TITLE: The effect of SSP therapy on elderly nursing home residents’ chronic
constipation

  ABSTRACT:
[Purpose] The aim of the present study is to examine the effects of silver spike point
therapy on elderly persons' chronic constipation. [Subjects and Methods] The subjects of
the present study were 30 elderly chronic-constipation sufferers who resided in a nursing
home and had other physical conditions that necessitated wheelchair ambulation. There were
three test groups in the present study: an silver spike point group, an acupuncture group,
and a control group; 10 subjects were assigned to each group. The silver spike point group
and the acupuncture group received their respective interventions, which were applied to
both sides of the Tiensu for 20 minutes per day, five days per week, over a four week
period. Weekly bowel movement frequency was recorded, and the Constipation Assessment
Scale and Bowel Function Assessment Form were used as data-gathering instruments.
[Results] Following treatment, the silver spike point and acupuncture groups showed
significant improvement, based on the Constipation Assessment Scale and the Bowel Function
Assessment Form, compared with the control group. [Conclusion] Based on the above results,
silver spike point therapy can be administered to alleviate chronic constipation in
elderly nursing home residents who cannot walk independently due to declining physical
functions.

BODY.INTRODUCTION:
Approximately 50% of elderly populations residing in nursing homes suffer from chronic
constipation1). Constipation is when a
person has fewer than three bowel movements per week1,
2). Although there are treatments for
constipation, including drugs, biofeedback, and surgery1, 2), these often cause unwanted
complications or are of limited effectiveness2). Recent studies have indicated that electro-acupuncture and
acupuncture therapies are effective treatments for chronic constipation2). Both electro-acupuncture and acupuncture therapies entail
inserting needles into the surface of the body to stimulate bodily functions.  Silver spike point (SSP) therapy is similar to acupuncture therapy and is commonly used in
physical therapy settings. It is a noninvasive, needless treatment in which low frequency
current stimulates the surfaces of acupuncture points. It can be used with patients who are
hypersensitive to needles and is advantageous in that it is not known to cause any
side-effects or complications3). In
previous studies4,5,6), SSP therapy has proved
effective at treating joint and physiological dysfunctions and pain control, Koo7) recently showed SSP therapy was more
effective than the consumption of dietary fiber alone at alleviating constipation in
patients in their 20s.  In this study, therefore, sought to expand upon these previous findings by administering
SSP therapy as a treatment for the chronic constipation of elderly nursing home residents
with conditions that necessitated wheelchair ambulation. The purpose of this study was to
determine if SSP improved the conditions of these constipation patients in the hopes of
helping to develop physical therapy intervention methods effective at alleviating
constipation.

BODY.SUBJECTS AND METHODS:
This study's sample consisted of 30 elderly chronic constipation sufferers who had scored
at least 20 points on a Korean version of mini mental state exam (K-MMSE)8) and were also suffering conditions that
necessitated wheelchair ambulation. The subjects were 65 years of age or older and resided
in an elder-care nursing home located in Yongin-Si, Gyeonggi-do. The study's protocol was
approved by the local ethics committee at the Namseoul University of Cheonan. When the study
subjects were selected, those experiencing digestive system lesions, skin disease, abdominal
wounds, or paralysis due to a neurological disorder were excluded. The study was explained
to each subject and subject's legal guardian, and only those who agreed to participate were
selected. This study strictly abided by the ethical guidelines of the Helsinki Declaration.
The general characteristics of the study's subjects are listed in Table 1Table 1.General characteristics of subjectsVariableSilver spike pont goupAcupuncture groupControl goupAge (yr)83.9 ± 5.483.5 ± 7.785.0 ± 6.2GenderMale212Female898K-MMSE (score)22.4 ± 1.122.2 ± 1.021.6 ± 0.8Weight (kg)43.9 ± 3.540.8 ± 3.340.9 ± 3.9Period of wheelchair (month)25.6 ± 21.435.6 ± 30.929.9 ± 25.7Active daily living (score)11.3 ± 1.811.4 ± 2.110.8 ± 1.6Frequency of meal (day)3.0 ± 0.03.0 ± 0.03.0 ± 0.0Meal type (frequency)Rice667Gruel443Thin gruel000Bristol stool form scale (type)Lumpy544Normal556Loose010Onset of constipation (yr)3.9 ± 2.85.1 ± 3.43.1 ± 2.0Values are shown as the mean±SD. K-MMSE: Korean Version of Mini Mental State Examination.  The study's subjects were then randomly divided into three groups: an SSP group, an
acupuncture group, and a control group. The SSP and acupuncture groups received their
respective treatments on both sides of their Tiensu (ST25) while in the supine position, as
this had previously proved effective when using the aforementioned treatments to alleviate
constipation2, 9). A Dynaroshiftor DS-3004 (Asahidenshi, Japan) was used to administer
treatment to patients in the SSP group. As per Koo's study7), the device's stimulation intensity level was set to 1 Hz, its phase
to 70 μs, and its electrode's adsorptive power (vacuum) to 200 mmHg. SSP therapy was
administered to each patient for 20 minutes per session, five times per week, over a four
week period. As the Dynaroshiftor DS-3004's intensity had been adjusted to a range of 10–25
mA, stimulation intensity was such that no visible muscle contractions occurred. The
acupuncture group received acupuncture treatments administered by licensed oriental-medicine
doctors for 20 minutes per session, five times per week, over a four-week period, and the
control group did not receive any form of treatment.  As for data collection, weekly bowel movement frequency, bowel movement form, degree of
constipation, and bowel function were recorded for each study subject. Bowel movement form
was classified according to the following types, based on the Bristol stool form scale:
lumpy, normal, and loose10). Degree of
constipation was determined using the Constipation Assessment Scale (CAS)11) and bowel function was determined using
the Bowel Function Assessment Form (BFAF)12). These surveys were administered to the study's subjects in person
by a nurse. The CAS consists of eight questions whose answers are measured on three point
scales, with higher scores equating to higher degrees of constipation. The BFAF consists of
12 questions whose answers are also measured on three point scales, with higher scores
equating to poorer intestinal function.  All the collected data were coded and analyzed using the statistical analysis program SPSS
WIN (ver. 21). The general characteristics of the study's subjects were analyzed using
descriptive statistics, and their homogeneity was confirmed using an χ2-test. The
results of these preliminary tests showed there was no significant difference between the
groups. Data from the subject groups' pre and post treatment measurements were then compared
using Wilcoxon signed-rank tests. Finally, Kruskal-Wallis H tests were used to analyze
changes in pre and post treatment measurements within each individual group. The statistical
significance level was set at α =0.05.

BODY.RESULTS:
Following their respective treatments, the SSP group experienced the most significant
reduction of constipation symptoms, based on data from the CAS and BFAF questionnaires. The
acupuncture group's symptoms were also significantly reduced, based on the BFW, CAS, and
BFAF (p < 0.05), while members of the control group reported no change to their symptoms.
With regards to the differences in treatment effects among the groups, compared with the
control group the SSP and acupuncture groups exhibited significant constipation alleviation
according to these patient's answers to the CAS and BFAF (p < 0.05) (Table 2Table 2.Effects of constipation symptoms on each treatment methodsVariableGroupBeforeAfterBowel frequency of week (frequency)Silver spike pont goup1.7 ± 0.12.1 ± 0.1Acupuncture group1.6 ± 0.12.0 ± 0.1†Control goup1.7 ± 0.11.8 ± 0.1Constipation assessment scale (score)Silver spike pont goup8.0 ± 0.65.6 ± 0.7†‡Acupuncture group7.9 ± 0.45.9 ± 0.6†‡Control goup7.2 ± 0.57.2 ± 0.4Bowel function assessment form (score)Silver spike pont goup25.1 ± 0.923.2 ± 0.4†‡Acupuncture group25.5 ± 0.824.0 ± 0.7†‡Control goup23.9 ± 0.623.5 ± 0.6Values are shown as the mean±SE, *p<0.05. †Significant difference between before and after the intervention within
group (p<0.05). ‡Significant difference between the treatment groups and control group
(p<0.05)).

BODY.DISCUSSION:
In addition to simple inconvenience, constipation can result in pain and other serious
problems, such as drug abuse13). In
particular, immobility and no exercise significantly associated with constipation14). Because all the participants in this
study were reliant on wheelchairs for basic mobility and had low ADL abilities, their other
medical conditions were thought to have adversely affected their chronic constipation. In
this study, after respective treatments, the SSP group showed significant condition
improvement in according to their CAS and BFAF and the acupuncture group showed significant
improvement in all of BFW, CAS, and BFAF (p < 0.05). The SSP group and the acupuncture
group showed significantly greater improvement in CAS and BFAF compared to the control group
(p < 0.05), and there was no significant difference in the results between the SSP group
and the acupuncture group.  ST25, which was used as an SSP point in the present study, is an acupuncture point2, 9)
that is connected to the brain's processing network and regularly figures into constipation
and functional diarrhea treatments2, 9). As a result, stimulating this point with
SSP, the present study's authors reasoned, would reduce chronic constipation in elderly
persons living in wheelchairs. Moreover, a review of previous studies on using acupuncture
therapy to treat constipation also indicated that stimulating ST25 with SSP would
effectively reduce constipation2, 15).  For instance, Koo7) reported that, after
six weeks of receiving SSP to both sides of ST25, Gihaesu (BL24), Taejangsu (BL25), and
Kwanwonsu (BL26), constipated patients in their 20s experienced decreases in their left and
right, rectosigmoidcolon, and total colon transit times, and their CAS responses evinced
more significant improvement compared with the responses of those who only increased their
dietary fiber intake. Similarly, another study also showed that CAS responses improved after
patients' S2–S3 were stimulated with low − frequency current16). Although many studies on the use of acupuncture in treating
constipation exist, studies of SSP therapy are currently quite rare. Therefore, the results
of the present study cannot be easily compared with those of others. That said, the present
study's results do show that stimulating ST25 with SSP is an effective means of reducing
constipation.  Furthermore, although the present study's subjects were treated in the supine position, one
advantage of SSP therapy is it can be implemented simultaneously with exercise because the
body can move freely during treatment3).
Immobile persons 2.5 times higher risks of constipation compared to mobile persons14). Further research on SSP therapy should
examine whether implementing this type of therapy concurrently with exercise17) is effective at improving intestinal
motility.  Our study has limitations as the colon transit time of bowel movements could not be
measured to prevent physical side effects on elderly persons due to many times of
radiography in a short time and drugs that were currently taken could not be controlled.
However, this study is meaningful in that reductions in constipation symptoms were shown
using reliable measurement methods. Moreover, these reductions were the result of SSP
therapy, which proved excellent at alleviating elderly persons' constipation.  Through this study, it could be seen that SSP therapy can be utilized as an intervention
for improvement of constipation of elderly nursing home residents with declined physical
functions and chronic constipation.

Question: Compared to Control  what was the result of Acupuncture  on Bowel function improvement ?
Evidence: Constipation assessment scale (score)Silver spike pont goup8.0 ± 0.65.6 ± 0.7†‡Acupuncture group7.9 ± 0.45.9 ± 0.6†‡
Answer: significantly increased