SHEN Qinghe (沈清河), GUAN Zhimin (管志敏), LI Yan (李燕), HAO Chunhua (郝春花)

1 Jiaxing Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medicine University, Jiaxing 314001, China

2 Fengqiao Town Health Center, Nanhu District of Jiaxing City, Zhejiang Province, Jiaxing 314001, China

Abstract

Keywords: Tuina; Massage; Pediatric Massage (Tuina); Embedding Therapy; Intradermal Needle Therapy; Liver Depression and Qi Stagnation; Constipation; Child

Constipation is characterized by straining bowel movements, dry stools, prolonged cycles, and incomplete sensation of bowel movements due to intestinal non-organic factors[1]. In recent years, due to the adjustment of dietary structure and the overindulgence in food and drink, the probability of children suffering from this condition has increased yearly[2]. At present, laxatives are commonly adopted to deal with this condition in Western medicine. This method takes effect quickly but shows obvious side effects, and the condition is easy to relapse after treatment[3]. In traditional Chinese medicine (TCM),acupuncture and Tuina (Chinese therapeutic massage)are commonly used as effective methods to treat constipation[4-5]. We adopted thumbtack needles combined with Tuina to manage this condition, and compared its efficacy with Tuina alone. The details are as follows.

1 Clinical Materials

1.1 Diagnostic criteria of Western medicine

The diagnostic criteria referred to theFunctional Gastrointestinal Disorders and the Rome Ⅲ Process[6].(1) The symptoms originated six months before diagnosis and were currently active for three months.The symptoms must include two or more of the following: ① straining during at least 25% of defecations; ② fewer than three defecations per week;③ sensation of anorectal obstruction/blockage for at least 25% of defecations; ④ manual manoeuvres to facilitate at least 25% of defecations; ⑤ lumpy or hard stools in at least 25% of defecations. (2) Loose stools are rarely presented without the use of laxatives. (3)Insufficient to diagnose as irritable bowel syndrome.

1.2 Key points of TCM syndrome differentiation

The symptoms met the key points of syndrome differentiation for liver depression and Qi stagnation:irritability, and constipation occurring or aggravated during emotional disturbances; a pale tongue with a thin coating, and a wiry and thready pulse.

1.3 Inclusion criteria

Those who met the above diagnostic criteria of Western medicine and the key points of TCM syndrome differentiation; aged between 1 and 12 years old;constipation lingered for at least two months with straining defecations, fewer than three defecations per week, and manual assistance was often needed to facilitate defecations; parents signed the informed consent, agreed with this treatment, and could actively cooperate through the treatment.

1.4 Exclusion criteria

Those who were receiving other treatments that may affect the indicators of this study; suffered from severe conditions such as cardiovascular, cerebrovascular, liver,and/or kidney diseases; suffered from mental disorders.

1.5 Statistical methods

The SPSS version 26.0 software was used for data analysis. The measurement data conforming to normal distribution and homogeneity of variance were expressed as mean ± standard deviation (±s). Pairedt-test was used for intra-group comparisons, and independent samplet-test was used for inter-group comparisons. Rank-sum test was used for the measurement data not conforming to normal distribution. The counting data were expressed as numbers or percentages of cases, and Chi-square test was adopted.P＜0.05 indicated statistical significance.

1.6 General data

We selected 60 children who met the inclusion criteria and visited the Outpatient Department of Tuina of Jiaxing Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medicine University between March 2019 and September 2020. They were randomly divided into a combined group and a Tuina group, with 30 cases in each group. This study was approved by the Medical Ethics Committee of Jiaxing Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medicine University (Ethics Approval No. 2018-JZLK-084). The parents of the kids were informed and agreed with this study.

There was no statistical significance in comparing the general data between the two groups (P＞0.05),indicating that the two groups were comparable(Table 1).

Table 1. Comparison of the general data between the two groups

2 Methods

2.1 Combined group

2.1.1 Tuina treatment[7]

Qing-Cleared Ganjing and Dachang 300 times,respectively; Yun-Circular Pushed Neibagua counterclockwise, Rou-Kneaded and An-Pressed Boyangchi 100 times, respectively; Tui-Pushed down Qijiegu 100 times; Cuo-Twisted and Mo-Rubbed the subcostal regions 50 times; Rou-Kneaded the abdomen clockwise 3 min; Rou-Kneaded Hegu (LI4) and Taichong(LR3) 50 times, respectively. Check Figure 1 for details.

2.1.2 Thumbtack needle treatment

After Tuina treatment, bilateral Hegu (LI4) and Taichong (LR3) were routinely disinfected. The disposable thumbtack needles of 0.20 mm in diameter and 1.2 mm in length were used. Clamped the adhesive tape of the needle with tweezers, inserted the needle tip into the point quickly and perpendicularly, stuck the outer ring of the needle to the skin, and pressed it with the finger pulp. Pressed it for 5-10 min each time,3-5 times a day.

2.2 Tuina group

The cases in the Tuina group were treated with the same pediatric Tuina as in the combined group.

2.3 Treatment course

The treatment lasted for four consecutive weeks(once every other day during the first two weeks, and three times a week during the second two weeks,making a total of 13 times of treatments).

Figure 1. Tuina manipulations

3 Observation of Clinical Efficacy

3.1 Observed items

According to the number of defecation times in a week, we calculated the number of defecation times that were not facilitated by laxatives or manual assistance.

3.2 Efficacy evaluation criteria

The efficacy was evaluated according to theExpert Consensus on TCM Diagnosis and Treatment of Constipation(2017)[8].

Cured: Stools returned to normal or to the pattern before constipation.

Markedly effective: Constipation was significantly relieved, and the defecation interval and stool quality were almost normal, or the stools were slightly dry, and the interval was within 48 h.

Effective: The defecation interval was shortened by 1 d, or dry stools were improved.Invalid: Constipation and other symptoms were not relieved.

3.3 Results

3.3.1 Comparison of the clinical efficacy

The cure rate and the total effective rate in the combined group were higher than those in the Tuina group, showing inter-group statistical significance(P＜0.05) and suggesting that the clinical efficacy of the combined group is better than that of the Tuina group(Table 2).

3.3.2 Comparison of the number of spontaneous bowel movements per week

Compared with the same group before treatment,the number of spontaneous bowel movements per week increased in both groups after treatment (P＜0.05).With the progression of treatment, the number of spontaneous bowel movements per week increased in both groups, and the number in the combined group was more than that in the Tuina group, showing statistical significance (P＜0.05). Check Table 3 for details.

The numbers of spontaneous bowel movements in the two groups at the 0, 1st, 2nd, 3rd, and 4th weeks were analyzed by analysis of variance for repeated measurement data. GraphPad 5.0 was employed to draw the error line diagram. The points represented the mean, and the error lines represented the standard deviation, which were connected by a straight line to show a trend. The diagram indicated that the effect of the combined group was better than that of the Tuina group (Figure 2).

Table 2. Comparison of the clinical efficacy between the two groups (case)

Table 3. Comparison of the number of spontaneous bowel movements per week between the two groups before and after treatment ( ±s time)

Table 3. Comparison of the number of spontaneous bowel movements per week between the two groups before and after treatment ( ±s time)

Note: Compared with the same group before treatment, 1) P＜0.05;Compared with the Tuina group after treatment, 2) P＜0.05

Group n Before treatment After treatment Combined 30 1.54±0.69 5.08±0.251)2)Tuina 30 1.65±0.86 3.22±0.231)

Figure 2. Trend of the number of spontaneous bowel movements per week of the two groups

4 Discussion

Constipation is actually a problem with water metabolism. The liver maintains the free flow of Qi. It influences the fluid distribution and the transportation and transformation of the spleen. The large intestine governs the thinner part of body fluids and eliminates the wastes. Connecting the small intestine, it has an essential impact on water metabolism and bowel/bladder movements. If the liver maintains its normal function to govern the flow of Qi, the large intestine will maintain its normal conduction, and thus the body fluids are transported orderly. Since the liver Qi is related to the conduction of the large intestine,regulating the liver and the large intestine is an important principle in treating constipation[9].

Children often experience exuberant liver Qi, which is a normal physiological phenomenon during their growth. The normal generation of liver Qi can help children grow. However, excessive or insufficient liver Qi may lead to corresponding disorders. The failure of the liver to maintain the free flow of Qi and liver Qi stagnation may cause indigestion, waste accumulation,and subsequent constipation.

Pediatric Tuina is a common method for constipation[10-11]. Qing-Clearing Ganjing, Rou-Kneading Hegu (LI4) and Taichong (LR3), and Cuo-Twisting and Mo-Rubbing the subcostal regions can soothe the liver,relieve depression, and strengthen the spleen.Qing-Clearing Dachang can promote bowel movements;Yun-Circular Pushing Neibagua counterclockwise and Rou-Kneading the abdomen clockwise can circulate Qi and resolve stasis; Rou-Kneading and An-Pressing Boyangchi can promote bowel and bladder movements;Tui-Pushing down Qijiegu can clear heat and dredge the bowels. The combination of these Tuina manipulations can regulate Qi, unblock the bowels, eliminate depression, and thus treat constipation[12].

Guided by the theories of cutaneous regions and Wei-Defensive Qi in TCM, thumbtack needle therapy continuously stimulates the skin and corresponding points by taping the needles into the skin to unblock the meridians and regulate the Zang-Fu organs[13-14]. Most children are afraid of acupuncture. The thumbtack needle is a new type of intradermal needle with the advantages of fast skin breaking, little pain, and long-lasting effect. Bilateral Hegu (LI4) and Taichong(LR3) are four important acupuncture points. In Chinese,they are entitled Siguan points[15]. Embedding the thumbtack needles at these four points can regulate liver Qi and dredge bowels, and thus treat constipation.It is especially suitable for treating constipation in children.

The results in this study showed that the number of spontaneous bowel movements per week in the combined group was significantly more than that in the Tuina group. The clinical efficacy of the combined group was also more significant than that of the Tuina group.The results indicate that the clinical efficacy of thumbtack needles combined with pediatric Tuina for constipation in children caused by liver depression and Qi stagnation is better than that of pediatric Tuina alone.This combined method is worthy of clinical promotion.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Project of Jiaxing City Science and Technology Bureau, Zhejiang Province (浙江省嘉兴市科技局基金项目, No. 2018AD32122).

Statement of Informed Consent

Informed consent was obtained from the guardians of the recruited children in this study.

Received: 27 May 2021/Accepted: 18 August 2021