Cerebral palsy (CP) is a nonprogressive neurologic condition that manifests as movement and muscle tone impairments due to neurological developmental abnormalities. It affects approximately 2.5 per 1,000 births worldwide (1). Children with CP suffer from highly reduced mobility and subsequent constipation. In addition, most children with CP who are constipated may also have other systemic symptoms, such as sleep disturbances (including prolonged sleep onset, shortened sleep duration, and easy awakening) and emotional irritability (2). As the most common problem, with a high incidence rate of 75%, constipation usually results from the intake of several components, including reduced fiber and liquid intake, mobility reduction, damage to the central nervous system, and therapeutic drugs (3–5). In addition, it worsens as the severity of CP increases (3).

To date, no consensus exists on the treatment of constipation in children with CP (6). The treatment mainly focuses on improving the symptoms of constipation, such as lifestyle guidance, pharmacological therapy and nonpharmacological therapy (7). Imanieh M.H. et al. compared three different therapeutic methods and suggested that effective and safe agents are still important treatmen choices in the treatment of chronic constipation in CP children (8). Veugelers R. et al. conducted a cross-sectional observational study and reported that children with severe generalized cerebral palsy often experienced constipation. Laxatives are common medicines, but their dosing is frequently inadequate to prevent symptoms (3). In addition, García Contreras A.A. et al. suggested the use of synbiotics, prebiotics, and probiotics to improve stool characteristics, such as a history of painful defecation (9). However, discomfort associated with anal administration, high drug dependence, and poor long-term efficacy are unavoidable.

As an important alternative and nonpharmacological treatment method to traditional Chinese medicine, Tui Na has shown effective therapeutic effects on constipation (10). However, to our knowledge, few studies have drawn accurate conclusions. The effect of Tui Na on constipation remains controversial and poorly documented.

In the present study, we conducted a randomized controlled clinical trial to investigate the efficacy of Tuina therapy for on idiopathic constipation in children with CP. In addition, we examined the tolerance and safety of Tui Na therapy via adverse effects.

This clinical trial was designed and approved by the Ethics Review Committee of The First Hospital of Hunan University of Chinese Medicine (approval number: HN-LL-KY-2022-010-01). Written informed consent was obtained from the parents of all the participants. The study was registered with the China Clinical Trial Registry on April 18, 2022 (registration number: ChiCTR2200058879).

From June 2022 to June 2023, a total of 60 CP children with idiopathic constipation, ranging in age from 16 to 98 (average, 42.70 ± 17.81) months, were enrolled. All the children in the group met the diagnostic criteria for CP and the Rome III criteria for constipation, and no constipation-related therapies were administered in the month before the study (11). All the children were randomly divided into Tuina and control groups (n = 30). The control group was subjected to basic treatment and 12 sessions of lactulose oral solution, whereas the Tuina group received basic treatment and 12 sessions of Liu's infantile Tuina treatment. No differences were found in terms of age, sex, body mass index (BMI), duration of disease, or other accompanying conditions. (P > 0.05, Table 1).

Children were excluded if they had organic lesions of the rectum or sigmoid colon or congenital anomalies (such as anal stenosis and intestinal stricture), if they had skin breakage or local infection, if they had constipation due to previous surgery, or if their parents were unwilling to participate in the study.

At 4 weeks after the final treatment, the percentage of infants with improved constipation was 23 (76.7%) in the Tuina group and 21 (70.0%) in the control group (P = 0.771).

Initially, no difference was observed in the CAS score between the treatment groups: 10.47 ± 2.27 vs. 11.76 ± 2.24 (P = 0,671, Table 3). The stool frequency in the Tuina group was 17 once per week and 12 twice per week, whereas in the control group it was 16 once per week and 12 twice per week (P = 0.550, Table 3). The mean number of weekly bowel movements in both groups was 1.45 ± 0.58 vs. 1.31 ± 0.55 per week. In addition, the number of infants who underwent bowel evacuation >2 h/d was comparable between the two groups (P = 0.795, Table 3).

At 4 weeks after the final treatment, the CAS score and bowel evacuation in both groups decreased significantly (P < 0.05). The number of weekly bowel movements increased significantly (P < 0.001). However, there was no difference in the CAS score or weekly bowel movements between the treatment groups after treatment: 3.63 ± 2.29 vs. 3.76 ± 1.89, 3.98 ± 0.55 vs. 3.98 ± 0.65 (P = 0,671, 0.217, respectively; Table 3).

The proportion of infants with more than 2 h per day of painful bowel evacuation decreased significantly in both groups (P = 0,671 and 0.217, respectively; Table 3). However, no significant difference was found between the groups 4 weeks after the final treatment.

No serious adverse reactions (such as diarrhea, abdominal pain, vomiting, subcutaneous redness, skin breakage, or syncope) were reported.

In the present study, our findings confirmed that Tuina was an effective therapy for children with CP with constipation. No serious complications were found throughout the entire treatment process.

As a basic therapy, lifestyle guidance emphasizes interventions in the diet, exercise, and bowel habits of the child. Early satiety and poor feeding often occur in approximately 41% of patients with CP, which contributes to undernutrition. To date, there is ongoing debate regarding the recommendation of dietary fiber and fluid intake due to the inadequacy of the study design. The American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) did not support fiber consumption to prevent constipation (15). However, lower fiber and fluid intake also worsens this condition (4). García Contreras A.A. et al. conducted an analytical cross-sectional study and reported that low fiber and fluid intake and the use of anticonvulsant polytherapy usually resulted in harder stools and lower defecation. They recommended that daily fiber and fluid intake are important for improving constipation (16). At our institute, we still agree with the hypothesis that appropriate fiber and fluid intake can improve constipation. We advised each child with dietary adjustment. Considering the diversity of participants, well-designed high-quality randomized controlled trials are urgently needed to determine the recommendation and appropriate quantity for CP children with constipation.

In children with CP, ambulatory function is often positively correlated with the extent of brain damage. Improving brain function may enhance the brain's ability to regulate the gastrointestinal system, playing a key role in treating constipation in children with CP. Most associations are found between constipation and neurologic diseases and the spine due to damage to the central nervous system. Deterioration of the neurological function of the brain in children with CP is positively correlated with the severity of constipation (17). Disruption of the neural modulation of colonic motility plays a crucial role in the process of constipation (18). Damage to the early central nervous system includes a series of adaptive neuroplasticity processes. Earlier interdisciplinary intervention can improve brain plasticity and improve an individual's condition (19). The acupoints Baihui, Sishencong and Fengchi are pressed to enhance brain function and improve intelligence, which regulate the qi and blood of the Du meridian,and the acupoints Baihui, Sishencong, and Fengchi are pressed to enhance brain function and improve intelligence, regulating the effects of mind regulation and brain development in the theory of traditional Chinese medicine. Our study revealed comparable efficacy between infantile Tuina and oral lactulose treatment for idiopathic constipation in children with CP. At 4 weeks after the final treatment, the percentage of infants with improved constipation was 23 (76.7%) in the Tuina group and 21 (70.0%) in the control group (P = 0.771). The tina of the head can promote blood circulation and improve the blood supply to the brain, which partially compensates for damaged brain tissue functions by accelerating the development of the nervous system.

Chronic disability and decreased motor activity due to muscle weakness in the gastrointestinal system are among the most common problems and are associated with the severity of the disorder (20). Deficiencies in abdominal, intestinal, and anal muscle strength may also trigger defecation disorders. A delay in transit time at the entire or segmental colon was associated with constipation in patients with CP. Tuina is a nonpharmacological therapy via performing manipulations on the body surface. The theoretical basis originates from the special meridian-acupoint theory of traditional Chinese medicine. Tuina can induce autonomic responses via cutaneo-visceral reflexes to improve constipation (21).

Children with CP the hypotonic type exhibit delayed motor development and reduced motor activity. Abdominal massage can promote gastrointestinal motility and has a direct therapeutic effect on constipation. In this study, the application of abdominal manipulation was emphasized, and a combination of rubbing, holding, kneading and vibrating techniques was applied directly to the abdomen of the child. The abdomen serves as the body's projection area for the stomach and intestines. External pressure stimulates the intestines, causing deformation or displacement, which promotes intestinal content transmission and facilitates defecation.Moreover, gentle and powerful manipulation of the abdomen can reflexively regulate the central system, reduce the excitability of the descending colon and rectal parasympathetic nerves, increase peristalsis of the descending colon and rectum, and create favorable conditions for defecation (22). The improvement in muscle strength not only increases daily activity and promotes intestinal peristalsis but also enhances the contraction of the abdominal muscles, anal muscles and intestinal wall muscles and increases abdominal pressure, all of which can accelerate fecal excretion and reduce the symptoms of constipation in children. In addition, stretching exercises could reduce spasticity, improve joint mobility, and enhance functional independence. These improvements increase the motility of the gut and relieve constipation by inducing parasympathetic stimulation (23).

There were several limitations in the present study. First, this was a small sample size study, and the follow-up time was only 4 weeks. However, the sample size was calculated via G*Power. Future studies should include a larger and more diverse population to improve external validity, including the addition of a sham Tuina group. Second, the age of the enrolled children was 16–98 (average, 42.70 ± 17.81) months old. Some results came from their parents due to incomplete comprehension and expression skills. Third, the Tuina in this study was performed by the same skilled therapist, but some variability in the standardization of stimulation intensity by manual manipulation is inevitable. A longer observation period is needed to achieve the long-term efficacy and recurrence rates of constipation in Tui Na.

In conclusion, constipation is a highly prevalent disease of the gastrointestinal tract in children with CP, and Tuina is as effective as medical care in addition to basic treatment. The results of this study suggest that Tui Na may serve as a viable alternative treatment for constipation.