A Short Review on “Optimisation of Acupoint Massage for Functional Constipation Patients with Anxiety”

Functional constipation is a common gastrointestinal disease which presents as persistent defecation difficulties, defecation time, or defecation interval. The main manifestations are loose stools, labored defecation, knotted defecation, and a feeling of incomplete defecation. Irritable bowel syndrome with constipation [1]. Epidemiological surveys show that the current incidence of functional constipation in Hong Kong is as high as 14.3%, and the incidence ratio between women and men is 1.3:1 [2]. With the investigation of the gut-brain axis, research shows that psychological factors are closely related to the onset of FC, while anxiety and depression are factors that commonly affect gastrointestinal functions [3]. Nevertheless, FC and anxiety are closely related to each other. The prevalence of anxiety disorders in patients with constipation is much higher than that of the general population [4]. The gut microbiota affects a variety of normal psychological processes and psychological phenomena. It is involved in the pathophysiology of multiple psychiatric and neurological diseases [5].The aggravation of constipation will worsen anxiety, thereby reducing the patients’ willingness for treatment. Hence, increasing the degree of constipation, forming a vicious cycle [6]. 

Acupoint massage is a widely utilized clinical method for alleviating FC in patients. However, there is a lack of specific research on the effects of acupoint massage as a standalone treatment for improving functional constipation in individuals with coexisting anxiety. Many studies have incorporated psychological interventions or other therapies in conjunction with acupoint massage, leading to varying levels of effectiveness. Moreover, acupoint massage may not be easily self-administered by patients. The objective of this study is to explore a more convenient and effective treatment approach for patients with functional constipation and provide valuable insights for the development of clinical treatment protocols.

• Data sources 

The first part is a review of clinical research literature from January 1, 2010, to December 31, 2020, at “China Biology Medicine Disc, CBM”, “National Knowledge Infrastructure, CNKI”, “China Science and Technology Journal Database, VIP”, “Airiti Library”, “ProQuest Health & Medical Collection”, “PubMed”, and “Embase". Literature reviews, meta-analysis, abstracts, newspaper articles, and literature that present incomplete data or repeated publication will be excluded from the database. The result would be selected and summarized into acupoint prescriptions and acupoint compatibility relationships with SPSS 26.0, being selected and established the acupoint prescriptions of this study. 

• Study design 

The second part is a randomized controlled, single-blind trial that enrolled 30 female FC participants for 6 weeks and observed for 4 weeks, with 15 cases in each of the acupoint massage treatment group (Group A) and the blank control group (Group B) respectively. Group A would do self-operated acupoint massage, once a day for 6 weeks. Inclusion criterias: Meet the Rome IV diagnostic criteria for FC; females aged between 18 and 64 years old; with clear consciousness and no language or communication barriers; have certain understanding and reading abilities, and have an education level of primary school or above; do not receive other medications that may affect intestinal functions within 2 weeks before treatment; sign the informed consent form. 

Primary outcomes: Complete Spontaneous Bowel Movements (CSBMs) and Bristol Stool Form Scale (BSFS). Secondary outcomes: Patient Assessment of Constipation Symptoms (PAC-SYM), Hamilton Anxiety Scale (HAMA), Self-Rating Anxiety Scale (SAS). CSBMs, BSFS, HAMA, and SAS are evaluated at the time of enrollment and once a week after enrollment, while the PAC-SYM is evaluated once every two weeks.

A total of 198 Chinese and English literature were initially screened with 209 acupuncture prescriptions, involving 48 acupoints. ST25 is the most frequently used acupoint, followed by ST37, BL23, TE6, ST36, and CV12. A total of 6 acupoint pairs were obtained by association rule analysis, and the support rate was 15% and the confidence rate was 90%, the core prescription has ST25, TE6, ST37, ST36, BL23, CV6, CV12. Although BL3 also has a high degree of support and confidence rate, its location is not convenient for self-operation, so it is not used. This study selected ST25, CV12, ST36, ST37, and TE6, all of which have a support rate of 15% or above and a confidence level of more than 90%, and have a strong compatibility relationship. It is expected that the above reliability and therapeutic effects of acupoints will be better. 

The result of the study suggests that acupoint massage can effectively improve the problems of female FC, by increasing defecation frequency, improving stool characteristics, improving drainage-related symptoms, and shows a long-term effect. 

Comparing the CSBMs scores of the two groups before the treatment, there was no statistically significant difference in the scores between the two groups (P>0.05). The scores of the treatment group at week 2, week 4, week 6 of treatment, and 2 weeks and 4 weeks after treatment were significantly improved compared to that before the treatment, and the difference was statistically significant (P < 0.01). Besides, the scores between the two groups at week 2, week 4, week 6 of treatment, and 2 weeks and 4 weeks after treatment were statistically significant (P < 0.01). The results suggest that the treatment can increase the number of complete spontaneous defecation among patients and the effect can be remained. 

Comparing the BSFS scores of the two groups before the treatment, there was no statistically significant difference in the scores between the two groups (P>0.05). The scores of Group A increased at week 4 of treatment compared to that before the treatment, and the difference was statistically significant (P<0.05). Comparing the scores between the two groups at week 2, week 4, week 6 of treatment, and 2 weeks and 4 weeks after the treatment, the difference in scores between the two groups was statistically significant (P<0.01). The results suggest that treatment can improve stool consistency and have constant effects. 

For PAC-SYM, it shows that the scores of Group A at week 4, week 6 of the treatment, and 2 weeks after the treatment were lower than before the treatment, and the difference was statistically significant (P < 0.05). 

For HAMA, it shows that the scores of Group A decreased at week 2 of the treatment compared with those before the treatment, and the average score of Group A dropped from moderate to mild. The difference was statistically significant (P < 0.05). 

The SAS scores suggest that at week 4 of the treatment in Group A were lower than those before the treatment (P<0.01), and the average score of the treatment group dropped from mild anxiety before the treatment to no anxiety symptoms and showed a continuing effect. 

The study found correlations between certain variables. The average improvement in the CSBMs and BSFS scores has no statistical correlations with the change in the HAMA score (P>0.05); the average improvement in BSFS score has a statistical correlation with the change in the SAS score (P < 0.01); and the average improvement in the PAC-SYM score has a statistical correlation with the change in the HAMA (P < 0.01) and the SAS scores (P < 0.01). When the BSFS score increases, the SAS score decreases; as the PAC-SYM score decreases, the HAMA and the SAS scores also decrease.

All in all, this comprehensive review highlights the potential therapeutic effects of acupoint massage therapy for FC patients with anxiety. The findings suggest that acupoint massage can alleviate defecation difficulties, improve stool characteristics, and reduce anxiety symptoms. The therapeutic effect is long-lasting. However, the limitations of the study, such as the small sample size and the need to consider additional factors like operation techniques and duration, should be addressed in future research. Furthermore, it is crucial to conduct additional high-quality RCTs with larger participant groups and stricter research methodologies. Overall, acupoint massage proves to be an easy, effective, and non-invasive treatment option that can significantly improve the symptoms of female FC with anxiety, benefiting public health.

1. Drossman DA (2016) Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology 150: 1262-1279.
2. Cheng C, Chan AOO, Hui WM, Lam SK (2003) Coping strategies, illness perception, anxiety and depression of patients with idiopathic constipation: a population?based study. Alimentary Pharmacology & Therapeutics 18: 319-326.
3. Zhou L, Lin Z, Lin L, Wang M, Zhang H (2010) Functional constipation: implications for nursing interventions. Journal of Clinical Nursing 19: 1838-1843.
4. Hosseinzadeh ST, Poorsaadati S, Radkani B, Forootan M (2011) Psychological disorders in patients with chronic constipation. Gastroenterology and hepatology from bed to bench 4: 159-163.
5. Liang S, Wu X, Jin F (2018) Gut-Brain Psychology: Rethinking Psychology From the Microbiota-Gut-Brain Axis. Frontiers in Integrative Neuroscience 12: 33-33.
6. Chan AO, Cheng C, Hui WM, Hu WH, Wong NY, et al. (2005) Differing coping mechanisms, stress level and anorectal physiology in patients with functional constipation. World journal of gastroenterology 11: 5362–5366.