Constipation is a common complaint among patients with acute stroke, with an incidence rate of approximately 48% [1]. Straining during stool movements increases intra-abdominal pressure, leading to a rapid rise in blood pressure. The consequent elevation in intracranial pressure increases stroke incidence and mortality rates [2].

Initial interventions for treating constipation usually focus on diet, liquid intake, physical activity, and lifestyle changes. Healthcare providers may prescribe stool softeners, laxatives, or enemas for further treatment if these interventions prove ineffective [3]. These medications can temporarily relieve constipation symptoms; however, they do not address the underlying cause and may result in alternating constipation/diarrhea or metabolism disorders. This can waste healthcare resources and negatively affect patients’ quality of life [4]. Approximately 24% of adults in the United States experience constipation, and 52.2% have adopted non-pharmacological approaches for its management. Therefore, non-pharmacological complementary therapies have gained increased attention recently [5].

In traditional Chinese medicine (TCM) theory, constipation is defined as difficulty in passing stools manifested as a reduced frequency in bowel movements, dry and hard stools, prolonged defecation time, or strenuous bowel movements despite the absence of hard stools. Acupressure, a complementary TCM therapy, is an effective method for preventing and managing constipation [6]. Acupressure involves stimulating acupoints by applying physical pressure using the fingers or elbows. Therefore, acupressure might be a complementary therapy for constipation management in addition to Western medicine.

Constipation is a condition where bowel movement frequency is less than three times per week, accompanied by unsatisfactory defecation, difficult stool passage, or infrequent stools, which are also key symptoms of gastrointestinal dysfunction [5]. The Rome IV diagnostic criteria for functional constipation, developed by the Rome Foundation Working Teams and Committees, have a specificity of up to 93.6% [7]. Two or more of the following symptoms must be present for at least 3 months (with symptom onset occurring at least 6 months before diagnosis) and at a frequency >25% to diagnose constipation: straining during stool passage, lumpy or hard stools, a sensation of incomplete evacuation, a sensation of anorectal blockage, use of manual maneuvers to facilitate defecation, and fewer than three spontaneous bowel movements per week.

Patients with stroke and physical dysfunctions may experience increased rectal sensation threshold and tension in the pelvic floor muscle owing to long-term bed rest. Consequently, colonic transit is decreased, making it difficult to pass stool, reducing patients’ quality of life [8], particularly in patients with brain lesions in the basal ganglia and thalamus [9]. Constipation is a common problem in patients with stroke. Straining during bowel movements can increase intra-abdominal pressure, leading to a rapid rise in blood pressure and an increased risk of stroke recurrence [10].

Stroke can induce inflammatory and immune responses in the brain and immune organs. The gastrointestinal tract, a major immune organ, possesses the largest pool of immune cells, accounting for more than 70% of the immune system. Issues related to the bi-directional communication between the brain and intestine, known as the brain-gut or gut-brain axis, may cause poor outcomes, such as intestinal motility disorders, intestinal dysbiosis, impaired intestinal permeability (“leaky gut”), intestinal bleeding, and gut-derived sepsis [11].

According to "the lung stands in interior-exterior relationship with the large intestine theory” of the TCM theory " the lungs and intestines are also suggested to be correlated based on new anatomical data from the autonomous nervous system (ANS) and clinical observations. "The lung controls the flow of the Qi mechanism, the large intestine controls the transmission and the body's vital fluids. The transmission function of the large intestine depends on the reduction and clarification of lung qi. When lung qi removal is blocked and cannot be carried out to the large intestine, it depletes the body's fluids, disturbs the distribution of fluids, leads to waste accumulation and constipation., the Qi-deficiency constitution, phlegm-dampness constitution, and autonomic nervous system unbalance, all common in patients with stroke, affect the visceral function, causing symptoms such as constipation, flatulence, and incontinence [12,31]. The condition is primarily associated with old age, female sex, physical inactivity, low educational level and income, concurrent use of antidepressants, and low food intake. Secondary factors include endocrine or metabolic disorders, nervous system disorders, such as Parkinson's disease and stroke, myogenic diseases, pharmacological treatment with opioids, and chronic or cancer-associated pain [5,9].

Acupuncture points, also known as acupoints, are specific sites in the circulatory routes of the Zang-Fu viscera and meridian collaterals that are distributed on the surface of the human body where Qi and blood can gather, transfer, and enter or exit the body. Acupressure exerts its effects on constipation by penetrating Qi and strengthening the body through the meridians and collaterals, triggering the flow of Qi within the meridians. This promotes unobstructed functional activities of Qi in the lungs and the recovery of gastrointestinal function [13].

Four studies have investigated the effectiveness of acupressure in improving constipation in patients with stroke. Chen [14] randomly divided 40 patients with stroke who had constipation in a rehabilitation ward into an experimental group, which received acupressure at the Hegu (LI4), Zusanli (ST36), and Tianshu (ST25) acupoints combined with abdominal massage, and a control group, which received a sham acupressure procedure. Each intervention session lasted 12 min in both groups and was performed twice daily by the same research nurse. Patients in the experimental group received interventions for 7 days and follow-up for 2 days (9 days in total). Results revealed that compared with the sham acupressure procedure, intervention involving actual acupressure provided considerable beneficial effects, including increased frequency of bowel sounds, alleviated abdominal distension, increased frequency of bowel movements, improved Bristol Stool Form Scale (BSFS) scores, alleviated sensation of anorectal blockage, reduced degree of straining during bowel movement, and reduced sensation of incomplete evacuation. Weng & Xu [15] randomly divided 118 patients with stroke who had constipation in a neurology ward into experimental and routine control groups. Patients in the experimental group were subjected to daily pressing and kneading of the bilateral Zusanli (ST36), Sanyinjiao (SP6), Zhigou (SJ6), Hegu (LI4), and Tianshu (ST25) acupoints by a nurse before getting up in the morning and before bedtime at night. Each intervention session lasted for 15 min, with each acupoint pressed and kneaded for 1–2 min, and the interventions were performed for 1 week. Results indicated that the experimental group had a significantly lower occurrence of constipation than the control group [15]. In an additional study, patients with stroke in an intensive care unit (ICU) were randomly allocated to an experimental group (18 patients) or a routine stool softener treatment group (17 patients). Patients in the experimental group received finger acupressure from a nurse at the Tianshu (ST25) and Guanyuanshu (BL26) acupoints. Each acupoint was massaged for 1 min, and the intervention was performed once daily for 1 week. Results revealed that the experimental group experienced a significant improvement in bowel movement frequency and constipation severity [16]. Wang et al. [17] randomly assigned patients with stroke who had constipation in a neurology ward to experimental and control groups. Patients of the experimental group were subjected to acupressure at the Tianshu (ST25), Daheng (SP15), Qihai (CV6), Guanyuanshu (BL26), Zusanli (ST36), and Shangjuxu (ST37) acupoints. After the intervention, the constipation symptoms of the experimental group had markedly improved, with better results than those of the control group [17].

The results of these studies indicate that acupressure can alleviate constipation. However, the acupoints employed in current research, which are located on the upper and lower extremities and the abdomen and are difficult to recall, may require patients to change positions. The need to change positions also increases the difficulty in performing acupressure and the risk of falls in patients with stroke. Focusing solely on abdominal acupoints for acupressure can enable clinical interventions to be performed on patients who are bedridden. In addition to preventing constipation, using solely abdominal acupoints ensures patient safety and increases the likelihood of patients or their family members self-executing acupressure interventions.

This study aimed to investigate the efficacy of acupressure in mitigating constipation, increasing bowel movement and sound frequency, reducing stool softener use, and enhancing stool appearance. We hypothesized that the change in the Constipation Assessment Scale (CAS) score in patients with stroke who received acupressure would be greater than that in patients who received a sham acupressure procedure. Compared with patients who underwent sham acupressure, patients with stroke who underwent acupressure had a reduced stool softener use, increased bowel sound frequency, and improved stool appearance.