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This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2009, Issue 2
http://www.thecochranelibrary.com
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
WHATS NEW . . . . . . . .
HISTORY . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .
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[Intervention Protocol]
Contact address: Hong Zhao, Department of Acupuncture and Moxibustion, Guang An Men Hospital, Chinese Academy of Traditional
Chinese Medicine, No.5,Beixiange Street, Beijing, Xuanwu district, 100053, China. hongzhao253@hotmail.com. (Editorial group:
Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group.)
Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD004117
This version first published online: 22 April 2003 in Issue 2, 2003. (Help document - Dates and Statuses explained)
This record should be cited as: Zhao H, Liu JP, Liu Z, Peng W. Acupuncture for chronic constipation. Cochrane Database of Systematic
Reviews 2003, Issue 2. Art. No.: CD004117. DOI: 10.1002/14651858.CD004117.
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To assess the beneficial and harmful effects of acupuncture therapy for chronic constipation.
BACKGROUND
Chronic constipation is a prevalent disorder. It comprises a group
of disorders which present as persistent, difficult, infrequent or
seemingly incomplete defecation. The overall prevalence of constipation in the United States was 14.7% ( Stewart 1999). Prevalence of chronic constipation in the United States compared to
Guangzhou City was 4.6% and 3.0% respectively (Stewart 1999;
Wei 2001). The prevalence of constipation increased with higher
education levels (Stewart 1999) and increased age (Talley 1996).
Tally (Talley 1996) reported that the prevalence of chronic constipation among persons aged 65 years and over was 24.4%. Women
have also been found to have a higher prevalence of chronic constipation than men (Schaefer 1998; Chen 2000).
Chronic constipation results from a disturbed colonic passage
and/or an impaired evacuation of the rectum. Secondary forms
of constipation due to systemic disorders or medications are frequent (Denis 1997). Diagnosing chronic constipation depends on
clinical symptom evaluation using standard scales such as Rome II
gastrointestinal questionnaire, Bristol Stool Form Scale, Cleveland
Clinic Score, or KESS (Knowles 2000; Pare 2001). Transit time
measurement (radiopaque markers), functional rectoanal evaluation (proctoscopy, anorectal manometry, defecography, cinedefecography), and electromyography (EMG) can help make the
diagnosis of chronic constipation and identify other underlying
disease (Kamm 1990; Stivland 1991; Heymen 1993; Jorge 1994;
Maleki 1998; Penning 2001).
The classification of chronic constipation is not very clear. Some
investigators separate constipated patients into three pathophysiological groups: slow colonic transit, pelvic floor dysfunction,
and irritable bowel syndrome (IBS) (Schiller 1996). Other investigators separate chronic constipation into four subgroups: disordered defecation, slow gastrointestinal transit, disordered defecation combined with slow-transit stool, and non-specific disorder
with no pathologic finding (Koch 1997; Nam 2001).
Therapy of chronic constipation is comprehensive and should be
managed according to the type of constipation. The general therapy includes fluid intake, dietary fibers and medications such as
laxatives and enemas, when necessary (Voderholzer 1997; Dey
1998; Wong 1999; Gorazziari 1999; Ni 2001). Functional obstructions in the rectum may require surgical therapy or specialized
forms of treatment such as biofeedback (Piccirillo 1995; Lubowski
1996; Pluta 1996).
In Traditional Chinese Medicine (TCM), chronic constipation is
called bianmi, dabiannan. It is divided into five types in TCM
according to the diagnosis through the tongue, pulse, and symptoms. The types included dry-heat of Intestine and Stomach, block
of Qi of Intestine, deficiency of Stomach and Spleen, deficiency
of Yang of Spleen and Kidney, deficiency of Yin of Intestine.
Acupuncture is a very important form of TCM, which is a
3000-year-old holistic system. Acupuncture therapy includes body
acupuncture, auricular acupuncture, scalp acupuncture, electroacupuncture, laser acupuncture, acupressure, or a combination of the above approaches. Body acupuncture and auricular
acupuncture are the most commonly used therapies for chronic
constipation (Yang 1996; Wu 1996). The record of acupuncture
in treatment of constipation can be traced back to the Jin Dynasty
according to the book A-B Classic of Acupuncture and Moxibustion. In China, many clinical studies have been done during
the last decades. Preliminary searches identified about 90 trials
on treatment of constipation with acupuncture in the Chinese
Biomedical Database (December 2002). The role and efficacy of
acupuncture for chronic constipation are unclear.
These inconclusive results may be due to the methodological weakness of the trials, such as inadequate blinding of patients, investigators or both, inadequate allocation concealment and insufficient duration of treatment. There is no known systematic review
of acupuncture in the treatment of chronic constipation. This review aims to review systematically all randomised controlled trials
(RCTs) and controlled clinical trials (CCTs), which examine the
effectiveness of acupuncture for chronic constipation.
OBJECTIVES
To assess the beneficial and harmful effects of acupuncture therapy
for chronic constipation.
METHODS
Sensitivity Analyses:
A sensitivity analysis will be carried out to determine if the findings from the primary analysis is changed by incorporating different trials in the analysis. This will be done by varying the inclusion criteria and repeating the analysis with the new data set.
In addition, the effect of including randomised controlled trials
reported only in abstracts and in languages other than English will
be examined. Furthermore, if a sufficient number of randomised
trials is identified, we plan to perform sensitivity analysis to explore the influence of trial quality on effect estimates. The quality components of methodology include adequacy of generation
of allocation sequence, concealment of allocation, and the use of
intention-to-treat (yes or no).
Subgroup Analyses:
If a sufficient number of randomised trials is identified, we will
perform the following subgroups analyses:
1. different types of acupuncture therapies (body acupuncture, auricular acupuncture, scalp acupuncture, electroacupuncture, laser
acupuncture, acupressure);
2. treatment duration (less than two weeks or more than two
weeks); and
3. duration of disease (less than 5 years, 5 to 10 years, more than
10 years).
Publication Bias:
Potential biases will be investigated using the funnel plot or other
corrective analytical methods (Egger 1997). We will use a linear
regression approach to measure funnel plot asymmetry on the
natural logarithm scale of the odds ratio.
ACKNOWLEDGEMENTS
Interim funding for the IBD Review Group has been provided by
the Canadian Institutes of Health Research (Institutes of Infection
and Immunity & Nutrition, Metabolism and Diabetes). Miss Ila
Stewart has provided support for the IBD Review Group through
the Olive Stewart Fund.
REFERENCES
Additional references
Chen 2000
Chen LY, Ho KY, Phua KH. Normal bowel habits and prevalence
of functional bowel disorders in Singaporean adults--findings from
a community based study in Bishan. Singapore Med J 2000;41(6):
2558.
Denis 1997
Denis P. Constipation. Contracept Fertil Sex 1997;25(9):7302.
Dey 1998
Dey AB. Constipation. Natl Med J India 1998;11(6):2802.
Egger 1997
Egger M, Davey Smith G, Schneider M, Minder C. Bias in metaanalysis detected by a simple, graphical test. BMJ 1997; Vol. 315,
issue 7109:629634.
Gorazziari 1999
Gorazziari E. Need of the ideal drug for the treatment of chronic
constipation. Ital J Gastroenterol Hepatol 1999;31(Suppl 3):S2323.
Heymen 1993
Heymen S, Wexner SD, Gulledge AD. MMPI assessment of patients
with functional bowel disorders. Dis Colon Rectum 1993;36(6):593
6.
Jorge 1994
Jorge JM, Wexner SD, Ehrenpreis ED. The lactulose hydrogen breath
test as a measure of orocaecal transit time. Eur J Surg 1994;160(8):
40916.
Kamm 1990
Kamm MA, Lennard-Jones JE. Rectal mucosal electrosensory testing-evidence for a rectal sensory neuropathy in idiopathic constipation.
Dis Colon Rectum 1990;33(5):41923.
Knowles 2000
Knowles CH, Eccersley AJ, Scott SM, Walker SM, Reeves B, Lunniss
PJ. Linear discriminant analysis of symptoms in patients with chronic
constipation: validation of a new scoring system (KESS). Dis Colon
Rectum 2000;43(10):141926.
Koch 1997
Koch A, Voderholzer WA, Klauser AG, Muller-Lissner S. Symptoms
in chronic constipation. Dis Colon Rectum 1997;40(8):9026.
Lubowski 1996
Lubowski DZ, Chen FC, Kennedy ML, King DW. Results of colectomy for severe slow transit constipation. Dis Colon Rectum 1996;
39(1):239.
Maleki 1998
Maleki D, Camilleri M, Burton DD, Rath-Harvey DM, Oenning L,
Pemberton JH, Low PA. Pilot study of pathophysiology of constipation among community diabetics. Dig Dis Sci 1998;43(11):23738.
Nam 2001
Nam YS, Pikarsky AJ, Wexner SD, Singh JJ, Weiss EG, Nogueras
JJ, Choi JS, Hwang YH. Reproducibility of colonic transit study in
patients with chronic constipation. Dis Colon Rectum 2001;44(1):
8692.
Ni 2001
Ni YH, Lin CC, Chang SH, Yeung CY. Use of cisapride with magnesium oxide in chronic pediatric constipation. Acta Paediatrica Taiwanica 2001;42(6):3459.
Pare 2001
Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking. Am J Gastroenterol
2001;96(11):31307.
Schaefer 1998
Schaefer DC, Cheskin LJ. Constipation in the elderly. Am Fam
Physician 1998;58(4):90714.
Schiller 1996
Schiller L. Chronic constipation: pathogenesis, diagnosis, treatment.
In: Champion MC, Orr WC editor(s). Evolving concepts of gastrointestinal motility. Oxford: Blackwell Science Ltd, 1996:22150. [:
0865429448]
Stewart 1999
Stewart WF, Liberman JN, Sandler RS, Woods MS, Stemhagen
A, Chee E, Lipton RB, Farup CE. Epidemiology of constipation
(EPOC) study in the United States: relation of clinical subtypes to
sociodemographic features. Am J Gastroenterol 1999;94(12):3530
40.
Stivland 1991
Stivland T, Camilleri M, Vassallo M, Proano M, Rath D, Brown M,
Thomforde G, Pembertom J, Phillips S. Scintigraphic measurement
of regional gut transit in idiopathic constipation. Gastroenterology
1991;101(1):10715.
Talley 1996
Talley NJ, Fleming KC, Evans JM, OKeefe EA, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Constipation in an elderly community:
a study of prevalence and potential risk factors. Am J Gastroenterol
1996;91(1):1925.
Thompson 1999
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine
EJ, Muller-Lissner SA. Functional bowel disorders and functional
abdominal pain. Gut 1999;45(Suppl 2):II4347.
Voderholzer 1997
Voderholzer WA, Schatke W, Muhldorfer BE, Klauser AG, Birkner
B, Muller-Lissner SA. Clinical response to dietary fiber treatment of
chronic constipation. Am J Gastroenterol 1997;92(1):958.
Wei 2001
Wei X, Chen M, Wang J. The epidemiology of irritable bowel
syndrome and functional constipation of Guangzhou residents.
Zhonghua Nei Ke Za Zhi 2001;40(8):517520.
Penning 2001
Penning C, Steens J, van der Schaar PJ, Kuyvenhoven J, Delemarre
JB, Lamers CB, Masclee AA. Motor and sensory function of the
rectum in different subtypes of constipation. Scand J Gastroenterol
2001;36(1):328.
Wong 1999
Wong PW, Kadakia S. How to deal with chronic constipation. A
stepwise method of establishing and treating the source of the problem. Postgrad Med 1999;106(6):199210.
Piccirillo 1995
Piccirillo MF, Reissman P, Wexner SD. Colectomy as treatment for
constipation in selected patients. Br J Surg 1995;82(7):898901.
Wu 1996
Wu S. Treatment of 38 cases of constipation by aural acupuncture.
Chinese Acupuncture and Moxibustion 1996;16(6):57.
Pluta 1996
Pluta H, Bowes KL, Jewell LD. Long-term results of total abdominal
colectomy for chronic idiopathic constipation: value of preoperative
assessment. Dis Colon Rectum 1996;39(2):1606.
Yang 1996
Yang J. Treatment of habitual constipation by acupuncture on Sanyinjiao. Chinese Acupuncture and Moxibustion 1996;16(8):59.
WHATS NEW
15 October 2008
Amended
HISTORY
Protocol first published: Issue 2, 2003
CONTRIBUTIONS OF AUTHORS
Hong Zhao initiated, designed the study and drafted the protocol. She will extract the data, conduct quality assessment and the statistical
analyses.
Jianping Liu provided methodological perspectives and techniques for writing the protocol, acted as an ombudsman for data extraction
and statistical analysis, and revised the protocol.
Zhishun Liu commented on and revised the protocol, and checked the data extraction.
Weina Peng will extract data, assess quality, and analyse data.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
Department of Acupuncture and Moxibustion,Guang An Men Hospital,Chinese Academy of TCM, China.
External sources
No sources of support supplied