This brief review of irritable bowel syndrome (IBS) management suggests that there are possible biomechanical, behavioural, as well as dietary strategies, that can commonly be helpful. IBS has been defined as abdominal pain, experienced more than once a month, associated with bloating and altered bowel habits. (Moore & Kennedy 2000) By definition, IBS is functional, that is, there is no infection or pathology associated with it. (Abrams et al 2002) It is more common in women than men, and is often associated with other chronic pelvic pain (CPP) symptoms. When IBS is chronic, core muscles (e.g. pelvic muscles) may become hyperalgesic with multiple trigger points. (Fall et al 2010)

Stress

Tak & Rosmalan (2010) discuss the role of the body's "stress responsive systems" in what has been termed functional somatic syndromes, such as IBS, as involving a "multifactorial interplay between psychological, biological, and social factors." Therefore, there is a need to move beyond a search for single causes of most conditions such as IBS, since, like many other complex and difficult-to-treat conditions, they commonly have multi-factorial aetiological features - possibly interacting with predispositions and altered stress-coping functions.

Beales (2004) has described a scenario that highlights multiple contributory factors to functional somatic syndromes: "Too much sustained, [stress] leads to the loss of internal balance, and results in reduced performance and a mind-body system in overdrive. In this state, the metabolism is struggling and cholesterol, blood sugar and blood pressure are often raised, resulting in ill health ... for instance, sufferers from irritable bowel syndrome may also commonly experience back pain, fatigue and loss of libido. Negative emotions, such as frustration and despair, can trigger exhaustion, which in turn can trigger breathing pattern disorders, as a consequence of the perceived threat to survival eliciting fight, flight or freeze reactions."

Massage offers a highly suitable stress modulating approach. (Moraska et al 2008)

Overbreathing & Colon Constriction

Ford et al (1995) have reported on the high incidence of increased colonic tone and dysfunction in hyperventilating individuals. Hypocapnic hyperventilation (low CO2 blood levels) produces an increase in colonic tone, and phasic contractility in the transverse and sigmoid regions. These findings are consistent with either inhibition of sympathetic innervation to the colon, or the direct effects of over-breathing on colonic smooth muscle contractility, or both.(Chaitow 2007)

Prather et al (2009) expand on these relationships, in review of the anatomy, evaluation, and treatment of musculoskeletal pelvic floor muscle (PFM) pain in women.

They note that persistent muscle contraction of the pelvic floor, related to noxious visceral stimulation, such as that deriving from endometriosis or irritable bowel syndrome, can lead to splinting and pain, with reduction of normal PFM function. Specifically, they report that viscerosomatic reflex activity may be responsible for increased resting tone of the pelvic floor with reduced ability to fully relax the muscle group as a whole. As a result, they suggest, adaptation occurs via recruitment of global muscles in the region (e.g. psoas and iliacus) leading to symptoms such as posterior pelvic and low back pain. Prather et al also point out that: "Proper breathing techniques, while performing exercises and activities, are essential for pelvic floor relaxation ... pelvic floor contraction during exhalation allows for synergy between the pelvic and respiratory diaphragms."

This is also a key to assisting IBS dysfunction.

Diet

In a comprehensive review of the subject Heizer et al (2009) suggest that dietary changes are worth attempting in an effort to relieve irritable bowel syndrome (IBS) symptoms. It is recommended that dietary restrictions should be introduced one at a time, beginning with any food or food group that appears to cause symptoms based on a careful patient history or review of a patient's food diary. The most effective duration for dietary trials has not been well studied, however 2 to 3 weeks is commonly suggested. A modified exclusion diet, followed by stepwise reintroduction of foods is likely to be more effective in finding problem foods, but it is more time-consuming.

General dietary recommendations for patients with IBS, based on clinical experience and anecdotal reports (Heizer et al 2009) include:

• avoiding large meals;
• reducing lactose (eliminate milk, ice cream, and yogurt);
• reducing fat to no more than 40 to 50 g/day;
• reducing sorbitol, mannitol, xylitol (mainly "sugarless" gum, read labels);
• reducing fructose in all forms, including high-fructose corn syrup (read labels), honey, and high-fructose fruits (e.g. dates, oranges, cherries, apples and pears);
• reducing gas-producing foods (e.g. beans, peas, broccoli, cabbage, and bran);
• eliminating all wheat and wheat-containing products;
• a diet low in fermentable oligo-, di-, and monosaccharides and polyols;
• and eliminate banana, corn, potato, eggs, and coffee.

Peppermint Oil

Research suggests that use of peppermint oil, particularly in cases of relatively mild IBS is likely to be of benefit in symptomatic treatment of IBS. (Capello et al 2007)

Tumeric (Curcumin)

While some studies have shown potential benefit for use of turmeric (curcumin) in treatment of IBS (a member of the ginger family of plants), no placebo-controlled studies have been conducted. (Heizer et al 2009)

Probiotics

The conclusion of a review of the evidence for use of probiotics in both IBS and inflammatory bowel disease are cautiously positive.(Iannitti & Palmieri 2010) Two meta-analyses (Nifkar et al 2008, McFarland & Dublin 2008)) and two comprehensive narrative reviews (Wilhelm et al 2008, Spiller 2008) on the use of probiotics in the treatment of IBS. All concluded that probiotics may be useful but there are many variables affecting the results such as the type, dose, and formulation of bacteria comprising the probiotic preparation, the outcome measured, as well as size and characteristics of the IBS population studied.

IBS is common. Patients with this condition may respond well to stress reduction, better breathing patterns, biomechanical normalisation (pelvic structures) and trigger point deactivation. For more on the topic of pelvic pain in general, enhanced breathing strategies, and manual therapy, go to: www.leonchaitow.com, or blog: http://chaitowschat-leon.blogspot.com.

Resources

1. Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Am J Obstet Gyn 2002;187:116-26.
2. Beales D. "I've got this pain..." Human Givens Journal 2004;11(4):16-8.
3. Cappello G, Spezzaferro M, Grossi L et al. Peppermint oil (Mintoil) in the treatment of irritable bowel syndrome: A prospective double blind placebo-controlled randomized trial. Dig Liver Dis 2007;39:530-6.
4. Chaitow L. Chronic pelvic pain: Pelvic floor problems, sacroiliac dysfunction and the trigger point connections. JBMT 2007;11(4):327-39.
5. Fall M, Baranowski A, Elneil S et al. EAU guidelines on chronic pelvic pain. Euro Urology 2010;57(1):35-48.
6. Ford M, Camilleri M, Hanson R. Hyperventilation, central autonomic control, and colonic tone in humans. Gut 1995;37(4):499-504.
7. Heizer W, Southern S, McGovern S. The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review. Jour of the Am Diet Assoc 2009;109(7):1204-14.
8. Iannitti T, Palmieri B. Therapeutical use of probiotic formulations in clinical practice. Clin Nut (In Press Corrected Proof; available online).
9. Prather H, Dugan S, Fitzgerald C et al. Review of Anatomy, Evaluation, and Treatment of Musculoskeletal Pelvic Floor Pain in Women. PM&R 2009;1(4):346-58.
10. Moore J, Kennedy S. Causes of chronic pelvic pain. Baillie're's Clin Obstet Gynaecol 2000;14(3)389-402.
11. Moraska A, Pollini R, Boulanger K et al. Physiological adjustments to stress measures following massage therapy: A review of the literature. Evid Based Complem Alt Med 2008. doi: 10.1093/ecam/nen029.
12. Riot, Goudet, Moreaux. Levator ani syndrome, functional intestinal disorders and articular abnormalities of the pelvis, the place of osteopathic treatment. Presse Medicale 2005;33(13):852-7.
13. Tak L, Rosmalen J. Dysfunction of stress responsive systems as a risk factor for functional somatic syndromes. Jour of Psychosomatic Res 2010;68(5):461-8.