Abdominal Massage and Moxibustion in Elderly Constipation: Clinical Benefits With Uncertain Mechanisms

Li et al. recently reported that, in 74 elderly patients with functional constipation, a 4-week protocol of abdominal massage combined with moxibustion, delivered five times per week in addition to usual bowel care, increased stool frequency, improved stool consistency, reduced Constipation Severity Instrument (CSI) and Patient Assessment of Constipation–Quality of Life (PAC-QOL) scores, and yielded a higher “total effective rate” than usual care alone. They also observed higher serum substance P (SP) and lower nitric oxide (NO) and vasoactive intestinal peptide (VIP) concentrations after treatment and interpreted these changes as evidence that the intervention modulates enteric nervous system activity and colonic motility 1. We fully agree that low-risk, non-pharmacological options are particularly attractive in older patients, and we commend the authors for conducting a randomized trial in this vulnerable group. However, we would like to offer several comments on the mechanistic interpretation and trial design. First, serum SP, NO, and VIP are distant and nonspecific surrogates of enteric neurochemical activity. Without complementary measures such as colonic transit, anorectal manometry, autonomic indices, or tissue-level biomarkers, it is difficult to conclude that excitatory enteric tone was truly enhanced. Moreover, correlations between changes in SP/NO/VIP and clinical outcomes (e.g., spontaneous bowel movements, CSI scores, or PAC-QOL scores) were not presented. The observed biochemical shifts might therefore reflect systemic effects of warmth, touch, and relaxation rather than gut-specific neuromodulation. Second, the combined intervention does not allow the individual contribution of abdominal massage and moxibustion to be quantified. Abdominal massage alone has already been shown in randomized trials and meta-analyses to increase bowel movement frequency, improve stool characteristics, and enhance quality of life in adults and frail elderly with chronic constipation, while acupuncture or moxibustion at abdominal acupoints has been reported to influence NO/VIP pathways and enteric neuron function 2-4. In the absence of factorial or sham-controlled groups, attributing the observed clinical and biochemical effects to a specific synergistic mechanism seems premature. Third, patients in the active arm received 1 h of therapist contact five times per week, whereas controls received usual care with follow-up. Such differences in attention and expectation are likely to amplify perceived benefit, particularly when subjective global response and a composite “total effective rate” are used as key outcomes. Contemporary constipation trials generally prioritize validated responder definitions based on complete spontaneous bowel movements, with prespecified secondary endpoints and adjustment for multiplicity; adopting similar standards would facilitate comparison with other pharmacological and non-pharmacological therapies. In summary, Li et al. provide clinically encouraging data supporting a structured abdominal massage plus moxibustion protocol for elderly patients with chronic constipation 1. We suggest, however, that the mechanistic conclusions remain hypothesis-generating and that future studies incorporate modality-specific or sham controls together with more direct motility- and enteric nervous system–related endpoints. Tae Hee Lee: conceptualization; literature review; writing – original draft; writing – review and editing. The author read and approved the final manuscript. The author has nothing to report. This work was supported by the Soonchunhyang University Research Fund. The author declares no conflicts of interest. This article is linked to Li et al., paper. To view this article, visit https://doi.org/10.1111/nmo.70207.