Yao JP, Chen LP, Xiao XJ, et al. Effectiveness and safety of acupuncture for treating functional constipation: an overview of systematic reviews. J Integr Med. 2022;20(1):13-25.
To determine the safety and efficacy of acupuncture for functional constipation (FC) by analyzing the reliability and results found in systematic reviews on the topic
Acupuncture may be superior to anticonstipation drugs for improving bowel movements and quality of life.
A meta-analysis of published systematic reviews of acupuncture for constipation
Investigators used 5 well-respected appraisal methodologies and tools to measure clinical outcomes, reporting accuracy, quality of evidence, and risk of bias. They queried the following electronic databases: PubMed (via MEDLINE), Cochrane Database of Systematic Reviews, Embase, Web of Science, the Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Science and Technology Periodical Database, and the Wanfang Data
This review identified 327 potential and relevant publications, ultimately narrowing results by removing duplicates (n=110) and screening out an additional 186 articles based on title and abstract review for inclusion/exclusion criteria.
Eventually, 31 full-text articles underwent extensive analysis. After investigators excluded 18 articles due to various unmet requirements (acupuncture not being the main intervention was most common), this meta-analysis reviewed a total of 13 systematic reviews (SR) published between 2012 and 2020.
Criteria for Inclusion
Investigators included studies if:
- Acupuncture was the primary treatment for FC
- Patients were diagnosed with FC based on the Rome IV/III/II criteria for functional gastrointestinal disorders without selection/exclusion based on ethnic background or gender;
- Acupuncture was performed without limit as to type or method of delivery;
- The comparison group received sham acupuncture, was not treated at all, experienced no other forms of active therapy, and was not taking anticonstipation drugs;
- Weekly complete spontaneous bowel movements (CSBMs) or weekly spontaneous bowel movements (SBMs) were the principal outcomes measured; and
- The Bristol Stool Form Scale (BSFS), the Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire, the total effective rate, the Cleveland Clinic Score (CCS), and the incidence of adverse events were used as measures of secondary outcomes.
Criteria for Exclusion
Studies were excluded if:
- Participants also exhibited constipation from irritable bowel syndrome, or from a secondary source (postoperative, drug-induced, etc.);
- Acupuncture was not a major intervention;
- Use of Chinese herbal medicine was part of any treatment protocol;
- Indirect comparisons or network meta-analysis (NMA) were a comparative measure;
- Extraction of data was not possible; or
- The study was a narrative review.
The remaining 13 systematic reviews analyzed for this article included 164 randomized controlled trials (RCTs) with a total of 12,304 patients. All 13 reviews originated in China.
Study Parameters Assessed
Among the criteria used to assess the systematic reviews, authors of this meta-analysis used AMSTAR 2 methodology to assess whether the SR had established their review methodology prior to initiating the study, and only 1 of 13 was in compliance. Only 1 of 13 SRs mentioned their study design. All 13 SRs indicated appropriate technique for assessing risk of bias in the RCTs included in their review.
Twelve of the 13 SRs were rated overall as “critical low” confidence for compliance with AMSTAR 2 rating factors. Only 1 of the 13 studies was rated with “low” confidence. Five of the 13 studies (38.5%) were rated with “low risk” of bias, while 10 of the 13 studies were rated with 70% of compliance (reporting was relatively complete) with reporting standards under PRISM-A criteria.
The quality of 40 different measured outcomes within the 13 studies varied between “moderate” quality (22.5%); “low quality” (57.25%); and “very low” quality (22.5%).
The overall quality of the SRs was not rigorous per reliability criteria (below).
Lack of rigor notwithstanding, the conclusion of the SRs was that acupuncture was found to be more efficacious than sham acupuncture for functional constipation, with improvements in both complete spontaneous bowel movements and the Bristol Stool Form Scale scores.
Serious adverse events were not associated with acupuncture.
Reliability of the systematic reviews:
Using the AMSTAR 2 tool, investigators rated 12 out of 13 SRs as “critically low” confidence and 1 study as “low” confidence.
Using the ROBIS criteria, they considered 5 out of 13 SRs to have “low risk” of bias.
Based on PRISMA-A, 10 out of 13 SRs had >70% compliance with reporting standards.
According to the article, the National Natural Science Foundation of China and the Foundation of the Science and Technology Department of Sichuan Province, China, provided grant funding for this SR. All authors declared themselves free of competing financial interests or personal relationships that could have influenced their work.
Practice Implications & Limitations
It is notable that all 13 of the SRs were done in China. The lack of rigor that investigators found highlights concerns often voiced in Western medicine regarding quality of research conducted in China. Unfortunately, we do not yet have enough published research conducted elsewhere on this topic. It is true that this article exposes the lack of reliable research, but it also concludes that acupuncture may be superior to sham acupuncture for improving CSBM and improving measures by the Bristol Stool Form Scale. So how are we to interpret this information?
With all 13 of the SRs considered as “low” or “critically low” confidence, the average clinician may not have an incentive to look further. Only 1 of the 13 analyzed SRs mentions acupuncture protocols and treatment methodologies. This lack of rigor in methodology is a problem noted by the authors of this meta-analysis, and it may leave clinicians without the proof needed to guide clinical decisions.
As is often the case in integrative medicine, we are left to tease out best practices based on the evidence we do have, weighing the risk versus benefit of nontoxic therapies with knowledge of the safety of traditional medicines based on thousands of years of practice.
While the evidence may not be rigorous, the authors suggest that acupuncture is more effective than anticonstipation drugs in improving frequency of bowel movements, as well as quality of life. They also highlight the potential for research (and anecdotal evidence), which supports use of acupuncture over pharmacology for the majority of cases involving functional constipation.
In summary, while this meta-analysis concludes that acupuncture offers a valued treatment option for functional constipation, the cited research is not conclusive because much of it does not meet the reliability criteria from an objective assessment.
In what might be considered the most reliable of the 13 SRs, the only “low confidence” SR (a 2021 article published in the Journal of Gastroenterology and Hepatology) addressed research regarding the use of acupuncture on functional gastrointestinal disorders.1
With all 13 of the SRs considered as 'low' or 'critically low' confidence, the average clinician may not have an incentive to look further."
In this article, the authors summarized evidence found in 61 RCTs and included outlines of acupuncture methodology and protocols used. Among 40 studies that compared acupuncture to pharmacology in the 2021 article, acupuncture was 95% more effective than pharmacotherapy in treating functional gastrointestinal disorders.
To this end, and as a practitioner of East Asian Medicine (EAM), I am inclined to trust the results, which suggest that acupuncture for functional constipation is more effective than drug interventions. In my clinical practice and after years of training and applied theory, I am confident that a good differential diagnosis and the use of acupuncture points, as well as other EAM modalities of tui na and herbs, will produce highly effective treatment for functional constipation.
While the research mentioned in this article is weak, there is strong empirical evidence from traditional Eastern medicine practitioners to support the use of acupuncture for functional constipation. As mentioned by the authors of this meta-analysis, further and more rigorous research is necessary to prove the point.