Acupuncture outperforms lactulose for the alleviation of post-stroke constipation and the regulation of gastrointestinal hormones. Qujing First People’s Hospital researchers investigated the benefits of the Shu Gan Tiao Qi (liver-soothing and qi-regulating) acupuncture protocol and a drug for the treatment of post-stroke constipation. Acupuncture provided superior short and long-term relief from post-stroke constipation and improvements in relevant gastrointestinal hormone levels. [1]

Primary outcome measures for the study included the time of the first spontaneous bowel movement after treatment, constipation symptom scores, and gastrointestinal hormone levels including somatostatin, motilin, substance P, and vasoactive intestinal peptide. Constipation symptom scores measure the severity of constipation based on the following 5 parameters: bowel movement duration, bowel movement intervals, stool characteristics, bowel movement difficulty, and incomplete bowel movements or bloating.

Higher constipation symptom scores indicate increased constipation severity. Somatostatin (SS) is a regulatory peptide that inhibits gastrointestinal function. Motilin (MLT) is a hormone that promotes intestinal mobility. Substance P (SP) is a peptide expressed in enteric motor neurons. Modern research confirms that constipation is associated with a decrease in SP. [2] Vasoactive intestinal peptide (VIP) is a peptide that regulates smooth muscle motility, epithelial cell secretion, and blood flow in the gastrointestinal tract. [3] Decreased VIP is associated with constipation. [4]

The average time of the first spontaneous bowel movement was 30.18 hours in the acupuncture group, while that in the drug control group was 43.22 hours (P< 0.05). The constipation symptom scores after 6-weeks of treatment and during the follow-up examinations were lower than those before treatment in the two groups (all P<0.05), with acupuncture treatments showing better results than lactulose oral solutions (both P <0.05).

MTL and SP were significantly increased while SS and VIP were significantly decreased after treatment in the two groups (all P<0.05). The acupuncture group produced greater improvements regarding gastrointestinal hormone level improvements compared with the drug control group (all P<0.05). No adverse effects were observed in the two groups.

 

Design
A total of 60 patients from Qujing First People’s Hospital participated in the study. All patients were diagnosed with post-stroke STC/constipation. The following selection criteria were applied:

  • Diagnosed with stroke according to the Diagnostic Criteria for Cerebrovascular Diseases formulated by Chinese Neuroscience Society and Chinese Neurosurgical Society [5]
  • Diagnosed with constipation according to the Rome III Criteria for Constipation and Constipation Symptoms and Efficacy Evaluation formulated by the Anorectal Surgery Group of Surgery Branch of Chinese Medical Association [6]
  • Ages between 18–90 years
  • Did not use laxatives and gastrointestinal motility drugs for at least 1 week prior to the study
  • Informed consent was signed

The following exclusion criteria were applied:

  • Could not tolerate or continue acupuncture treatment
  • Coagulation dysfunction or using anti-coagulant drugs such as warfarin and heparin
  • Irritable bowel syndrome (IBS)
  • Constipation secondary to diseases other than stroke
  • Serious mental illness or cognitive impairment
  • Severe and comorbid liver or kidney damage

Participants were randomized into an acupuncture treatment group and a drug control group, with 30 patients in each group. There were no significant differences regarding all relevant demographics between the two groups (P>0.05), setting the basis for a fair comparison of results. The treatment group had 14 males and 16 females. The mean age of the treatment group was 56 years. The average course of disease was 16.8 months.

The control group had 17 males and 13 females. The mean age of the control group was 57 years. The average course of disease was 16.2 months. The treatment group received conventional acupuncture. The control group was given lactulose oral solutions. Both groups underwent treatment for 6 weeks with a 4-week follow-up examination.

 

Acupuncture and Drug Therapy
For the drug control group, 20–30 ml of lactulose oral solution was taken first thing in the morning every day. A full medication course was comprised of 6 continuous weeks. The acupoints selected for the treatment group were the following:

  • Danzhong (CV17)
  • Qihai (CV6)
  • Tianshu (ST25)
  • Neiguan (PC6)
  • Gongsun (SP4)
  • Taichong (LV3)

Two experienced licensed acupuncturists were chosen to implement acupuncture therapy. Patients were instructed to empty their bladders completely before treatment. Treatment commenced with patients in a supine position.

After disinfection of the acupoint sites, a 0.35 mm × 40 mm disposable filiform needle was inserted into each acupoint with a high needle entry speed. For Danzhong, the needle was inserted obliquely toward Jiuwei (CV15) to a depth of 20-30 mm. For Qihai, the needle was inserted perpendicularly to a depth of 20-30 mm. For Tianshu, the needle was inserted perpendicularly to a depth of 30-40 mm. For Neiguan, the needle was inserted deeply toward Waiguan (TB5) until an electric shock sensation was obtained. For Gongsun and Taichong, the needle was inserted perpendicularly to a depth of 15 mm. A 30-minute needle retention time was observed. One acupuncture session was applied every day, for a grand total of 6 weeks.

 

Summary
Objective and subjective data indicates that acupuncture is effective for the treatment of post-stroke constipation. Acupuncture bowel movement improvements were correlated with effective regulation SS, MTL, SP, and VIP levels. The Shu Gan Tiao Qi (liver-soothing and qi-regulating) acupuncture protocol involves the application of acupoints Danzhong (CV17), Qihai (CV6), Tianshu (ST25), Neiguan (PC6), Gongsun (SP4), and Taichong (LV3). Patients interested in learning more about treatment are recommended to contact local licensed acupuncturists.

Looking at the point selection made by the research team, they chose traditional acupoints often used for the treatment of constipation and then tested it with a modern scientific method. Tianshu (ST25) is a local acupoint that is the Front-Mu point of the large intestine. Its traditional function is to regulate the intestines, spleen, and stomach. Additionally, this acupoint regulates qi and blood and eliminates stagnation. Its use for the treatment of constipation is clinically documented for well over a millennia. Moreover, the research team selected experienced licensed acupuncturists to apply the acupoints. Essentially, the clinical study attempted to adhere to traditional acupuncture techniques within the parameters of a controlled investigation seeking to limit variables.

Another classic acupoint selection was Neiguan (PC6) and Gongsun (SP4). In Traditional Chinese Medicine (TCM), these points are paired to relieve heart, chest, and stomach related disorders. This paired combination is part of the eight confluent points of the eight extra meridians in TCM. SP4 is the confluent point of the Chong (thoroughfare) vessel and PC6 is the confluent point of the Yinwei (yin linking) vessel. Together, they are combined to treat digestive disturbances. The researchers selected this combination based on traditional usage and tested it with the scientific method, finding the total combination of points effective for the treatment of post-stroke constipation.

 

References:
[1] Gao YH, Li JM, Su M, Li YL. Acupuncture with smoothing liver and regulating qi for post-stroke slow transit constipation and its gastrointestinal hormone level [J]. Chinese Acupuncture and Moxibustion, 2017,37(02):125-129.
[2] Hutson JM, Chow CW, Borg J. Intractable constipation with a decrease in substance P-immunoreactive fibres: is it a variant of intestinal neuronal dysplasia? [J]. J Pediatr Surg. 1996 Apr;31(4):580-3.
[3] Fahrenkrug J. Transmitter role of vasoactive intestinal peptide [J]. Pharmacol Toxicol. 1993 Jun;72(6):354-63.
[4] Koch TR, Carney JA, Go L, Go VL. Idiopathic chronic constipation is associated with decreased colonic vasoactive intestinal peptide [J]. Gastroenterology. 1988 Feb;94(2):300-10.
[5] Chinese Neuroscience Society, Chinese Neurosurgical Society. Diagnostic criteria for various cerebrovascular diseases[J]. Chinese Journal of Neurology, 1996, 29 (6): 379-381.
[6] The Anorectal Surgery Group of Surgery Branch of Chinese Medical Association. Constipation symptoms and evaluation of curative effects[J]. Chinese Journal of Gastrointestinal Surgery, 2005, 8(4): 355-356.

 

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