Acupoint Application Combined with Acupoint Massage for Treating Constipation in a Patient with Chronic Obstructive Pulmonary Disease

Here we demonstrate acupoint application combined with acupoint massage for treating constipation in a patient with chronic obstructive pulmonary disease (COPD).

Chronic obstructive pulmonary disease (COPD) is a common and frequent disease in elderly patients, with a tendency for progressive exacerbation. Constipation that reduces the quality of life and triggers the risk of diseases is a common concomitant symptom in patients with COPD. Currently, western medical treatment does not achieve the desired results for patients. A high recurrence rate accompanies it, whereas traditional Chinese medicine (TCM) has a long history and rich experience in treating chronic diseases. Both acupoint application and acupoint massage are characteristic therapies of TCM, with minor side effects, high safety, simple operation, and outstanding advantages. They are effective in treating constipation for patients with COPD and are considered an ideal alternative therapy for patients with chronic constipation. The purpose of this article is to introduce the method of acupoint application combined with acupoint massage for the treatment of constipation in patients with COPD, including the selection of points, items, treatment time, and operation procedure.

Chronic respiratory diseases are the third leading cause of death in the world, and COPD is the leading cause of death from chronic respiratory diseases, placing a heavy burden on both individuals and society¹. China has the largest number of patients with COPD in the world: about 99 million, with a prevalence rate of 8.6%². Constipation is a common complication in COPD patients and is associated with high levels of polypharmacy³. There is evidence that more than 39% of COPD patients experience constipation, and constipation was positively correlated with the severity of dyspnea, timing of exacerbations, and complications of COPD⁴. It is highly suspected that constipation is associated with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). AECOPD accelerates the disease progression in COPD patients and is the leading cause of death in COPD patients⁵. Therefore, it is time to pay attention to the treatment of constipation in patients with COPD.

The majority of patients manage their constipation by themselves, mainly using dietary adjustments and laxatives. Studies have shown that osmotic laxatives are often the drug of choice for people with constipation⁶. However, the use of medications is sometimes not effective in improving constipation symptoms. It is associated with adverse reactions or poor tolerance. Up to 50% of patients with constipation are not fully satisfied with the results of their current treatments^7,8. Therefore, it is necessary to find alternative therapies with good efficacy and high security. In the treatment of chronic constipation, acupoint stimulation therapy is beginning to show some advantages⁹. With the guidance of the concept of holism, syndrome differentiation, and treatment, as well as meridian acupoint theory in TCM, both acupoint application and acupoint massage are used to treat diseases by stimulating specific acupuncture points on the body surface^10,11. Acupoint application can make the drug directly absorbed by the local skin. It achieves the effect of channeling meridians and harmonizing qi and blood by stimulating the acupuncture points, thereby improving the symptoms of constipation¹⁰. Acupoint massage stimulates the sacral nerve, regulating defecation by increasing the interstitial cell number and controlling rhythmic contractions or peristalsis through activating bowel movements¹². Numerous pharmacological and clinical studies have confirmed the clear efficacy of herbs such as Rheum officinale Baill in the treatment of constipation^13,14. A demonstration of acupoint application combined with acupoint massage for treating constipation in a patient with chronic obstructive pulmonary disease is presented in this article.

The clinical study protocol was reviewed and approved by the Clinical Research Approval Committee of the Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine (Record No. KY2022014).

1. Preparations before operation

1. Items preparation:
   1. Prepare items such as Rheum officinale Baill, normal saline, Iodine volts swab, medical tape, medical gauze, medical bending plate, hand disinfectant, and medical rubber glove (Table of Materials).
   2. Use an ultra-micro pulverizer to make 100 g of Rheum officinale Baill into powder in advance and seal it in a plastic bag for later use.
   3. Before treatment, please take 15 g of Rheum officinale Baill powder and use 15 mL of normal saline to make a paste of medicinal powder. Place the paste on a curved plate.
2. Patient preparation:
   1. Advise the patient to empty the bladder in advance. Let the patient lie on his/her back, bend the knees, relax, and fully expose the abdomen.
3. Operator preparation:
   1. Close doors and windows, pay attention to protect the patient's privacy and prevent the patient from catching a cold.
   2. Select Shenque point (RN8) and bilateral Tianshu points (ST25) on the patient's abdomen¹⁰, and evaluate the local skin of the patient's points to ensure that the skin around the selected points is free of lesions or damage while keeping the local points clean and dry (Figure 1 and Figure 2).
      ​NOTE: The Shenque acupoint (RN8) is in the umbilical region, central umbilical cord. The Tianshu point (ST25) is located in the abdomen, 2 finger-cun each around the navel (finger-cun means the proportional unit of the thumb, 2 finger-cun equals ~6.67 cm)¹⁵.

2. Operating steps

1. Disinfect the hands, then press the Shenque point (RN8) and bilateral Tianshu points (ST25) of the patient's abdomen with the thumb fingertip. Press each acupuncture point 50 times, and make sure to rotate the thumb in a clockwise direction while pressing (Figure 3).
   1. Change the intensity of pressing the acupoints from weak to strong. Press at ~1 s/time and at a frequency of 30-60 times/min until the patient feels a slight feeling of soreness. If the patient does not tolerate it during the procedure, stop the operation immediately.
2. Rub the palms of both hands until they are warm, then massage the patient's abdomen 50 times clockwise with the palms (Figure 4). Gradually massage from the navel to the outer circle and then from the outer circle back to the navel.
   NOTE: The scope of the circle is centered on the navel, with 2 finger-cun as the radius, i.e., the radius is equal to ~6.67 cm.
   1. Ensure the massage action is gentle and the force is not too heavy. Ensure the frequency of massage is from slow to fast, stable and moderate, about 30-50 times/min. It is best to feel slightly warm in the abdomen. If the patient develops intolerance during the procedure, stop the operation immediately.
3. Wear medical rubber gloves and use iodine volts swabs to disinfect the patient's local acupoints. Take about 3/4 of the prepared medicine from the medical bent plate, roughly divide it into 3 equal parts, make them into a shape similar to a ring (diameter x thickness of about 3 cm x 0.5 cm) and apply them to medical gauze separately.
4. Fix the medical gauze containing the medicine to the Shenque point (RN8) and Tianshu points (ST25) in the patient's abdomen with medical tape, respectively. Remove it 6 h later.
5. Require the patient to wear clean and breathable clothes after the acupoint application operation.
   1. Ask the patient to avoid strenuous exercise to prevent the drug from falling off and flowing. Promptly remove the drug residues from the patient's local skin and assist the patient in getting dressed.
   2. Inform the patient not to scratch if the local skin is itching, burning, or painful, and remove the drug in time. Keep the local skin clean with normal saline.

Patients with COPD are diagnosed and treated according to "The Global Initiative for Chronic Obstructive Lung Disease", published in 2023¹⁶. The diagnostic criteria for constipation referred to the "Clinical Practice Guideline on the Evaluation and Management of Chronic Constipation for Chinese Adults" issued by the Chinese Society of Colorectal Surgery, Chinese Society of Surgery, Chinese Medical Association in 2022¹⁷. Efficacy was assessed based on the Patient Assessment of Constipation Symptoms (PAC-SYM) form completed before and after the patient's treatment¹⁸. A patient with constipation who met the requirements in the Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, was selected, and only acupoint application combined with acupoint massage was used to treat constipation after obtaining the patient's consent. The patient was treated once daily during the 5-7 am time frame each morning for a 1-week course of treatment. PAC-SYM scores were also completed before the start of treatment and after the completion of treatment.

Based on the PAC-SYM score completed by the patient, the pre-treatment and post-treatment score results were 18 and 6, respectively (Table 1). The results showed that acupoint application combined with acupoint massage could significantly improve constipation symptoms. Previous studies have confirmed that both acupoint application and acupoint massage could treat constipation with minor side effects, high security, obvious curative effect, and outstanding advantages^19,20. Acupoint application combined with acupoint massage improved the efficacy of constipation in COPD patients, and previous clinical studies have shown that acupoint application combined with acupoint massage was more than 90% effective in the treatment of constipation in COPD patients^21,22. Overall, acupoint application combined with acupoint massage is effective and safe in treating constipation in patients with chronic obstructive pulmonary disease.

Figure 1: Location map of abdominal Shenque acupoint (RN8). The Shenque acupoint (RN8) is in the umbilical region, the central umbilical cord. Please click here to view a larger version of this figure.

Figure 2: Location map of bilateral Tianshu acupoint (ST25). The Tianshu acupoint (ST25) is located in the abdomen, 2 finger-cun each around the navel (finger-cun means the proportional unit of the thumb, 2 finger-cun equals approximately 6.67 cm). Please click here to view a larger version of this figure.

Figure 3: Finger press manipulation diagram. The operator presses the patient's acupoint with the thumb, rotating the thumb clockwise while pressing. Please click here to view a larger version of this figure.

Figure 4: Palm massage manipulation diagram. Rub the palms of both hands until warm, then massage the patient's abdominal acupoints in a clockwise direction with the palm of the hands. Please click here to view a larger version of this figure.

Table 1: Patient assessment of constipation symptoms (PAC-SYM) Please click here to download this Table.

The elderly population is at high risk of COPD. Older people experience varying degrees of gastrointestinal decline, while hypoxia and reduced activities in COPD patients increase the risk of constipation. In addition, COPD patients are prone to negative psychological emotions such as nervousness, anxiety, depression, depression, and restlessness, which can cause increased pelvic floor muscle tone, resulting in paradoxical movements between rectal and canals during defecation and inhibition of intestinal peristalsis^3,23. COPD belongs to the category of "lung distension" in TCM. Lung manifests in Qi and governs in breath, as well as disperse and descent of lung Qi²⁴. The lung corresponds to the large intestine, according to the theory of TCM. The lung transmits body fluid and moistens the large intestine through the function of spreading and descending so that the conduction function of the large intestine is normal. COPD is due to the dysfunction of the circulation and descending function of the lung, causing abnormal stool or obstruction and constipation²⁵.

The significance of some therapeutic measures such as increased fluid intake, physical activity, fiber-rich diet, and nutritional supplements recommended to relieve constipation is still questionable²⁶. Medication results in some side effects. Highly permeable drugs such as glycerin and lactulose may cause bloating, abdominal pain and even bleeding hemorrhoids, so they are not recommended for daily use²⁷. Biofeedback therapy requires multiple clinic visits, so it is only available at a few specialized centers²⁸. Since the above treatments have limitations and cannot meet the treatment needs of patients, alternative therapies such as acupoint application and acupoint massage are becoming increasingly popular^29,30. In the treatment of chronic constipation, acupoint stimulation therapy is beginning to show some advantages⁹. Acupoint application combined with acupoint massage can avoid the liver first-pass effect and gastrointestinal irritation. Some studies have proved that acupoint application combined with acupoint massage is effective and safe in the treatment of chronic constipation³¹. Acupoint application combined with acupoint massage can significantly improve the efficacy of constipation in COPD patients. Previous clinical studies have shown that the effective rate of acupoint application combined with acupoint massage in the treatment of constipation in COPD patients is more than 90%, while the effective rate of treatment that only ensures sufficient water and appropriate food fiber intake is less than 80%^21,22. Acupressure combined with acupressure is considered an ideal alternative therapy for patients with chronic constipation.

The key to the whole operation is to make the patient's local acupuncture acupoint warm and sore to fully open up the flow of qi during acupressure massage time, according to the midnight-noon ebb-flow acupuncture theory of TCM, select the time period from 5 am to 7 am when qi and blood flow to the large intestine meridian for treatment³².

Studies have reported that a small number of people will have local skin erythema, papules, blisters, and other adverse reactions after receiving acupoint application, which can spontaneously subside after removing the acupoint application³³. Operators can reduce the occurrence of adverse reactions by understanding allergies, adjusting diet plans, and shortening treatment time. If adverse reactions occur, promptly clean up local skin residues and closely monitor vital signs³⁴.

Shenque Acupoint (RN8) and Tianshu Acupoint (ST25) are effective acupuncture acupoints commonly used to treat constipation³⁵. The ganglion corresponding to the Tianshu acupoint (ST25) is consistent with the distribution of ganglia and sacral plexus in the large intestine. Stimulation of the Tianshu acupoint (ST25) can promote and enhance gastrointestinal peristalsis to effectively improve constipation³⁶. Studies have shown that ST25's pathway in regulating constipation is closely related to inflammation and adipocytokines or leptin³⁷. Studies have also shown that stimulation of Tianshu acupoint (ST25) can improve intestinal motility in constipated rats, which may be related to its upregulation of the immune activity of the colonic muscular plexus vasoactive intestinal peptide and substance P³⁸. At the same time, stimulation of bilateral Tianshu Acupoint (ST25) can improve slow transit constipation-induced changes in colonic smooth muscle structure to treat constipation³⁹. Studies have shown that stimulating Shenque Acupoint (RN8) can improve water content in fecal matter and the rate of intestinal transport in rats with functional constipation, possibly by regulating the expression of the aquaporin-3 (AQP3) and Nuclear factor-kappaB (NF-κB) signaling pathways⁴⁰. Shennong's Herbal Classic of Materia Medica recorded that Rheum officinale Baill had the effect of cleaning the stomach and intestines, pushing Chen Zhixin, and improving the water valley.

At present, acupoint stimulation therapy is widely used in digestive system diseases such as constipation, diarrhea, and functional dyspepsia, with definite curative and minor side effects⁴¹. Gastrointestinal symptoms are considered to be one of the most common adverse events of chemotherapy⁴². Some studies have shown that almost 80% of cancer patients experience nausea, about 70% of cancer patients experience constipation, and over 50% of cancer patients experience vomiting and diarrhea during chemotherapy⁴³. In the future, we can combine acupoint application and acupoint massage with chemotherapy for cancer patients to reduce the gastrointestinal side effects of chemotherapy. Hopefully, it will improve the treatment and quality of life of cancer patients.

Finally, the demonstration of the operation of acupoint application combined with acupoint massage for treating constipation in COPD in this study has some limitations. The sample size of this study is small and data from only one patient is presented here. In the future, a large sample size will be included to demonstrate the effectiveness of acupoint application combined with acupoint massage, with the aim of guiding the treatment of constipation in COPD patients to provide a clinical basis.

There are no competing financial interests in this article.

We acknowledge the financial support from the National Training Program for Clinical Excellence in Chinese Medicine (National Chinese Medicine Human Education Letter [2022] No. 1), "100 Talent Plan" Project of the Hospital of Chengdu University of Traditional Chinese Medicine (Hospital office [2021] 42) and Sichuan Provincial Administration of Traditional Chinese Medicine Scientific and Technological Research Program (2021MS093, 2021MS539, 2023MS608).