Electroacupuncture Combined with Chinese Medicine Ironing Therapy for Functional Constipation

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.

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.

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.

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).

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).

We conducted CSBMs, CSS, and PAC-QOL questionnaires before and after treatment. Before treatment, CSBMs, CSS, and PAC-QOL scores of all groups showed no statistical difference and were comparable. After 4 weeks of treatment, CSBMs increased, and CSS scores decreased in all groups. The CSBMs, CCS, and PAC-QOL scores of group C were better than the control group, groups A and B (p < 0.05). The PAC-QOL score of group B was better than group A (p < 0.05) (see Table 2). The results suggest that electroacupuncture combined with CMIT can improve the frequency of patients' voluntary bowel movements, constipation, and quality of life. No severe adverse reactions occurred in all groups.

Figure 1: Materials for electroacupuncture. (A) Acupuncture needle. (B) 75% ethanol disinfectant. (C) Medical cotton swab. (D) Electronic needle therapy instrument. Please click here to view a larger version of this figure.

Figure 2: Materials for Chinese medicine ironing therapy. (A) Fennel. (B) Disposable sterile cloth bag. (C) Disposable sterile gloves. Please click here to view a larger version of this figure.

Figure 3: Quchi (LI11) acupoint position. Locate the acupoint at the middle of the line between the lateral end of the elbow stripe and the humerus's external epicondyle. Please click here to view a larger version of this figure.

Figure 4: Shangjuxu (ST37) acupoint position. Locate the acupoint 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 tibia. Please click here to view a larger version of this figure.

Figure 5: Electroacupuncture of Quchi (LI11) and Shangjuxu (ST37). Please click here to view a larger version of this figure.

Figure 6: Acupoints for abdominal ironing treatment. Zhongwan (CV12) was in the upper abdomen, anterior median line, 4 F-cun above the umbilicus. Shenque (CV8) was in the middle of the umbilicus. Tianshu (ST25) was on the abdomen, in the horizontal umbilicus, 2 F-cun from the anterior median line. Guanyuan (CV4) was in the lower abdomen, midline anterior, and 3 F-cun below the umbilicus. Please click here to view a larger version of this figure.

Figure 7: Leave the reyan bag at Zhongwan (CV12) and continue ironing. Please click here to view a larger version of this figure.

Table 1: Characteristics of the patients at baseline.

Table 2: Comparison of CSBMs, CSS, and PAC-QOL scores. (^a, compared to the control group, p< 0.05. ^b, compared to group A, p < 0.05. ^c compared to group B, p < 0.05).

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 medicine treatment of FC is mainly based on various types of laxatives and gastrointestinal mitogenic drugs. Long-term use of these drugs may lead to nausea, vomiting, abdominal pain⁴⁴, electrolyte disorders⁴⁵, colonic retinopathy^46,47, and increase the economic burden on individuals and society.

Chinese medicine believes that constipation is closely related to the spleen and stomach⁴⁸. There are various methods of TCM treatment for FC, including acupuncture^49,50, tuina therapy⁵¹, acupressure⁵², herbal ironing⁵³, and herbal enema⁵⁴, which are effective.

FC is among the 43 common diseases the World Health Organization recommends for electroacupuncture treatment⁵⁵. The efficacy of acupuncture in treating constipation and diarrhea ranks among the top two⁵⁶and has distinctive advantages. Studies have shown that acupuncture can enhance intestinal motility²², regulate gastrointestinal function, and reduce constipation symptoms⁵⁷.

Electroacupuncture at Shenque (CV8) acupoint has been proven to improve fecal water content and intestinal transport rate in rats suffering from functional constipation, possibly by the regulation of the aquaporin-3(AQP3) expression and nuclear factor-kappa B(NF-κB) signaling pathways⁵⁸.

Fennel has been used in traditional medicine for various ailments related to the digestive, endocrine, reproductive, and respiratory systems⁵⁹. Fennel has many pharmacological effects such as antioxidant, anti-inflammatory, antimicrobial, antithrombotic, hypotensive, gastroprotective, hepatoprotective, memory enhancing, and antimutagenic activities⁶⁰. The heated reyan bag stimulates the abdominal Zhongwan (CV12), Shenque (CV8), and other acupoints, promoting Qi, removing blood stasis, and clearing collaterals. Abdominal massage along the direction of significant intestine excretion increases the rhythmic contraction of the small and large intestines, speeds up transport, and makes stool soft and easy to discharge^61,62.

Acupuncture is an invasive procedure that may involve the risk of fainting needles, sticking needles, bleeding, and wound infection, so it requires an experienced physician to perform the function and promote sterility awareness. In this study, electroacupuncture was used to enhance the acupuncture needle sensation and improve the therapeutic effect on the one hand, to ensure the consistency of acupuncture treatment on the other hand, and to avoid the influence of different operators' performing acupuncture techniques on the trial.

The acupoints selected for this study were Quchi (LI11) and Shangjuxu (ST37), which are the points of recruitment of the large intestine and the end of lower healing, respectively. Both of these points are considered primary acupoints in TCM for treating diseases of the internal organs and are commonly used in patients with FC³⁴. The combination of Quchi (LI11) and Shangjuxu (ST37) belongs to the compatibility of He-sea points, which is used to treat the inner fu-organs. Neijing believes that the effect of the combined points and the lower combined points is the same⁶³. A previous study⁶⁴ has shown that the compatibility of He-sea points can significantly increase CSBMs, improve the difficulty of defecation and the quality of life of patients, and the combination of points and points can maintain efficacy for 4 weeks after stopping treatment.

The overheated reyan bag will enhance the patient's discomfort and even cause skin burns, so the reyan bag needs to be moved gently and quickly at the beginning of the treatment and then placed on the Zhongwan (CV12) for continuous ironing treatment after the patient gets used to the temperature of reyan bag.

The present study has certain limitations. First, FC is divided into slow transmission, outlet obstruction, and mixed types, which behave differently¹. In this study, FC was not typed, and there was a lack of comparison of efficacy indicators related to different types of FC, thus failing to clarify the types of FC that are sensitive to electroacupuncture combined with CMIT. Second, this study was a single-center study with a small sample size, and the heterogeneous effect of comorbidities on treatment effectiveness was not analyzed. Therefore, further trials are needed to investigate the clinical advantages and disadvantages of electroacupuncture combined with CMIT for FC, complement existing treatments, and explore whether electroacupuncture combined with CMIT is the best treatment for FC.

Compared with Western medicine alone, electroacupuncture combined with CMIT can improve the frequency of patients' voluntary bowel movements, constipation, and quality of life.

The author has no conflict of interest to disclose.

This study was supported by the Key Research and Development Plan (Major Science and Technology Special Project) of the Sichuan Provincial Science and Technology Department (Number: 2022YFS0392) and the Key Discipline Construction Project of the Sichuan Provincial Administration of Traditional Chinese Medicine (Number:202072).