Dan-Dan Tian,Xiao-Qiang Geng,Wen-Min Niu

1Shaanxi University of Traditional Chinese Medicine,Shanxi,China.

Introduction

Constipation is a common clinical symptom in stroke patients with high morbidity and mortality.According to related reports,constipation is associated with prolonged hospital stay,neurological deterioration,and death[1].The incidence of constipation after stroke is between 29%and 79%[2].The probability of incidence of constipation after four weeks of stroke was 55.2%[3].Most of the patients who suffer from stroke are elderly patients.The elderly have Qi and blood deficiency,and thus,are lacking in strength. Their large intestine loses nourishment and causes bowel movement to slow down,leading to constipation.At the same time,constipation,which is a complication of common clinical diseases has a risk of inducing heart and cerebrovascular diseases.In severe cases,it even threatens the life and health of patients.Therefore,keeping the stool smooth is essential for the successful rehabilitation of patients with stroke,and avoiding a series of serious complications caused by fecal failure[4].

The use of acupuncture treatment for constipation has a long history in China.Bianqueshenyingzhenjiuyulongjing(A.D.1271~1368,Yuan Dynasty)has stated:“Use Zhaohai(KI6)to treat constipation;Zhigou(TE6)is efficient in patients with pain perceived in the ribs”[5].Leijingtuyi(A.D.1368~1644,Ming dynasty)states:“patients suffering from constipation and pain in the ribs should treated by Zhigou(TE6)”[6].Zhenjiuxinfayaojue(A.D.1616,Qing dynasty)states:“Zhaohai(KI6)is to be used in the treatment of epilepsy occurring at night,and constipation”[7].Studies on modern acupuncture used in a wide spectrum of diseases have also shown that it has good curative effects on digestive diseases such as functional constipation, functional diarrhea,diaphragmatic spasm,and functional dyspepsia[8].

Atpresent,the exactmechanism ofaction of acupuncture treatment in curing constipation is still unclear,but some studies have shown that the receptors in the vicinity of the human Shu acupoints are stimulated by acupuncture to form a corresponding impulse that is transmitted to the central nervous system through the peripheral nerves.The feedback signal released by the central system is transmitted to the corresponding organs through the efferent nerve,and the reaction system of the organs respond to realize the therapeutic effect of acupuncture.Studies have found that acupuncture can enhance gastrointestinal motility by precipitation of the somatic reflex and activation of the spinal pathway,thereby promoting bowelmovements,and treating functional constipation[9-14].Acupuncture can activate neurons in Barrington’s nucleus and the dorsal nucleus of the vagus nerve via stimulating somatic sensory nerve,and then activate the parasympathetic nerves and promote distal colonic movement[15-16].

This research aimed to apply acupuncture to treat constipation after stroke;the results were compared with those obtained from treatment using the lactulose oral solution.

Method

Therapeutic method

Acupuncture group involved th e conventional treatment and rehabilitation for function recovery including the administration of acupuncture.The bilateral acupoints selected were:Daheng(SP15),Fujie(SP14),Zhigou(TE6),Zhaohai(KI6),Yingxiang(LI20),and Shaoshang(LU11).The patient was placed in the supine position and the acupuncture site was disinfected.A 0.30 mm×50 mm acupuncture needle is used to place an oblique stab of 20-30 mm from Daheng(SP15)to the abdominal knot,to expedite the Qi conduction.A straight stab of 20-30 mm is applied at Zhigou(TE6),Yingxiang(LI20),and Zhaohai(KI6),and the needle is rotated until the acupoints give an acid bilges feeling.At the Shaoshang(LU11)site,the point stab method is applied.Except at Shaoshang(LU11),the needles were retained at all other points for 30 min.Once a day,1 course of treatment is 1 week,2 consecutive courses of treatment.

Western medicine group involved involved the conventional treatment and rehabilitation for function recovery.Including the administration of 30 ml of lactulose oral solution(Registration number of imported drugs:H20120381),once a day in the morning.A curative effect was observed with two doses.

Diagnostic criteria

Internationalstandard diagnostic criteria foracute ischemic stroke and constipation were adopted[17,18].

Inclusion criteria

(1)The diagnostic criteria of acute ischemic stroke were met;(2)the diagnostic criteria of constipation were met;(3)age range between 40-78 years and sexuality not restrictive;(4)the patients had stable vital signs,clear consciousness,and no barriers to communication,acupuncture,rehabilitation,and other forms of treatment;(5)the patients agreed to the study and signed the informed consent.

Exclusion criteria

(1)Not in accordance with the inclusive criteria;(2)constipation caused by organic diseases such as colorectal cancer, inflammatory bowel disease, intestinal tuberculosis, pseudo intestinal obstruction, and megacolon;(3)presence of serious complications such as heart failure,kidney failure,or malignant tumors and unstable life signs;(4)acute stage of stroke mania.

Observation of curative effect

Observational indexClinical symptoms of constipation:according to the"Constipation symptoms and efficacy evaluation questionnaire",a symptom score evaluation table prepared by the anorectal surgery group of the externalmedicine branch ofthe Chinese medical association in 2005,was used to determine the efficacy[19](Table 1).The clinical symptoms of constipation were evaluated before treatment,one week after treatment,two weeks after treatment,and one month after discharge.

Table 1 Constipation symptom assessment

Criteria of curative effects(1)the criteria of the“Standard of TCM disease and syndrome diagnosis”published by the state administration of traditional Chinese medicine(TCM)in 2017 were used to determine the efficacy of treatment.The criteria are as follows:(1)cure:defecation once within two days,quality of the feces becomes emollient and discharge is smooth,no short-term relapse and constipation symptom integral is more than 75%;(2)improvement:defecation once within two days,quality of the feces becomes emollient but discharge is not smooth,constipation symptom integral is in the range of 25-50%.(3)no improvement:the symptoms of the patients show no improvement,and constipation symptom integral is less than 25%.The efficacy rate calculation formula is:

Efficacy rate=(Cure+Improvement)/Total cases×100%

Statistical method

In this study,all collected data were statistically analyzed using the SPSS 25.0 statistical software. The measurement data were denoted as(x±s).Ridit analysis was used to compare the differences in clinical efficacy between the groups.Paired t test was used to analyze the change in symptom scores.All test results were evaluated consideringP<0.05 as statistically significant.

Results

General information

In total,60 inpatients admitted between February 2018 and October 2018 at the department of encephalopathy,in the first affiliated hospital of Shanxi University of TCM were selected.The patients were randomly divided into an acupuncture group and a lactulose group by the random number method,resulting in 30 patients in each group.There were 12 male and 18 female patients in the acupuncture group,ranging in age between 42 and 78 years,with an average age of 55.0±5.0 years.The course of the disease was 0.02-3 years,with an average duration of 1.5 years.There were 15 male and 15 female patients in the acupuncture group,ranging in age from 40 to 72 years,with an average age of 57.0±5.0 years.The course of disease ranged from 0.04-2 years,with an average duration of 1 year.There were no statistically significant differences in age,course of disease,and sex distribution among the four groups(P>0.05).

Comparison of constipation scores

Constipation scores compared between the two groups before treatment showed no statistical difference(P=0.968).The constipation scores of the two groups were significantly lower than that before treatment,and the difference was statistically significant(P<0.001).After one week of treatment,constipation scores of the two groups were compared,and the difference was not statistically significant(P>0.05).After two weeks of treatment,the constipation scores of the acupuncture group was lower than that of the western medicine group,and the difference was statistically significant(P<0.05).Follow-up was done one month after discharge,and the constipation score of the acupuncture group was lower than that of the western medicine groups,and the difference was statistically significant(P<0.05).(Table 2)

Comparison of curative effects

After one week of treatment,the two groups were compared with regard to efficacy of treatment and no statistical difference was noted(P>0.05).After two weeks of treatment,the acupuncture group showed a curative effect higher than that of the western medicine group,and the difference was statistically significant(P<0.05).After two weeks of treatment,the acupuncture group had a higher curative effect than the western medicine group,and the difference was statistically significant(P<0.05).(Table 3)

Discussion

Constipation after stroke is caused by a series of reasons such as inactivity,lethargy,insufficient water intake,deficient nutrition intake, depression, cognitive impairment,and drug intake[21].Stroke patients tend to be older people.As people get older,there may be a degree iof idegeneration iof bodily physiological function.After stroke,the central nervous system and peripheral nervous system ofpatients undergo changes,and transmission time through the small and large intestines may be prolonged,leading to incomplete defecation[22].It is well known that the central nervous system is involved in the control of visceral function and its injury can lead to gastrointestinal injury[23].In addition,patients with constipation after stroke are more prone to complications such as pneumonia,urinary tract infection,upper gastrointestinal bleeding,and secondary stroke[24].The gastrointestinal tract is reported to contain 200 million to 500 million neurons constituting what is called“the second brain” [25].Hence,constipation can aggravate damage to the central nervous system and neurons.Constipation and stroke influence each other and hinderthe disease recovery [26].Therefore,itis necessary to treat constipation at the earliest.

Table 2 Comparison of constipation score

Table 3 Comparison of curative effect

The conventional drugs used in the treatment of constipation include osmotic laxatives, stimulant laxatives,secretagogues,5-hydroxytryptamine receptor activators,etc.However,these medicines can cause side effects such as headaches,diarrhea,nausea,and abdominal pain[27].In addition,constipation can recur after drug withdrawal and long-term use can lead to drug dependence.This forms a vicious cycle.Constipation could further lead to a large amount of endotoxin absorption,obstructing the recovery of stroke patients.

Stroke is called a Zhongfeng in TCM.TCM believes that the occurrence of constipation after stroke is related to a disorder in the balance of Qi and blood.Suwen(B.C.220~211,Han Dynasty)says that the reversal of blood and Qi can result in the onset of Zhongfeng,indicating that constipation after stroke is due to the reversal of Qi that cannot come down,and hence the excreta cannot be discharged normally.Constipation can aggravate or cause a relapse of symptoms of cerebral hemorrhage and cerebral infarction.Therefore,key to the treatment of constipation after stroke lies in regulating Qi.In this experiment,the method of acupuncture was adopted,and the acupoints Daheng(SP15),Fujie(SP14),Zhigou(TE6),Zhaohai(KI6),Yingxiang(LI20),and Shaoshang(LU11)were selected bilaterally.The spleen and stomach is an exterior-interior relationship,so the function of stomach depends on the spleen.Daheng(SP15)point belongs to the spleen foot Taiyin meridian,and has the function of rotating the Qi and regulating the stomach and intestines.Fujie(SP14)belongs to the spleen foot-Taiyin meridian which makes it an important point of treatment for constipation.Zhigou(TE6)point belongs to the Shaoyang sanjiao meridian and is the main clinical point for the treatment of constipation.Zhaohai(KI6)belongs to the kidney foot Shaoyin meridian,which is the key pointofnourishing Yin.Shaoshang (LU11) and Yingxiang (LI20)belong to the lung hand Taiyin meridians. The lung and large intestine is an exterior-interior relationship,so the curative effect of dredging large intestine stagnation can be achieved by regulating the lung Qi.

There isa significantdifference in the clinical efficacies of the treatment of post-stroke constipation with acupuncture and lactulose oralsolution.The acupuncture method has the characteristics of simple acupoint selection,visible curative effect,no adverse reactions,no drug-free dependence,and no drug dependence or addiction.Oral lactulose may cause adverse reactions such as diarrhea and abdominal pain and may lead to resistance on long-term use.We treated patients with constipation after stroke for one week and two weeks and observed the short-term efficacies.The scores of constipation symptoms in the two groups were significantly lower than those before treatment.The clinicalefficiency ofthe acupuncture group was significantly better than that of the western medicine group.The efficacy evaluation of constipation remains incomplete due to the absence of any long-term efficacy evaluation indicators.Therefore,we followed up the improvement of constipation in patients after stroke at one month after discharge and calculated the constipation symptom scores and clinical efficacy.The results showed that the patients who underwent acupuncture for the treatment of constipation after stroke showed better long term effects than those who took lactulose oral solution.The acupuncture is a safe method with no side effects and is a long-lasting and highly feasible treatment method suitable for clinical application.

Conclusion

Oral administration of western medicine and acupuncture treatmentforstroke afterconstipation resulted in alleviation of constipation symptoms in both groups,and the efficacy rate of the acupuncture group was higher than that of western medicine group.Moreover,acupuncture has better long-term curative effects.Acupuncture is safe,has no side effects,and is highly feasible and suitable for clinical application.

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