Safety and Effectiveness of Moxibustion and Abdominal Massage in Hospitalized Older Patients With Constipation: A Retrospective Study

Constipation is defined as the abnormal delay or infrequent passage of dry hardened feces, usually resulting from excessive absorption of water from the large bowel.^1,2 According to the Rome II criteria,³ a diagnosis of functional constipation can be established when in the preceding 12 months, there were 2 or more of the following symptoms (> 25% of defecations) for at least 12 weeks (not necessarily consecutive): straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal blockage, manual maneuvers to facilitate defecation, and <3 defecations per week. However, because most of these symptoms are subjective and it is difficult to accommodate all individual variations in bowel habits, there is no universally accepted definition of constipation.⁴

Factors that contribute to the development of constipation include inadequate intake of fiber and fluid, ignoring or suppressing the urge to defecate, and overuse of laxatives or other elimination aids.^5-8 Older age itself is also a risk factor for developing constipation,⁹ as the prevalence of constipation is reported to be 16% to 26% in individuals aged ≥65 years in community settings and increases to 80% in long-term care residents.^9,10 In addition, this common complaint in older adults may lead to psychological impairment, such as anxiety, depression, and pain disorders.¹¹ For older patients admitted to hospitals, additional factors such as preexisting disease, immobility, surgery, difficulty in accessing toilet facilities, and inappropriate medication prescribing^12,13 may further increase the risk of constipation. However, constipation is often underdiagnosed and undertreated, which may increase morbidity and prolong hospital stays.^14-16

Instead of pharmacological management (such as bulk-forming laxatives, osmotic laxatives, and stimulant laxatives with or without fiber),¹⁷ nonpharmacological management, such as lifestyle and dietary modification, is the first recommended treatment of chronic functional constipation.⁴ Nevertheless, prescribing for constipation based on physicians’ habit and tradition, rather than evidence-based principles, is not uncommon.¹⁸ Inappropriate use of laxatives (especially long-term use), however, may exacerbate constipation by causing cathartic damage to the colon and decreasing bowel function. More studies are needed regarding optimal therapeutic solutions for constipation, and there are some promising nonpharmacological interventions.

Moxibustion, which is a type of Chinese medicine treatment that uses the heat generated from burning Artemisia vulgaris (mugwort) to stimulate an acupoint, has been reported by several studies as a potentially effective treatment for constipation.¹⁹ Abdominal massage is another intervention that has been found to relieve constipation, has almost no side effects, and can easily be taught to patients.²⁰ Considering there is limited evidence about the use of moxibustion and abdominal massage for treating constipation in elderly hospitalized patients, the current study investigated the safety and effectiveness of moxibustion and abdominal massage in this population.

Study design and participants. Medical charts of hospitalized elderly patients (aged ≥60 years) with constipation in the Nanjing Drum Tower Hospital between January 2018 and January 2020 were retrospectively reviewed to assess for eligibility. The inclusion criteria were 1) patients who were aged ≥60 years; 2) patients who had a diagnosis of constipation defined as a Constipation Assessment Scale²¹ (CAS; Table 1) score ≥3; and 3) patients who were able to be fed orally. The exclusion criteria were 1) patients who had any communicative, cognitive, affective, or verbal difficulties that would prevent them from requesting the additional interventions; 2) patients who had a psychiatric diagnosis, abdominal hernia, inflammatory bowel disease, irritable bowel syndrome, bowel cancer, intra-abdominal infection, or history of abdominal surgery; and 3) patients who had been treated with opioids. Detailed steps for the inclusion of the study participants are presented in Figure 1.

Routine nursing care. All the included patients received routine nursing care for constipation during hospitalization that included extra intake of fluid and fiber. Patients with constipation were required to ingest an extra 1500 to 2000 mL of water each day in addition to normal daily fluid intake under supervision and to consume a small high-fiber meal 30 minutes before their regular dinner. This meal consisted of 1 cup of applesauce, 1 cup of wheat bran, and 2 cups of prune juice (in total, about 30 grams).

Moxibustion and abdominal massage. Since 2019, in addition to routine nursing care, some patients with constipation in the Nanjing Drum Tower Hospital received moxibustion and abdominal massage as additional interventions for constipation. The decision to receive the interventions were made by the patients themselves and by clinicians from the Department of Traditional Chinese Medicine (DTCM). In brief, when a patient had constipation, the treating physician would inform the patient about the option of receiving traditional Chinese medicine-based interventions (ie, moxibustion and abdominal massage). If the patient agreed, the treating physician would contact a clinician from the DTCM to determine whether the adjuvant therapy was appropriate. If allowed the clinician from the DTCM would perform the interventions; this did not change the standard care the treating physician provided.

In brief, moxibustion was performed by first twisting the dried mugwort leaves (“moxa”) into a square shape, approximately 1 cm in size, followed by reshaping the moxa with 2 hands to create a cup with a base diameter of 80 mm and a height of 100 mm.²² Two of these moxa cups were then placed, one on the acupoint Tianshu (which is located 2 cun, or the width of two thumbs, adjacent to the midpoint of the navel) and the other on the acupoint Zusanli (which is located 3 cun below the shaft of tibia). The top of each cup was ignited with a lighter or burning incense (Figure 2). The cup burned from the top down; when two-thirds of the cup was burned or the patient experienced slight pain with a burning sensation, it was rapidly and smoothly removed with tweezers. After that, the cup was replaced with a new one, which was ignited. The quantity of moxibustion depended on the patient’s specific condition, but 5 rounds for each acupoint were considered standard. During moxibustion, the clinician from the DTCM would monitor the patient for any adverse events (including burns), and the intervention would be stopped immediately when the patient had any relevant complaints or when the clinician noted any adverse events.

Abdominal massage was performed in accordance with the Abdominal Massage Application Guideline developed by Uysal et al.²³ Patients were placed in a supine position with the head-of-bed angle elevated from 30 degrees to 45 degrees, and liquid body oil was used during the massage to facilitate easy movement of the hands on the skin. There were 4 basic strokes used in abdominal massage: stroking, effleurage, kneading, and vibration. Stroking was applied over the dermatome of the vagus nerve, iliac crests, and down both sides of the pelvis toward the groin, and this was repeated several times before effleurage. Effleurage strokes followed the direction of the ascending colon, across the transverse colon and down the descending colon, while kneading was applied down the descending colon, up the ascending colon, and down the descending colon. The massage ended with vibration over the abdominal wall. Each abdominal massage was performed for 15 minutes and each patient received the massage twice a day.

Study outcomes. During the study period, patients admitted to the geriatric department were visited daily by a nurse, and relevant information regarding symptoms or complaints was collected and recorded. In addition, the Geriatric Depression Scale (GDS)²⁴ was measured once a week. For patients with constipation, the CAS was also measured once a week.

In the current study, gastrointestinal symptoms, CAS score, and GDS score were the study outcomes, which were evaluated 2 weeks after the start of the interventions. To evaluate gastrointestinal symptoms, medical records of the included patients were reviewed to identify the following gastrointestinal symptoms: heartburn, diarrhea, flatulence, and reduced bowel sounds. To evaluate effectiveness for constipation, CAS was extracted from the medical records and based on Chinese normal range: “cured” was defined by fully resolved symptoms and a CAS score of 0; “improved” was defined by relieved symptoms or a CAS score <3; “ineffective” was defined as persistent symptoms and a CAS score greater than or equal to baseline.

To evaluate potential benefit in psychological improvement, GDS (Table 2) was used to evaluate depression. Based on the Chinese normal range, subjects whose GDS scores ranged from 11 to 17 were defined as being prone to mild depression, and subjects whose GDS scores were >17 points were defined as being prone to severe depression.

Statistical analysis. Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as number (frequency). Comparisons of continuous variables between groups were analyzed by Student t test, and comparisons of categorical variables between groups were analyzed by chi-square test. A P value less than .05 was considered as statistically significant. SPSS v18.0 (IBM) was used for all analyses.

Ethical considerations. The study is a retrospective study approved by the Ethics Committee of Nanjing Drum Tower Hospital. All data used were routinely collected in daily practice and deidentified before analysis. Patient consent was waived after approval by the Ethics Committee. The study was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patient consent for publication was not applicable.

Baseline characteristics of participants. A total of 200 patients were included, of whom 100 received routine nursing care only, and 100 received the additional interventions (ie, moxibustion and abdominal massage). The control cohort had an average age of 72.27 ± 8.98 years, and 61% were male, the cohort with additional interventions had an average age of 72.95 ± 7.30 years, and 67% were male; there was no statistical significance between groups (P = .558 and P = .377, respectively). Other baseline characteristics, including body mass index, comorbidities, diet, lifestyle, and medication use, were also similar between the 2 cohorts (P for all > .05; Table 3). The 2 cohorts also showed similar baseline CAS scores (7.14 ± 3.67 vs 7.48 ± 2.96; P = .472) and proportions of subjects with symptoms of depression (severe depressed 31% versus 29%; P = .849; Table 4).

Safety of the additional interventions. At 2 weeks after the interventions, when compared to the control cohort, the cohort with the additional interventions had more diarrhea (9% vs 21%; P = .017) but less flatulence (46% vs 23%, P = .001), while there was no statistically significant difference in heartburn and reduced bowel sounds (P for all > .05, Table 5).

Effectiveness of additional interventions. When evaluated at 2 weeks after the interventions, the CAS was 5.37 ± 5.34 and 3.80 ± 4.47 (P = .025), respectively, for the control cohort and the cohort with additional interventions. Improvement in constipation evaluated by CAS could be observed in both cohorts when compared with the baseline, but the cohort with additional interventions had a higher effective rate (51% vs 68%, P = .028; Table 5). Changes in proportions of depression are shown in Table 5. The cohort receiving additional interventions achieved a significant decrease in patients who were severely depressed (from 29% to 15%), and a significant increase in patients who were not depressed (from 29% to 38%, P = .034). No significant improvement in depression was observed in the control cohort, which almost remained unchanged (severely depressed, 31% to 28%; P = .477).

To the best of the author’s knowledge, this study is the first that evaluated the safety and effectiveness of moxibustion and abdominal massage in addition to routine nursing care in the treatment of constipation in hospitalized older patients. The additional interventions (ie, moxibustion and abdominal massage) eradicated constipation in almost one-third of patients, whereas routine nursing care eradicated constipation in only one-quarter of patients. Although eradication was not achieved in all patients, the cohort with moxibustion and abdominal massage showed a higher effective rate compared with the cohort that received routine nursing care only. In terms of GDS, significant decreases in numbers of depressed patients were observed in the cohort with additional interventions, whereas it remained nearly unchanged in the control cohort.

Constipation is a common health problem in clinical practice. Previous studies have suggested that constipation may contribute to an impaired rehabilitation and poor quality of life.²⁵ Moxibustion is a treatment modality originating from traditional Chinese medicine using burning mugwort to stimulate acupuncture points, which has been used to treat various digestive diseases.^26,27 In theory, moxibustion can regulate and modulate the function of qi and blood, support health, and expel pathogens via stimulating acupoints to unblock the meridians and collaterals.²⁸ When the moxa cones are applied to certain acupoints, the intestines can be triggered by the thermal stimulation. Systematic review from Fan et al²⁹ evaluated the clinical effect of acupuncture and moxibustion therapies for chronic pelvic inflammatory disease, and showed significant differences between acupuncture-moxibustion intervention group and control group in terms of total effective rate [OR = 5.63, 95% CI (4.24, 7.47), P < .0001], cure rate [OR = 3.18, 95% CI (2.59, 3.89), P < .0001], and recurrence rate [OR = 0.11, 95% CI (0.03, 0.47), P < .05]. Because of heterogeneity of outcome measures in the included studies, the effectiveness of moxibustion is still inconclusive. In the current study, the effectiveness for the eradication of constipation after intervention was greater in the cohort with additional interventions when compared to the control cohort, which received only routine nursing care.

Little is known regarding the effect of moxibustion on psychological function. The current study investigated the potential effect of moxibustion on GDS and showed that the cohort with additional interventions achieved significant decreases in the number of patients with symptoms of depression than the control cohort, which received only routine nursing care.

A growing body of evidence has suggested that abdominal massage may be an effective strategy in the management of constipation.³⁰ Abdominal massage is characterized by simplicity, convenience, and safety and may be performed by the patient or a nurse. Many studies indicated that abdominal massage applied to patients diagnosed with constipation reduced symptoms of constipation, decreased the time intervals between defecations, and increased quality of life,^30,31 as well as increased the number of bowel movements, stool weight, and stool consistency.³²

Concerns regarding moxibustion and abdominal massage are skin scald and patient adherence due to itch and other discomforts, both of which need to be further investigated and improved. In the current study, it was expected that these events would be be rare (they were not formally analyzed due to a lack of relevant data of good quality). In addition, patients receiving moxibustion and abdominal massage may have higher risk of heartburn and diarrhea. This may be related to the intolerance of both moxibustion and abdominal massage in some elderly patients. Therefore, it is also necessary to discern the reasonable indications of the two specific nursing interventions to avoid relevant complications. In the current study, significantly more diarrhea (9% vs 21%) occurred in patients who received the additional interventions than the other group; thus, attention should be paid to this adverse effect.

Limitations of the study include a retrospective study design, an insufficient duration to assess the long-term safety and effectiveness of the additional intervention, and a failure to distinguish specific and nonspecific effect of moxibustion and abdominal massage. Safety outcomes of the intervention itself (such as itch and skin scald) were also not investigated due to lack of relevant data. In addition, as a retrospective study, the interventions cannot be performed in a strictly defined manner, which may limit the generalizability of the findings. The authors chose 2 weeks as the time point to evaluate the outcomes, which may be arbitrary. Future studies are needed to evaluate outcomes in a dynamic way.

To investigate the safety and effectiveness of moxibustion and abdominal massage in hospitalized elderly patients with constipation, the current study retrospectively included 200 hospitalized older patients with constipation who received or did not receive moxibustion and abdominal massage. It was found that patients who received moxibustion and abdominal massage experienced more relief of constipation. The findings suggest that in addition to routine nursing care, moxibustion and abdominal massage may help to further relieve constipation and depression. However, attention must be paid to the increased occurrence of diarrhea.

Kexin Li, MD¹

¹Geriatric department, Nanjing Drum Tower Hospital, Nanjing 210008, China

POTENTIAL CONFLICTS OF INTEREST: none disclosed

Address all correspondence to: Kexin Li, MD, Geriatric Department, Nanjing Drum Tower Hospital, Nanjing 210008, China; email: lkx930812@126.com
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request