Complementary Therapies in Medicine 57 (2021) 102665
Available online 16 January 2021
0965-2299/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
The effects of abdominal "I LOV U" massage along with lifestyle training on constipation and distension in the elderly with stroke
Zahra Fekri
a, Nahid Aghebati
a,b,*, Tahereh Sadeghi
b, Mohammd taghi Farzadfard
caDepartment of Medical Surgical nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
bNursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
cMedical School, Mashhad University of Medical Sciences, Mashhad, Iran
A R T I C L E I N F O Keywords:
Abdominal massage Lifestyle education Elderly Stroke
A B S T R A C T
Introduction: Constipation and distension are dominant gastrointestinal problems after stroke in the elderly.
Always they are treated by the use of laxatives and fibers. Abdominal massage along with a healthy lifestyle can be a solution.
Purpose: This study aimed to investigate the effect of abdominal massage and lifestyle training on constipation and distention of the elderly with stroke.
Method: This study was a randomized clinical trial that was conducted on elderly patients with stroke at Qaem hospital of Mashhad, Iran. 68 patients were randomly allocated into control (n =34) and intervention (n =34) groups in 2017−2018. Finally 29 elderly in the intervention and 34 in the control group completed the study.
Intervention included the abdominal massage by using "I LOV U" method along with lifestyle education. Each abdominal massage lasted for 15 min, twice daily for ten days that was performed at first session by the researcher and then continued by the key care giver. Data were collected by the demographic form, constipation assessment score (CAS), distension measurement tool (meter), and food tolerance evaluation checklist.
Results: The results indicated that both groups were homogeneous in demographic variables (P >0.05). The repeated ANOVA showed a more significant decrease in abdominal circumference of the intervention group during the 10- days study (P =0.029).The Friedman test showed a significant difference in frequency of defe- cation in two groups in 10- day study (P <0.0001). Therefore the CAS Score was significantly decreased in intervention group more than the control group (0.30 <0.98 <1.59, P =0.001, EF =0.44). The food tolerance frequencies through Gavage (P =0.20), and also orally (P <0.001) were significantly improved in the inter- vention group.
Conclusion: According to results, the abdominal massage along with lifestyle training could improve constipation and distension and also increase food intake tolerance in the elderly patients with stroke.
1. Introduction
Nowadays, the phenomenon of aging and its related problems is a very important issue that has attracted the attention of scholars of various sciences.1 According to the United Nations Information Center, 26 % of the Iran’s population will be over 60 years of age by 2050;
hence, paying attention to needs of the elderly is a social necessity.2 The elderly suffer from gastrointestinal complications such as constipation and distension due to the aging process. On the other hand, if they suffer from nervous system diseases such as stroke, the risk of gastrointestinal complications increases in them.3 The annual incidence of first-time
stroke is 139 (95 % CI, 128–149) per 100 000; for men, 144 (95 % CI, 128–159), and for women, 133 (95 % CI, 118–148) in Iran.4
Constipation is a common gastrointestinal complication in stroke patients.5 According to a systematic review the incidence of constipation in patients with stroke varied from 29 % to 79 %.6 Therefore, an inter- vention, which can reduce gastrointestinal complications have many health benefits for the elderly with stroke.6
Accordingly, Li and colleagues concluded that despite the fact that the constipation is a common complication in nervous system diseases especially in elderly, there is no adequate investigation about the treatment and management of constipation in elderly patients with
* Corresponding author.
E-mail address: [email protected] (N. Aghebati).
Contents lists available at ScienceDirect
Complementary Therapies in Medicine
journal homepage: www.elsevier.com/locate/ctim
https://doi.org/10.1016/j.ctim.2021.102665
Received 26 February 2020; Received in revised form 28 August 2020; Accepted 11 January 2021
stroke.6
Thus, the common solution in these patients is to use different lax- atives with short-term effects, to which patients become accustomed over time, while imposing high costs and complications on patients.7
As nurses are always the first line people in touch with the stroke elderly patients in the hospital, they should implement some in- terventions independently to alleviate the patient’s constipation and gastrointestinal complications.8 Therefore using some non-pharmacological methods to alleviate constipation and distention that can be used by the nurses independently is necessary.9
Abdominal message is a non-pharmacological nursing interven- tion,10,11 that has been suggested and applied recently for the treatment of constipation and distension in neonates,12 Parkinson’s patients,13 and cancer patients.14 However, results of a review study on the constipation consider the efficacy of abdominal massage subject to further studies, while it is believed that there is no most effective abdominal massage technique for relieving the constipation,15 so that the clockwise massage by hand on abdomen with low to moderate pressure is more common.11 However, Tekgündüz et al. utilized an abdominal massage in pre- term infants by applying a clockwise direction over the intestines and colons on the abdominal wall (I LOV U). Their massage technique was directed along the rout of bowel movements which was significantly effective on preterm- infants fool tolerance.16 Although this was an effective massage technique which was done by the parents, it can’t be generalized to the other populations like elderly.
On the other hand, low fluid diet, low fiber, and sedentary life are predisposing factors of constipation in the elderly.7 Some studies have pointed out the effectiveness of diet modification and constipation improvement activity.17–19
As lifestyle training is also a nursing intervention, if patients have no good diets, sufficient activity and movement, massage alone is unlikely to improve the patients’ long-term gastrointestinal complications.20
Thus it is necessary to input some educations such as modifying the diet and considering sufficient activities in addition to an effective abdominal message in nursing process.9
According to the researches there are some clinical trial studies about the effectiveness of multiple forms of abdominal message on the constipation,9,10,21,22 some systematic7 and critical reviews17,20 about the methods of alleviating constipation and gastrointestinal complica- tions in elderly, intensive care unit23,24 and stroke patients.8 Also there is a narrative review which suggests a guideline proposed using abdominal massage along with modifying the life style to relieve con- stipation and distention without applying it in a clinical trial.25 Despite the multiple studies on this subject, it is considered that the bowel management strategies for constipation in adults especially in elderly with stroke are limited. The available evidence suggests that structured bowel programs and nurse-led interventions in bowel care have a sig- nificant effect in improving bowel evacuations, which merits further evaluation.8
Therefore the present study aimed to determine the impact of the "I LOV U" abdominal massage along with a lifestyle modification training on constipation and distention of hospitalized elderly patients with stroke.
1.1. Research objectives
- Determining the effect of "I LOV U" abdominal massage along with lifestyle training on the constipation of elderly with stroke - Determining the effect of "I LOV U" abdominal massage along with
lifestyle training on the distention of elderly with stroke
- Determining the effect of "I LOV U" abdominal massage along with lifestyle training on the food tolerance (as a secondary outcome) of elderly with stroke
2. Materials and methods 2.1. Study design and sample selection
The present study was a randomized, pre-test posttest non-blind controlled clinical trial in elderly patients with stroke. The research environment was acute neurological ward of Qaem Hospital of Mash- had, Iran from Aguste 2017 to February 2018.
The sample size was obtained 26 in each group according to a study26 with regard to type I error: 0.05 and test power 80.
But in the process of the study the researchers found that the dura- tion of the constipation improvement in patients were different. Some of the patients’ constipations improved after three or four days massage in intervention group. Then the researchers decided to increase the sample size to decide more confidently about the effectiveness of massage on the duration of the constipation improvement time to catch higher effect size. Then by considering the attrition 34 samples were considered for each group.
In the research duration time about 100 stroke elderly were admitted to the acute neurologic ward. But 68 patients had the inclusion criteria.
34 were allocated in intervention and 34 were allocated in control group. To do the randomization, the randomization.com website were used (Fig. 1).
At first 100 randomized digits from 1 to 100 achieved from the site.
Randomly the 50 digits considered for intervention and 50 for control group (100 digits were considered because of the attritions). The random digits kept in two separate pockets.
Then from the beginning of the study the first patient that had all of the inclusion criteria numbered as 1. The researcher saw the random digits, if the number 1 were in the intervention list the patient would considered to be in the intervention group, if the number 1 were in the control list the patient would be in the control group. Then the second patient 2, third 3 and so on. This method of sampling were continued until completing all of the 68 patients in each group.
The elderly were selected according to the inclusion criteria: age: (65
<age < 90), having a definitive diagnosis of Ischemic stroke; going through the acute time of the stroke at least 72 h; score 5 and higher in constipation assessment score (CAS); Glasgow coma scale above 7;
Having a key caregiver.
Exclusion criteria were involved: unwillingness to participate in the study; the patient death; previous abdominal or pelvic surgery; disorders such as pancreatitis, gastrointestinal ulcer or cancer, liver or kidney failure; ulcers on abdominal wall; a situation when the key caregiver could not continue abdominal message more than 3 times; being NPO; a situation when a semi-upright position is prohibited for the patient; the patient shows the symptoms of acute abdomen.
During the study 5 patients in the control group didn’t’ continued the research. 2 died, 3 didn’t continued the abdominal message training.
Therefore, data analysis was performed on 29 elderly in the intervention group, and 34 elderly in the control group (Fig. 1).
2.2. Instruments
The research instruments included demographic information and disease history form, the constipation assessment scale (CAS), Meter, Food intake and defecation daily checklist.
2.2.1. Demographic and disease information form
This form was structured by the researchers according to the litera- ture. That has two sections. First: the closed questions about the personal information. Second questions about the disease information such as the type and site of the stroke, chronic diseases, drug history.
2.2.2. Constipation assessment scale (CAS)
CAS was used to assess patient’s constipation. The tool has 8 ques- tions with 3 grades. Grade 0 means that the patient has no constipation.
Grade 1 means that the patient has moderate constipation. Grade 2 means severe constipation. If the patients get a 1–4 score in the CAS, they have mild constipation. Score 5–9 in the CAS tool indicates mod- erate constipation. Score 10 and above indicates severe constipation.
The tool assesses the clinical severity of constipation, including 8 characteristics: Frequency of defecation; abdominal distension, bloating and changes in gas excretion; fluid secretion around the stools during the defecation; feeling of fullness and pelvic pressure; anal pain during defecation; low stool volume; and failure to defecate for 24 h. It is a valid scientific tool which was first designed and psychometrically evaluated by Mc Millan and Williams in 1989 to evaluate the severity of con- stipation. Furthermore, Ghaffari et al. (2007) confirmed the instrument translation validity in Persian. They confirmed its reliability with a 24 -h interval test-retest with Pearson correlation coefficients of r =% 82 and r
=% 84. In the present study, the reliability was confirmed by obtaining the kappa coefficient of higher than 0.7 by inter-observer reliability.
CAS was completed before the intervention and ten days after.
2.2.3. Meter
To measure the distention, the researcher measured the abdominal round by a meter every day in the morning.
2.2.4. Food intake and defecation daily checklist
The checklist was designed by the researchers. It was concluded three parts. First the report of daily defecation and the abdominal physical exam by the researcher. Second part was concluded the reports of daily food intake in patients that had NG-tube. The report of 12 h food intake such as the gastric residual, gavage type and amount of food was written.
Third part was concluded the reports of daily food intake in patients
that had oral intake. The reports of 12 h food intake such as the amount and type of food, and also if the patient had nausea or vomiting was assessed.
The content and face validity of the checklist, was confirmed by the help of 10 faculty members (gastrointestinal nurses and specialists) of Mashhad university of medical sciences.
2.3. Procedure
After completing the informed consent, the elderly were allocated to the experimental or control group. Then the demographic and disease form, and the CAS were completed by the help of the patient’s key care giver. Then the intervention were started in the experimental group in ten days. The checklist were completed daily. The CAS scale were completed before the intervention and ten days after.
2.3.1. Implementation steps in experimental group
The intervention in experimental group were divided in to two parts.
Abdominal message and life style training.
2.3.1.1. Abdominal message. According to the Tekgündüz et al. (2014), who were introduced the I LOV U abdominal message in neonates, the message technique can be learned by the patients’ care giver. Therefore, despite the researcher was a gastrointestinal RN, and is doing abdominal message professionally in about 10 years, the main purpose in this research was training the patient’s key care giver to do the message for the patients every day even after the end of the research. Because con- stipation and distention are always continuous gastrointestinal compli- cations in elderly.
Thus at the beginning of the research, the researcher did the Fig. 1. the CONSORT flow diagram of the study.
abdominal message for the patient individually and asked the patient’s care giver to observe the procedure. Then the researcher asked the care giver to do the message in the supervision of the researcher. When the researcher confirmed that the patient’s care giver can do the message individually, then asked him/her to do the message for the patient. A checklist was used to assess the ability of the care giver to do the message.
2.3.1.1.1. The steps of ILOVU abdominal message. - At the begin- ning, the researcher asked the pa- tient to be in a supine posi- tion in a relaxed manner.
- The researcher explained the procedure face to face to the patient and the key caregiver
- Then the procedure of diaphragmatic breathing was thought to the patient.
- The massager’s dominant hand was shaped like a paddle, and then the circular clockwise massage was performed in line with the bowel movements on abdominal wall with medium pressure.
- Abdominal massage had an "I LOV U" technique. Circular abdominal massage movements were performed in the form of letters I, L, U, and O towards the bowel movements of colon and small intestine.
- For massage of the left side, the patient was position in supine, and the massage was performed circularly by writing the letter I on the left upper quadrant (LUQ) and continued vertically downward along the Left lower quadrant (LLQ).
- To write a letter L, the massage started from the right lower quadrant (RLQ) of abdomen along the upward segment of colon to the right upper quadrant (RUQ), and then from the transverse segment of massage colon to the left upper quadrant (LUQ).
- To write a letter O exactly around the navel in umbilical region, the massage was along the small intestine.
- To write a letter U, all areas, where we massaged by writing I and L, were re-massaged continually. To write a letter U, massage started from the right lower quadrant (RLQ) along the upward segment of colon to the right upper quadrant (RUQ), and then continued along the transverse segment of colon to the left upper quadrant (LUQ).
Then, the left upper quadrant (LUQ) was massaged, and we vertically continued downward along the descending colon segment to LLQ.
The duration of each massage was 15 min twice daily, once 2 h after breakfast and another 2 h after lunch for ten days.
2.3.1.1.2. The life style education content. The life style education content in this study was included: The mean volume of daily fluid intake (30cc/kg) if there were no fluid limitation, Daily amount of fiber intake (18− 32gr) by taking a pamphlet about the food with fiber to the patient, education the correct technique for Gavage in addition to the appropriate position during defecation and daily active or passive physical activities. The appropriate technique for defecation was divided in to two parts that was thought according to the patient’s ac- tivity limitations: 1- Sitting in a position that the hip had been bended in 90 degree while the body would be in a state condition.2- Being in a lateral position while the hip and knee should be flexed.
Prior to the intervention, the pre-test (to determine constipation, distension and food tolerance) was performed in both groups. Then, the abdominal massage and lifestyle training were performed in the inter- vention group.
As long as the elderly were in the hospital, the researcher completed the constipation and distension instrument, daily at the beginning of the morning between 7:00 to 7:30.Then it was performed by phone contact after discharge.
The control group received only the routine educations about the
lifestyle and diet trainings. After completing the research and the completing the posttest scales, the control group received the image file of massage on the final day. The data were analyzed by SPSS16 through descriptive tests such as mean, standard deviations and frequencies and also some analytical statistics like repeated measure ANOVA, man Whitney U test, chi square and etc.
2.3.1.1.3. Ethical considerations. The approval of the research were obtained from the ethics committee of Mashhad University of Medical Sciences: IRMUMS.NURSE.REC.1397.004. The research were registered in Iran Randomized clinical Trail registration site:
IRCT20180721040547N1. Before the sampling each patient or the key care giver completed the informed consent. And the patients and their care givers were free to leave the research in any time they wanted.
3. Results
The mean and standard deviation of the elderly age was 78.1±8.4 years in the intervention group and 76.7±8.3 years in the control group.
Independent t-test did not show any significant difference between groups (P =0.508). There were no significant difference between two groups in terms of other demographic and disease data (P > 0.05) (Table 1).
According to the results, most of the patients had no defecation in the first day in both groups (P =0.19). But from the fourth day most of the patients in intervention group had defecation, which was significantly more than the control group (P =0.004, contingency coefficient (day 4,5) =0.34, 0.39). The data showed that the defecation of most of the patients in control group was started in seventh day (Table2). According to the general rules of thumb given by Cohen and Miles & Shevlin (2001), if the contingency coefficient in the chi square test is more than 0.29, it will have a middle effect size. In this case, the contingency co- efficient was 0.3.
Results of t Student test of comparing the mean and standard devi- ation of the constipation assessment scores (CAS) before the interven- tion, did not show any significant difference (P =0.435) between two groups (Table 3). While the results of the analysis showed a significant improvement (P <0.001, CI(0.30,1.59), EF =0.44) in the mean of the constipation assessment scores (CAS) in the intervention group in comparison with the control group after ten days intervention.
Also the results indicated that while all of the elderly in both groups consumed magnesium hydroxide syrup before the study, the consump- tion of magnesium hydroxide syrup reached 64.7 % in the control group and 20.7 % in the intervention group after the intervention (Table 3).
Results indicated that 65.5 % of the elderly in the intervention group
Table 1
Demographic characteristics of the elderly in both intervention and control groups.
Variable
Intervention group
(n =29) control
group
(n =34) Test result
Mean±sd Mean±sd
Age (years) 78.1±8.4 76.7±8.3 t =0.7, df =61
P =0.50 Independent t -test
Sex Male 20 24 X2 =0.20, df =1
P =0.88
Female 9 10
Food intake pathway
Gavage 12 (41.4) 19 (55.9) X2 =1.317, df = 1 P =0.25
Oral 17 (58.6) 15 (44.1)
BMI (kg/m2) 27.2±4.3 27.8 4.5
Z=-0.5 P =0.60 Mann-Whitney U test
Care giver
Spouse 12(41.4) 11(32.4) X2 =0.6, df =1 P =0.80
Children 15(51.7) 20(58.8)
Nurse 2(6.9) 3(8.8)
and 55.9 % in the control group had severe constipation, while none of patients had mild constipation. After intervention, Mann-Whitney U test results indicated that the elderly in both groups had significant changes in the severity of constipation, so that 55.2 % of the intervention group and 17.6 % of the control group had mild constipation after the inter- vention (P <0.001) (Table 3).
In accordance with the results of repeated measure ANOVA, the range of distention in ten days intervention was significantly decreased during the days in intervention group, the test showed a significant
effect of time (P <0.001, partial eta squared =0.19) and group (P = 0.02, partial eta squared =0.075) in this variable. The results showed Partial Eta Squared =0.19 >0.14 that according to the general rules of thumb given by Cohen and Miles & Shevlin (2001) for eta-squared, this means that the effect size of the frequency of abdominal messages along with appropriate life style in ten days is large (Fig. 2).
According to the elderly’s food intake pathway, 12 (41.4) patients in intervention group and 19 (55.9) patients in control group were taking food through NG tube, while 17 (58.6) patients in intervention and 15 (44.1) patients in control group were taking food orally. Chi square test did not show any difference between two groups about the food intake pathway (P =0.25) (Table1).
Results showed that the rate of food tolerance through gavage were increased two days after intervention in experimental group, while this rate was increased in control group after 8 days (Fig. 3). Man Whitney U test showed a significant difference between two groups about the numbers of food tolerance in elderly that were intake food through NG tube (P =0.036).
Also the results showed that in the intervention group the elderly had food tolerance after two days orally but in the control group most of the elderly tolerated food after 7 days (Fig. 4). t-test revealed a significant difference between two groups in the numbers of food tolerance through mouth during ten days (P <0.001).
4. Discussion
Results of the present study indicated that the abdominal massage by the "I LOV U" technique along with life style education could improve constipation, reduce distension, and increase food tolerance rate through NG tube and mouth in the elderly with stroke.
The results of this research showed that the "I LOV U" abdominal massage technique along with life style education could irritate the elderly patients’ bowels more effective than the life style education lonely. The results showed that the defecation habit was started in most of the elderly in intervention group in the fourth and fifth days of intervention, while the defecation habit in control group often started in seventh day. According to the general rules of thumb given by Cohen Table 2
Comparison the existence of defecation in elderly in two groups in 10 days.
Days Control group
(n =34) Number (%)
Intervention group (n =29) Number (%)
Result Chi Square test
First day Yes 4 (11.8) 7 (24.1) X2 =1.66
P =0.19 No 30 (88.2) 22(75.9)
Second day Yes 6 (17.6) 7 (24.1) X2 =0.403
P =0.52
No 28)82.4) 22(75.9)
Third Day Yes 6 (17.6) 8 (27.6) X2 =0.895
P =0.34
No 28)82.4) 21 (72.4)
Forth Day Yes 10 (29.4) 19 (65.5) X2 =8.213
P =0.004 CC* =0.34 No 24 (70.6) 10 (34.5)
Fifth Day Yes 14 (41.2) 22 (75.9) X2 =7.68
P =0.006 CC* =0.33 No 20 (58.8) 7 (24.1)
Sixth Day Yes 15 (41.4) 25 (86.2) X2 =11.961
P =0.001 CC* =0.39 No 19 (55.9) 4 (13.8)
Seventh Day Yes 27 (79.4) 25 (86.2) X2 =0.501 P =0.47 No 7 (20.6) 4 (13.8)
Eighth Day Yes 28 (82.4) 26 (89.7) X2 =0.68 P =0.40 No 6 (17.6) 3 (10.3)
Ninth Day Yes 27 (79.4) 27 (93.1) X2 =2.396
P =0.12
No 7 (20.6) 2 (6.9)
Tenth Day Yes 27 (79.4) 27 (93.1) X2 =2.396
P =0.12
No 7 (20.6) 2 (6.9)
Test Result
Friedman X2 =208.796 P <0.0001
*Contingency Coefficient.
Table 3
Comparison the CAS mean scores, taking laxatives and the frequencies of food tolerance before and after the intervention in the elderly in two groups.
Group Intervention (n =29) control
(n =34) Test result*
Variable CAS Before
Mean±SD 10.3±1.7 9.9 ±1.9 t =0.78
CI (-1.31,0.57) P =0.435 Constipation score before the intervention
Number (%)
Mild 0 (0.0) 0 (0.0) Z=-0.8
P =0.435 Mann-Whitney
Medium 10 (34.5) 15 (44.1)
High 19 (65.5) 19 (55.9)
CAS After
Mean±SD 4.7±0.75 5.7±1.5
t =3.24 CI(0.30,1.59) P =0.001 EF =0.44 Constipation score after the intervention
Number (%)
Mild 16 (55.2) 6(17.6) Z=-4.6
P <0.001 Mann-Whitney
Medium 13 (44.8) 28 (82.4)
High 0 (0.0) 0 (0.0)
Magnesium hydroxide syrup Yes Before
n(%) After
n(%) Before
n(%) After
n(%) Test Result
29(100.0) 6 (20.7) 34(100.0) 22(64.7) X2 after =12.28
P =001
No 0 (0.0) 23 (79.3) 0 (0.0) 12(53.3)
Castor oil Yes 11 (37.9) 2 (6.9) 13 (38.2) 10 (29.4) X2 after =5.14
P =0.28
No 18 (62.1) 27 (93.1) 21 (61.8) 24 (70.6)
Food tolerance frequencies
Gavage n =12
14±1.49 n =19
11.25±3.95
Z=-2.325**
CI(-2.73, -0.24) P =0.036
Oral n =17
13.35±2.16 n =15
7.19±2.36 t =3.41
P <0.001
*Independent t-test.
**Mann-Whitney U test.
and Miles & Shevlin (2001), the contingency coefficient in this case were CC* =0.34 in fourth day and CC* =0.39 in fifth day. This results shows that the abdominal message along with life style education in this study could have a middle effect size on the starting time of defecation habit in elderly with stroke.
Consistent with the present study, there are studies about the effec- tiveness of abdominal message on the constipation of elderly with chronic constipation,9,13,22 constipation of ICU patients21,27,28 and the functional constipation.29 All of the studies were showed the effective- ness of abdominal message on constipation. But according to the results of this study, the data showed that abdominal message along with life style education not only can improve the score of constipation, but also can shorten the duration of time of starting the defecation habit in elderly after stroke. For example, In Lamas’s study,22 the elderly did not show any significant improvement in their constipation scores until the
fourth week, but the improvement was significant after week 8. In the present study, the mean days of constipation recovery were 3–5 days after the intervention. It can be concluded that the use of abdominal massage along with life style training such as having enough liquid, doing appropriate physical activity and performing correct position during the defecation can push forward the starting date of the defeca- tion habit in elderly with stroke.
Furthermore, the laxative consumption significantly decreased after the intervention. All of elderly consumed magnesium hydroxide syrup before study in intervention and control groups, but the magnesium hydroxide syrup consumption decreased to 80 % in the intervention group after the intervention. The finding was inconsistent with findings of Lamas22 who concluded that abdominal massage failed to reduce laxative intake. The inconsistency was due to the chronic constipation in the elderly in Lamas’s study and the association of abdominal massage Fig. 2.Comparison the Mean scores and Confidence intervals of round of the abdominal measurement (distention) in elderly in two intervention and control groups in 10 days.
Fig. 3.The rate of Gavage food tolerance in elderly with stroke during ten days in two intervention and control group.
with lifestyle training, as well as the association of abdominal massage with gastrointestinal tract peristalsis. But the finding of this research are consistent with the results of mokhtare and colleagues (29)who studied the effectiveness of abdominal message along with PEG (polyethylene glycol) in patients with functional constipation.
In the present study, not only the post-intervention constipation score improved, but also the constipation severity reduced and the severity of constipation increased by mild to moderate in patients in both groups, while most of patients had mild constipation in the inter- vention group. The results indicated that abdominal massage by an "I LOV U" method with lifestyle training could significantly reduce the clinical severity of constipation in patients. However, the severity of constipation decreased in the control group patients who received the lifestyle training, but most patients had moderate constipation levels.
Consistent with the present study, results of a study by Hanai et al.
(2016) titled "the examination of effect of self-care program on con- stipation in 30 breast cancer patients during chemotherapy" indicated that abdominal massage improved the constipation.14 In Hanai’s study, the percentage of severe constipation decreased by 40 %, but the severe constipation decreased by 65 % in the present study. Side effects of taking chemotherapy drugs, which reduce intestinal Peristalsis, and also the shallow abdominal massage may be reasons for the reduction of severe constipation improvement in Hanai’s study. In the present study, however, patients were not treated with chemotherapy drugs, and the abdominal massage was structured and in line with gastrointestinal peristalsis. Hanai’s study was consistent with the present study in terms of lifestyle training content.
Consistent with the present study, McClurge et al. (2016) conducted a study on the effects of abdominal massage on constipation in 16 elderly patients (mean age: 72) with Parkinson’s disease", that concluded the abdominal massage and lifestyle training improved symptoms of constipation in the elderly, but its data were not statisti- cally significant. The insignificance of the constipation improvement could be statistically due to the experimental nature of McClurge’s study and the small sample size and long follow-up in his study. 13
In a study by Seyed Rasouli et al. (2016) titled "A comparison of the effects of reflexology and abdominal massage on constipation in 20 or- thopedic patients in Azerbaijan, abdominal massage improved symp- toms of constipation in orthopedic patients26; and their results were consistent with results of the present study.
In a study by Seyed Rasouli, abdominal massage was simple, regardless of direction of the gastrointestinal peristalsis; however, the constipation recovery trend was studied day-to-day and indicated that the constipation significantly improved from day 3, while the con- stipation improvement was from day 6–7 in the present study. The dif- ference could be due to the mean age of samples (56 year) in Seyed Rasouli’s study, but the patients of the present study were the elderly
with stroke. Both aging and stroke are two factors that delay the onset of symptoms of constipation recovery.
The findings of the present study indicated that the measurement of abdominal circumference and mean day of recovery, the abdominal massage plus lifestyle training based on daily abdominal measurements significantly reduced distension (abdominal bloating) in the interven- tion group compared to the control group. The results also indicated that patients’ distension decreased in the intervention group on average during 4–5 days. In line with the results of the current study on abdominal circumference, Kahraman and Ozdemir,28 and Dehghan et al.,21 also showed significant decrease in the patients’ abdominal circumference.
Consistent with the present study, Tekgündüz et al. (2014) con- ducted a study on the effect of abdominal massage by "I LOVE U" tech- nique on the nutritional tolerance of 14 preterm infants" and concluded that abdominal massage improved abdominal distension during a 5-day intervention.16 Consistent with Tekgündüz study, results of the present study indicated the improvement of bloating in the elderly. However, Tekgündüz indicated the bloating improvement at the end of study (day 5) in infants, but did not mention the bloating improvement during the study days. In the present study, the process of abdominal distension improvement was quite clear with daily abdominal circumference measurements.
Given the infant population of Tekgündüz ’s study and their earlier bloating improvement (day 5), their follow-up time was shorter than the present study; hence, based on results of Tekgündüz’s study and the present research, massage by an "I LOV U" technique could be effective in the elderly, but number of days of intervention was higher than infants.
Results of a study by Fatehipour et al. (2016) on the effect of abdominal massage on the gastrointestinal function and incidence of aspiration in 35 patients admitted to intensive care units of hospitals in Kerman were consistent with the present study and it indicated that the Swedish abdominal massage reduced the abdominal distension.24 A remarkable point in Fatehpour’s study was that the Swedish abdominal massage twice a day for three consecutive days rapidly showed symp- toms of abdominal flatulence improvement after the third day, but in the present study, symptoms of abdominal flatulence improvement emerged from the day six. The reason for this difference might be the technical difference of Swedish abdominal massage with abdominal massage of "I LOV U".
Swedish abdominal massage is professional and requires special training. It was performed by a researcher in Dehghan’s study, but in the present study, the massage technique was taught to the patient caregiver who performed massage for the patient during the study. In this regard, the caregiver cooperation and accuracy in massaging and adhering to proper nutrition principles to relieve bloating and constipation and a Fig. 4. The rate of oral food tolerance in elderly with stroke during ten days in two intervention and control group.
variety of patient caregivers might be the reasons for delayed symptoms of bloating in the present study. In addition, the duration of each Swedish massage was 45 min that might further stimulate the intestines.
A side goal of the present study was to reduce costs of treatment and length of hospitalization due to gastrointestinal complications in the elderly with stroke and also to reduce the dependency of the elderly caregivers on health centers to achieve abdominal massage and lifestyle training for caregivers. However, no training was provided for patient caregivers in Dehghan’s study; and the researcher performed the abdominal massage.21
Findings of the present study indicated that abdominal massage with lifestyle training based on the measurement of gastric residual volume and nausea and vomiting of the elderly twice daily prior to gavage and morning and evening oral nutrition increased the food tolerance (oral and gavage nutrition) in the elderly patients with stroke in the inter- vention group; and the findings became significant. In the intervention group, symptoms of improvement in gavage tolerance were seen in the elderly in the intervention group on days 2–3, and in the control group on day 7; and symptoms of improvement in oral food tolerance in the intervention group on days 1–2, and in the control group on day 5.
Results of a study by Tekgündüz et al. (2014) titled "the impact of abdominal massage on the food tolerance of 14 preterm infants in Turkey" indicated that abdominal massage reduced the volume of neonatal gastric residual volume, thereby increasing the neonatal gavage tolerance and increasing their weight gaining.16 The conclusion was consistent with the present study. In neonates, there were symptoms of gavage tolerance improvement on day 5 of the intervention, but symptoms of gavage tolerance were seen on days 2–3 in the present study. The reason for the difference can be attributed to the combination of abdominal massage with lifestyle training in the present study.
Also in a study found that the Swedish abdominal massage increased the gavage tolerance (reduction of gastric residual volume) in patients,21 and it was consistent with the present study.
It is noteworthy that the increased gavage tolerance (reduction in gastric residual volume) was significant after the third day of inter- vention in Dehghan’s study,21 and after the second day of intervention in the present study. The association of abdominal massage with lifestyle training was a reason for accelerating the rate of gavage tolerance (reduction in gastric residual volume) in the present study.
The main limitations of the research were at first the differences in caregivers. Sometimes the researcher should took much times for each care giver to learn the message. The other limitation was the different duration of the time of hospitalization in patients in the study. Some patients were hospitalized more than two weeks, then the researcher could supervise the process of abdominal message in each patient in ten days. But some patients were discharged before the end of the research and the researcher must follow the patients by telephone call.
5. Conclusion
The present study indicated that the use of massage by an "I LOV U"
technique and lifestyle training could improve constipation and distension in addition to reduce their need for taking laxative drugs.
However, the abdominal massage is a simple-inexpensive procedure that does not have any complexity, and anyone can be trained and able to do it. In the present study, the use of massage by an "I LOV U" technique in direction of normal bowel movements and bowel stimulation helped ease gas excretion and reduce constipation, but the method, along with lifestyle training such as consuming fiber-containing foods and move- ment and activity, could greatly improve gastrointestinal complications.
Therefore, it decreased frequency of the elderly with severe constipation and increased frequency of mild to moderate constipation.
The research results indicated that abdominal massage and lifestyle training could be used to improve gastrointestinal complications in the elderly with stroke.
Author statement
As the author statement is one of the important option for submit- ting, I assessed all of the titles of author guideline but I didn’t find any file about author statement. All of the authors of this manuscript are agree with the data declared in the manuscript. And all are agree with submitting the manuscript
Declaration of Competing Interest The authors declare no conflict of interest.
Acknowledgments
This article has been adapted from a master’s dissertation of Geri- atric nursing with the ethics code of IRMUMS.NURSE.REC.1397.004 in Nursing and Midwifery School of Mashhad University of Medical Sci- ences, Mashhad, Iran. It has been registered as a clinical trial ID of IRCT ID: IRCT20180721040547N1. The authors would like to express their gratitude to the financial and research department of Mashhad Uni- versity of Medical Sciences, the participating patients and their family member hospitalized in neuroscience ward, and the staff of Qaem, hospitals for their contribution in this study. All of the financial costs have been supported by the research deputy of Mashhad University of Medical Sciences.
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