the sites of tumours. Indeed, the treatment of constipation in patients affected by breast cancer was the most studied, likely due to its high prevalence in younger women. In cases of breast cancer, methods such as massage, abdominal muscle stretching and education on proper defecation position were found to reduce antiemetic-induced constipation [20]. Additionally, visceral osteopathy [25] and auricular acupressure [28] were proposed for treating chemotherapy-related constipation, while aerobic and resistance training were recommended for unspecified types of constipation [25]. TENS of relevant acupuncture points [19], massage [33], electro-acupuncture [31,32] and acupressure [34] significantly alleviated symptoms of constipation in cases of opioid-induced constipation. Meanwhile, TENS of ankle was proposed for unspecified constipation [27].
Pancreatic, lung and genito-urinary involvement also seemed to benefits from TENS [19] and electro-acupuncture [31,32] in cases of opioid-induced constipation. Specifically, for pancreatic and lung cancer patients, massage [33] for opioid-induced constipation, TENS for analgesic-induced constipation [21] and TENS of the ankle [27], massage [24] and aerobic and resistance training [25] for unspecified constipation, were proposed.
For the genito-urinary system, postoperative rehabilitation that included mobilization and walking was proposed for unspecified constipation [22], while acupressure was recommended for opioid-induced constipation [34].
The methods of the assessments used to quantify treatment effects varied among studies, even for those exploring similar domains. These assessments aimed to show an im-provement in symptoms related to constipation and overall quality of life. In particular, the effects of treatment on the severity of symptoms were very much studied. For instance, abdominal massage was evaluated using CAS [20,24], and electro-acupuncture was studied using the four-point Likert scale [30]. Acupuncture was analysed based on the Rome III diagnostic criteria, the Cleveland Clinic constipation score [26], and the constipation symptom score [29]. The effectiveness of electro-acupuncture was also gauged by the number of spontaneous bowel movements per week [31,32] and the Bristol stool form scale [30][31][32]. Auricular acupressure was evaluated with the stool-form score and CAS [28]. Finally, TENS was assessed using the bowel function index [19].
Anxiety and depression related to constipation were also explored. The HADS was used to assess the effects of massage and aerobic and resistance training [25]. The self rating anxiety scale [26] and the self-rating depression scale were used for electro-acupuncture stimulation [26].
Finally, patient satisfaction and expectations were evaluated for electro-acupuncture using the Patient's Global Assessment of Treatment Effectiveness [31,32], and a satisfaction survey was used for mobilization and walking training [22].
While the current literature generally agrees on the beneficial effects and potential clinical applications of the strategies proposed for treating cancer-related constipation, it is necessary to contextualize the results with patient-specific clinical characteristics. These characteristics, such as fatigue, nausea, and level of autonomy, were less analysed in previous studies, but they could affect the adherence to treatment. Furthermore, the diverse causes of constipation may significantly influence therapy responses. As such, the outcomes should be stratified according to the specific drug causing the constipation or the determination that the constipation is related to low levels of motility.
Lastly, additional research is not only required to develop a common alternative therapeutic program, but also to establish a universally accepted clinical assessment methodology to achieve more homogenous results.
Another aspect warranting investigation is the role of cellular oxidative stress in cancer development [40]. Oxidative stress is associated with various diseases [41][42][43], including cancer [40]. On the contrary, regular, moderate and structured exercise, along with visceral therapy, appear to alleviate the negative effects caused by free radicals. These activities offer numerous health benefits, including reduced risk of all-cause mortality, skeletal muscle sarcopenia, chronic disease, constipation and premature death in elderly people [44][45][46]. Therefore, physiotherapy should be proposed as supportive therapy in patients with cancer [44]. Indeed, exercise and diet generally help to manage constipation [46]. However, physical activity can also induce oxidative stress, inflammation and muscle fatigue [44]. Consequently, micronutrients and natural compounds, commonly known as nutraceuticals, should be included in the regimen to prevent or mitigate exerciseinduced oxidative stress and associated symptoms. For instance, supplementation with Lcarnitine enhances body strength, sports endurance and exercise capacity, while delaying the onset of fatigue, a typical symptom related to cancer that hinders adherence to rehabilitation and physical exercise [47]. Therefore, specific strategies for alleviating constipation should be integrated into a broader project aimed at improving overall health in patients with cancer.

Limitations
Unfortunately, the limited number of articles and lack of homogeneous, quantitative data prevented the execution of a meta-analysis. Therefore, not all questions have been adequately addressed.
First, can rehabilitation, osteopathy and acupuncture improve constipation in patients affected by cancer? According to the available literature, they can. However, the determinations of the type of therapy and the ideal timing for each approach cannot be definitively and clearly explained.
Secondly, does the response to treatment depend on the pathophysiology of constipation (i.e., drug-induced constipation versus functional constipation)? Several articles included in this systematic review investigated the role of rehabilitation strategies, osteopathy and acupuncture in opioid-induced constipation. However, others did not specify the type of constipation under study.
Lastly, is there a variation in treatment response based on the location or stage (severity) of the primary tumour? More evidence is needed to answer this question.
Indeed, despite the total number of patients affected by cancer across all included studies, a population amounting to 6757, the heterogeneity of data regarding the proposed therapeutic strategies, in terms of types and timing, causes of constipation (primary or secondary to different drugs or related to low levels of motility), severity of symptoms associated with constipation, and the varied location and stages of tumours, complicates quantitative comparisons of the results. Specifically, the cause of constipation, which is not always investigated, can significantly influence treatment responses (i.e., constipation related to low levels of motility may respond better to physical activity).
While it doesn't appear that the tumour site represents a significant variable, the proposed strategies should still consider this aspect to avoid biases related to symptoms associated with a specific tumour (i.e., gastrointestinal tumours could cause bowel dysfunctions, a confounding factor for the results).
Another significant challenge of the study is the high variability of clinical assessments. Although the investigated domains are similar (severity of symptoms associated with constipation, quality of life, anxiety, and depression mood in cancer patients), the lack of homogeneity in the scales used precludes a quantitative analysis that could better clarify the impact of the proposed strategies.
Furthermore, the lack of descriptions of patients' clinical characteristics and the tumour stages are significant limitations of the study, as associated symptoms (such as nausea, fatigue, level of autonomy, presence of metastasis, etc.) could negatively influence the outcomes.

Conclusions
Constipation is a common problem among cancer patients, and a challenging one to prevent.
The use of abdominal massage/manipulation and personal care management could be recommended, provided that specific training is given to the patient or caregiver in order to manage constipation. Physical exercises could be included if the clinical conditions of cancer patients permit. Acupressure, acupuncture and TENS could be incorporated when administered by an expert operator.
Regrettably, the current literature does not enable a determination of which strategies work best, how much to recommend, what type of constipation responds better to the proposed treatments (functional or secondary), or how much the severity of symptoms, the tumour's localization, and the stage influence the outcomes.
Although rehabilitation and alternative strategies may provide benefits for constipation in oncological patients, further studies are needed to overcome the limitations of the current literature. These studies should aim to establish the optimal protocols, their timing and lasting effects, and determine the influences of cancer stage, location and the cause of constipation on the results.