2.5.1. Intervention description

Receiving usual rehabilitation care, the duration is 4 weeks.

Dietary care: nurses will instruct patients to eat more fruits, vegetables, coarse grains, and other high-fibre and nutrient-rich foods, avoid beans and milk, and ensure adequate daily intake of water to soften the stools, thus providing a smooth bowel movement.

Defecation care: use suppositories or laxatives as an aid to defecation as prescribed by the doctor. If the patient is severely constipated, perform a manual cleansing enema for defecation.

Psychological care: ① Nurses will communicate with patients in a cordial and amiable manner in order to establish a good nurse-patient relationship. ② Actively explain to patients about constipation to increase their knowledge of this disease. ③ Take the initiative to communicate with the patients’ family to increase social support and patients’ confidence. ④ Encourage patients to divert negative emotions by listening to music and chatting, and so on.

Receiving the therapy of “combination 3 methods progression” in addition to usual rehabilitation care.

The tool used in this treatment is Taiji pestle needle, which was designed by Li's pestle needle heritage workshop of Affiliated Hospital of Chengdu University of TCM. It includes 4 different types of needles: Seven luminaries-mixed Yuan Pestle, Five Star-Three Terrace Pestle, Vajra Pestle, and Kui Xing Pen (Fig. ​(Fig.2).2). They are all in full brass and their lengths are 10.5 cm, 11.5 cm, 10.5 cm, and 8 cm respectively. The method of holding pestle needle includes pencil operated method (Fig. ​(Fig.3)3) and straight grip method (Fig. ​(Fig.4).4). Pencil operated method is suitable for the treatment of head, face, chest, abdomen, and areas with few muscles of extremities. Straight grip method is suitable for the treatment of waist, back, sacrum, and areas with rich muscles of extremities. Treatment techniques include Diankou, Shengjiang, Kaihe, Yunzhuan, and Fenli (Table ​(Table1).1). The criteria for the selection of acupoints refer to the book “Pestle Needle Studies” published by the Chinese Press of Traditional Chinese Medicine.^[48] There are 2 specific acupoints: Bazheng acupoints (8 array acupoints) and Heche Road (the road for the vehicle). Using an acupoint as Zhong Gong, a circle is drawn with a certain distance (usually is 3 cun, and 1 cun≈20 mm) as a radius from the center of Zhong Gong. This circle is then divided into 8 equal parts (heaven, earth, wind, cloud, dragon, tiger, bird, and snake) to form 8 acupoints, and is called the outer 8 array. The distance from Zhong Gong to the outer 8 array is then divided into 3 equal parts and 2 circles are drawn, which are called the middle and inner 8 array. The acupoints on the inner, middle, and outer 8 array form the Bazheng acupoints (Fig. ​(Fig.5).5). The back of the human body has 7 Heche Road (Fig. ​(Fig.6),6), one of which is the posterior median line and the other 6 are parallel lines of 0.5 cun, 1.5 cun, and 3 cun apart from the posterior median line. The number of acupoints selected for this therapy is 13 (Table ​(Table2).2). The operation steps are as follows: ① Take the 8 array acupoints of Shendao (DU11), use Vajra Pestle and Seven Luminaries-Mixed Yuan Pestle to perform Fenli technique for about 3 minutes, then use the tip of Five Star-Three Terrace Pestle to perform Diankou technique for about 3 minutes. ② Take the 8 array acupoints of Yaoyangguan (DU3) and perform with the same tools and techniques as above. ③Take the Heche Road of Da zhui (DU14) to Changqiang (DU1), use the tip of the Seven Luminaries-Mixed Yuan Pestle to perform Shengjiang technique for about 5 minutes or until skin is slightly red. Then use the tip of Kui Xing Pen to perform Kaihe technique and the tip of Five Star-Three Terrace Pestle to perform Diankou technique for about 3 minutes respectively. Finally, use the shank of Vajra Pestle to perform Yunzhuan technique for about 1 minute. ④ For those who suffer from emotional discomfort and sadness, add Zhangmen (LR13), Sanyinjiao (SP6), and Taichong (LR3). For those who have weak bowel movements, add Tianshu (ST25), Zushanli (ST36), and Shangjuxu (ST37). For those who like to eat hot and spicy food, and drink insufficient water, add Xuehai (SP10), Weizhong (BL40), Chengshan (B57), Zushanli (ST36), Sanyinjiao (SP6), and Baliao acupoint. The frequency of treatment is about once a day, 5 days a week and the duration is 4 weeks.

Diagram of pestle needle (from left to right: Kui Xing Pen, Vajra Pestle, Five star-Three terrace pestle, Seven Luminaries-mixed Yuan Pestle).

Pencil operated method.

Straight grip method.

The detailed methods of treatment techniques for pestle needle therapy.

Diagram of Bazheng acupoints.

Diagram of Heche road.

Location of acupoints for pestle needle therapy.

Treatment techniques include Zhian, Moyun, Zhirou, and Tinie (Table ​(Table3).3). The criteria for the selection of acupoints refer to the book “Tuina Studies” published by the Chinese Press of Traditional Chinese Medicine.^[49] The number of acupoints selected for this therapy is 12 (Table ​(Table4).4). The operation steps are as follows: ① The patient is placed in a supine position and Zhirou technique is applied to Zhongwan (RN12), Guanyuan (RN4), Qihai (RN6), Tianshu (ST25), Daheng (SP15) in turn. ② Place the patient in a prone position, apply Tinie technique to Changqiang (DU1) and Zhirou technique to Pishu (BL20), Weishu (BL21), Ganshu (BL18), Dachangshu (BL25). ③ Apply Zhian technique to Shenshu (BL23), Changqiang (DU1), and Moyun technique to Baliao acupoint. The frequency of treatment is about 20 minutes once a day, 5 days a week and the duration is 4 weeks.

The detailed methods of treatment techniques for Tuina.

Location of acupoints for Tuina.

① Explain the importance of functional exercise and instruct the patient to perform abdominal breathing for 40 times. ② Instruct the patient to massage abdomen clockwise with the base of palm until skin is slightly red. ③ Instruct the patient to perform straight leg raising for 15 to 20 times, bridge-style movement for 5 to 10 times and hip contracting exercise for 10 to 15 times, then relaxing after lasting 5 seconds each time. ④ Pull the anal sphincter horizontally and vertically for 10 to 15 times respectively. ⑤ Finger stimulation for 15 to 20 seconds until the bowel wall is relaxed and feces flows. ⑥ Instruct the patient to simulate defecation. The frequency of treatment was once a day, 5 days a week and the duration is 4 weeks.