Electroacupuncture Combined with Chinese Medicine Ironing Therapy for Functional Constipation

Summary

Electroacupuncture combined with Chinese medicine ironing therapy can effectively improve patients' constipation symptoms and their quality of life. Here, we present a protocol to describe the treatment process of electroacupuncture combined with Chinese medicine ironing therapy for functional constipation.

Abstract

Functional constipation (FC) is a dysfunctional gastrointestinal disease with the main clinical manifestations of complex bowel movements, incomplete bowel movements, reduced frequency of bowel movements, and dry and hard stools, which seriously affect patients' quality of life and psychology. Electroacupuncture improves constipation by performing acupuncture on specific points in the body to accelerate intestinal peristalsis. Chinese medicine ironing therapy (CMIT) can warm up the meridians, accelerate local blood circulation, promote gastrointestinal dynamics, and accelerate gastric emptying. This study elaborated on the method and steps of electroacupuncture combined with CMIT for functional constipation, including patient selection, material preparation, operation procedure, postoperative care, and precautions. The therapeutic effect of the method was also evaluated. The results of the study showed that after 4 weeks of treatment, compared with Western medicine alone, electroacupuncture combined with CMIT can improve the frequency of FC patients' voluntary bowel movements, constipation, and quality of life. There were no obvious adverse reactions.

Introduction

Functional constipation (FC)¹is a chronic digestive disease that seriously affects patients' quality of life, mainly manifested by complex bowel movements, low frequency of bowel movements, hard or lumpy stools, and strained bowel movements². FC significantly impacts the life and psychology of patients³ and is an essential factor in inducing severe diseases such as abdominal pain⁴, sleep disorders⁵, colon cancer⁶, and cardiovascular diseases⁷. Studies show that about 10%-15% of the global population is affected by FC⁸. FC is chronic and poorly treated, with nearly 50% of patients not fully satisfied with conventional treatment⁹, as a substantial public health problem that imposes a significant financial burden on patients^10,11. Therapeutic measures for FC include general treatment (increased fluid intake, dietary fiber supplementation^12,13, and exercise¹⁴) and pharmacological treatment (volumetric laxatives¹⁵, osmotic laxatives¹⁶, stimulant laxatives¹⁷, 5-hydroxytryptamine 4 receptor agonist¹⁸, and probiotics^19,20,21). However, most drugs have adverse effects such as drug dependence, diarrhea, bloating, flatulence, intestinal cramps, and esophageal obstruction. Therefore, the search for an effective treatment for FC with few side effects has attracted the attention of clinicians.

Acupuncture is a form of treatment that originated in ancient China and is often used to treat various digestive disorders. Based on acupuncture, electroacupuncture applies mild and continuous electrical stimulation to strengthen needle feeling and improve clinical efficacy. Electroacupuncture improved weekly complete spontaneous bowel movements (CSBMs)²² and raised the Bristol Stool Form Scale (BSFS) score²³. The mechanism may be related to promoting intestinal motility²⁴ and increasing 5-hydroxytryptamine and tryptophan hydroxylase in the colon²⁵. In general, electroacupuncture can effectively improve the clinical symptoms of FC patients²⁶ and enhance the quality of life and treatment satisfaction of patients^23,27.

Chinese medicine ironing therapy (CMIT) means heating a Chinese herbal medicine bag (called a reyan bag) and moving it back or rotating it at specific points. CMIT reduces nociceptive nerve excitability, improves blood circulation, promotes intestinal motility, and improves constipation through the physical effects of medicine and temperature²⁸. Foeniculum vulgare Mill, commonly called fennel, has been used in CMIT mainly to bring into play its ability to promote Qi, warm the meridians, regulate the elevation of the spleen and stomach to eliminate stagnation, and pass stools²⁹.

This study combined acupuncture with CMIT and acted on the gastrointestinal acupuncture points of FC patients to improve their constipation symptoms, providing a new and effective method for treating FC patients.

Protocol

The Institutional Review Committee of Zigong First People's Hospital reviewed and approved the clinical program. The treatment process, treatment principles, and adverse reactions were explained to the patients in detail in this study, and the patients were carried out after signing the informed consent form.

1. Patient assessment

1. Inclusion criteria:
   1. Include patients who meet the Rome IV diagnostic criteria for functional constipation³⁰.
   2. Include patients aged between 21 and 69 years old, regardless of gender.
   3. Before treatment (>14 days), ensure no medication was used to treat constipation (except for emergencies).
   4. Include patients who are not involved in other ongoing clinical studies.
   5. Include patients with no organic bowel disease confirmed by e-colonoscopy.
   6. Include patients who volunteered to join the study and signed informed consent.
2. Exclusion criteria
   1. Exclude patients with other endocrine, metabolic, neurological, or postoperative diseases or medication-induced constipation.
   2. Exclude patients with irritable bowel syndrome, inflammatory bowel disease, or other structural bowel disease.
   3. Exclude patients with mental illness, cognitive dysfunction, or aphasia.
   4. Exclude patients who received acupuncture and CMIT within the past 4 weeks.
   5. Exclude patients with cardiac pacemakers.
3. Intervention measures
   1. Divide patients into four groups using a random comparison table method.
      NOTE: The groups involved in this study are the control group, experimental group A (electroacupuncture group), experimental group B (CMIT group), and group C (electroacupuncture + CMIT group). The control group was given standardized treatment guided by Management of Functional Constipation in Children and Adults³¹ and the Consensus Opinion on Integrated Chinese and Western Medicine Treatment of Functional Constipation (2017)³².
   2. Ensure that all patients increased their water (2000 mL of water daily) and dietary fiber intake (30 g), developed good bowel habits (once a day), and performed regular exercises(three times a week for 30 min), such as bicycling and walking.
   3. Give the patients in the control group lactulose oral solution thrice daily, 15 mL each time, before meals for 4 weeks³³.
   4. Treat the patients in Experimental Group A with electroacupuncture for 30 min five times in 1 week for 4 weeks based on the control group.
   5. Treat the patients in Experimental Group B with CMIT for 20 min daily for 4 weeks based on the control group.
   6. Treat the patients in Experimental Group C with electroacupuncture (30 min five times a week) and CMIT (20 min daily ) for 4 weeks based on the control group.
   7. After 4 weeks, assess the treatment effects of the two groups by weekly complete spontaneous bowel movements (CSBMs)³⁴, the Cleveland constipation scoring system (CSS)³⁵, and the patient assessment of constipation quality of life scale (PAC-QOL)³⁶.

2. Material preparation

1. Prepare the electroacupuncture equipment (Figure 1).
2. Prepare the disposable sterile cloth bag, fennel seeds, and disposable sterile gloves required for Chinese medicine ironing therapy (Figure 2).

3. Treatment process

1. Electroacupuncture treatment
   1. Body posture: Let the patient lie on the treatment bed, relax, and be comfortable.
   2. Locate and select acupoints:
      1. Locate Quchi (LI11) at the middle of the line between the lateral end of the elbow stripe and the humerus's external epicondyle³⁷(Figure 3).
      2. Locate Shangjuxu (ST37) point at the anterolateral side of the lower leg, 6 cun (12 cm³⁸) below the Dubi, with one cross finger (middle finger) from the front edge of the tibia³⁷ (Figure 4).
         ​NOTE: Select points according to the study of meridian and acupoint³⁹. Cun is a special measurement unit in TCM. It is the distance between the distal interphalangeal joint and the proximal interphalangeal joint of the index finger. Based on the literature, 1 cun is approximately 2.0-2.2 cm^38,40.
   3. Use 75% alcohol to disinfect the operator's hands and the affected skin to prevent infection.
      NOTE: Electroacupuncture should avoid skin damage, nodules, and scarring; keep warm, and stay emotionally relaxed.
   4. Insert the needle vertically into bilateral Quchi (LI11) and Shangjuxu (ST37) points of the patient 1 cun (2 cm³⁸) through lifting, inserting, twisting, turning, and other manipulations so the patient feels sore or numb.
   5. Set the waveform of the electroacupuncture instrument to continuous wave⁴¹, frequency to 1.5 Hz, and current intensity to 0.5 mA. (Figure 5).
   6. Perform acupuncture for 30 min at a time five times a week for 4 weeks.
2. Chinese medicine ironing therapy
   1. Examine the patient's abdominal ironing area for skin integrity without breakage.
   2. Put fennel (300 g) into a disposable sterile cloth bag (20 cm x 30 cm), heat it in a microwave oven for 3 min (temperature 50 to 70 °C), and tie the reyan bag tightly.
   3. Wear sterile gloves, expose the patient's abdominal skin, and apply the reyan bag to Zhongwan (CV12), Shenque (CV8), Tianshu (ST25), and Guanyuan (CV4) (Figure 6).
      1. Press the reyan bag clockwise with the patient's navel as the center.
      2. In the beginning, use a lighter pressure and move it slightly faster. As the temperature of the reyan bag decreases, use a heavier pressure, slower, lasting about 5 min.
      3. When the patient's skin feels warm without burning pain, apply the reyan bag to Zhongwan (CV12) to continue the hot compress (Figure 7). Apply the reyan bag at each acupoint for 5 min. Perform this for 20 min each once daily for 4 weeks of treatment.

4. Statistical analysis

1. Express the continuous variables as mean ± standard deviation. Use one-way analysis of variance for multi-group comparison and the LSD-t test for pairwise comparison between groups.
2. Express the categorical variable as cases (percentage) and use the Chi-square test to compare groups. Test level α = 0.05 (two-tailed).

Results

This study screened and included 60 patients with FC from August 2022 to December 2022 who attended the Zigong First People's Hospital. The random number table method was used to divide the patients into the control group, experimental group A (electroacupuncture group), experimental group B (CMIT group), and group C (electroacupuncture + CMIT group), with 15 cases each. There were no statistical differences in gender, age, and disease duration among the four groups (see Table 1).

Discussion

The primary pathophysiological basis of FC is the decrease of intestinal motivity caused by sympathetic nerve tension and parasympathetic nerve excitability⁴². The pathogenesis of FC may be related to intestinal neurotransmitter dysfunction, oxidative stress index balance disruption, aquaporin expression abnormalities, abnormal changes in serum ions, intestinal flora disorders, colorectal sensory and motor function abnormalities, and psychological effects⁴³. Western medicin...

Materials

Name	Company	Catalog Number	Comments
75% alcohol disinfectant	Shandong Anjie Gaoke Disinfection Technology Co. LTD	Q/371402AAJ008
Absorbent Cotton Swab	Zigong Jisheng Medical Equipment Co. LTD	Chuan machine registration 20162140199
Acupuncture needle (0.25 mm x 50 mm)	Suzhou Medical Supplies Factory Co. LTD	Su machine registration 20162270970
Disposable sterile cloth bag	Zigong first People's Hospital material department	N/A
Disposable sterile gloves	Kefu Medical Technology Co. LTD	Xiang machine registration 20202140410
Fennel	Huazhou Huayi Chinese Medicine slices Co.LTD	Yue 20160614
G91-A type electronic needle therapy instrument and supporting electrode wire	Suzhou Medical Supplies Factory Co. LTD	Su machine registration 20172270675
Lactulose oral solution	Abbott Trading (Shanghai) Co. LTD	H11022318