kht and ibs

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VOLUME 35 | NUMBER 6 | NOVEMBER/DECEMBER 2012 403

Copyright 2012 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.

The Effect of Korean Hand Acupunctureon Young, Single Korean Students WithIrritable Bowel Syndrome

Received June 10, 2011; accepted December 27, 2011.

About the authors: Hyo Jung Park, PhD, RN, is Assistant Professor atDivision of Nursing Science, College of Health Sciences, Ewha WomansUniversity, Seoul, Republic of Korea.

Chiyoung Cha, PhD, RN, is Assistant Professor at Division of NursingScience, College of Health Sciences, Ewha Womans University, Seoul,Republic of Korea.

This work was supported by the Ewha Womans University ResearchGrant of 2009.

The authors declare no conflict of interest.

Correspondence to: Hyo Jung Park, PhD, RN, Division of NursingScience, College of Health Sciences, Ewha Womans University,

52 Ewhayeodae-gil, Seodaemun-gu, Seoul, Republic of Korea (e-mail:[email protected]).

ABSTRACT

The purpose of this study was to test the effectiveness of Korean hand acupuncture (KHA) on bowel symptoms,stress, mental health, and heart rate variability in women with irritable bowel syndrome. From a total sample of 42

women with irritable bowel syndrome diagnosed with Rome III, 21 were randomly selected to be given KHA,

whereas 21 were given sham KHA. The KHA group received KHA on 16 spots related to bowel symptoms, whereas

the sham KHA group received treatment to areas unrelated to bowel symptoms. KHA needles were applied for 25

minutes, twice a week, for 4 weeks. After the treatment, bowel symptoms were measured using a Bowel Symptom

Severity Scale, stress using a global assessment of recent health, mental health using the Symptom Checklist-90

Revised, and heart rate variability. SAS 9.1 (SAS Institute, Cary, NC) was used to analyze the data, and a chi-square

test, ttest, and paired ttest were used for analysis. The KHA group had a decrease in symptoms such as loose

stool, bloating, abdominal discomfort, and abdominal pain compared with the sham KHA group (p .05). However,

there were no significant effects on stress, mental health, and heart rate variability. KHA was effective for bowel

symptoms such as loose stool, bloating, abdominal discomfort, and abdominal pain, and it could be applied to

patients with irritable bowel syndrome. There is a need for further research on the effectiveness of KHA in women

with irritable bowel syndrome using more diverse physiological indexes.

Hyo Jung Park, PhD, RN

Chiyoung Cha, PhD, RN

DOI: 10.1097/SGA.0b013e318274b1f2

Irritable bowel syndrome (IBS) is one of the func-tional gastrointestinal (GI) disorders that areaccompanied by continual symptoms, such asabdominal pain, discomfort, constipation, and

diarrhea, without any structural or biochemical cause.Irritable bowel syndrome has significant negativeeffects on quality of life. Managing this condition is

also costly. It has been estimated that IBS accounts for2 million physician visits each year, making it thefourth most expensive GI disorder in the United States(Sandler et al., 2002).

Literature ReviewThe prevalence of IBS reaches 7%10% in the world,depending on the criteria used for diagnosis (Spiegel,

2009), and is reported to be between 3.0% and 28.0%in Korea (Cho et al., 2004; Hwang et al., 2006; Park,2008; Son, Jun, & Park, 2009). The prevalence of IBSis reported to be higher among younger age groups andwomen than among older age groups and men (Hwanget al., 2006). Although IBS is not a life-threateningdisease, it is known to require long-term medicationtherapy and may affect quality of life as it causesabsences from school or work (Creed et al., 2001).

The exact cause of IBS is not known; however,according to the literature, IBS is influenced by genetic

and environmental factors, a change in the autonomicnervous system (ANS), altered bowel function andincreased sensitivity, abnormal function of the braingut


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The Effect of Korean Hand Acupuncture on IBS


404 Copyright 2012 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing

medication to alleviate the symptoms (Choi, 2006).However, medications were reported to have a tempo-rary effect (Balboa et al., 2006) and many patientswere not satisfied with the outcomes. A report thatabout half of the IBS patients visited at least one com-plementary and alternative medicine (CAM) practi-

tioner and 60% of them took supplements during thepast 6 months (Cha, Heitkemper, Jarrett, & Cain,2008) indicates that receptivity toward CAM therapiesruns high in this population.

Economically advantaged IBS patients frequentlyseek CAM modalities. Nonconventional therapiessuch as cognitivebehavioral therapy (Boyce,Gilchrist, Talley, & Rose, 2000; Drossman et al.,2003), hypnosis (Palsson & Whitehead, 2002; Tan,Hammond, & Furrala, 2005), mindfulness-basedstress reduction (Zernick, 2009), and relaxation tech-niques (Boyce, Talley, Balaam, Koloski, & Truman,2003) were shown to be effective in relieving IBSsymptoms. Taking supplements such as peppermintoil (Merat et al., 2010), probiotics (Brenner, Moeller,Chey, & Schoenfeld, 2009), and soluble fibers (Bijerk,Muris, Knottnerus, Hoes, & De Wit, 2004) was alsoreported to reduce bowel symptoms among IBSpatients.

The use of Korean hand acupuncture (KHA), one ofthe commonly used traditional CAM modalities, issteadily increasing in Korea. KHA was developed inKorea, produces a rapid therapeutic effect, and rarely

results in pain and side effects after treatment; thus, ithas drawn a great deal of interest not only in Koreabut also in other countries (Yu, 1994). KHA is fre-quently recommended by Oriental medicine practition-ers (Kim & Cho, 2001). KHA improves energy (Chi)and blood circulation by balancing complementary yetopposing forces, Yin (slow, soft, yielding, diffuse) andYang (fast, hard, solid, focused), in the entire body.KHA is known to help control chronic abdominalcomplaints, including the symptoms of abdominalpain, diarrhea, and constipation, and to effectivelyenhance mental stability and stress release by control-

ling cerebral blood flow (Yu, 2003).In addition, KHA was reported to be an effective

intervention for female patients who had undergonehysterectomy or those with premenstrual syndrome(PMS) (Shin et al., 2004; Shin, Ha, Park, & Heitkemper,2009). In Shin and colleagues (2004) study, fiveKorean women who had undergone hysterectomyreceived KHA. The patients pain scores decreased andtemperatures in the peripheral parts of the body effec-tively cooled, as measured by digital infrared thermo-graphic imaging (Shin et al., 2004). In a second study

(Shin et al., 2009), seven Korean women with PMShad significantly reduced overall PMS symptom sever-ity scores following 10 sessions as compared with a

axis, psychosocial factors, and stress (Kalantar, Locke,Zinsmeister, Beighley, & Talley, 2003; Robert, Orr, &Elsenbruch, 2004).

Researchers have investigated the abnormal func-tion of the ANS in IBS patients. Abnormal activationof the sympathetic nervous system increases visceral

sensitivity to foods, and gas is a frequent occurrence inpatients with functional GI disorders such as IBS(Park, 2006). Patients with IBS have highly activatedsympathetic nervous systems and decreased activity ofthe parasympathetic nervous system compared withtheir counterparts (Hattori, Watanabe, Kano,Kanazawa, & Fukudo, 2010; Heitkemper et al., 2001,1998). Constipation-predominant IBS patients, in par-ticular, were found to have deterioration in function inthe parasympathetic nervous system when comparedwith healthy adults (Heitkemper et al., 2001).Alteration in ANS function and consequent influenceon bowel function open a new field for nurses to utilizeacupuncture, which regulates the ANS, as a nursingintervention for functional bowel disease.

Psychosocial factors and stress among IBS patientshave also been frequently studied. When women areunder stress, gut sensitivity tends to increase morereadily than that of men (Heitkemper, Jarrett, & Bond,2004), and women experience higher occurrence ratesand greater symptom severity.

Heart rate variability (HRV) measures a fluctuationin beat-to-beat heart rate intervals (Tak et al., 2009).

This is often used as a noninvasive objective indicatorof alterations in ANS activities (Kleiger, Stein, &Bigger, 2005). When resting HRV parameters weremeasured in IBS patients, low frequency (LF) and highfrequency (HF) were lower and the LF/HF ratio washigher than that in their healthy counterparts (Mazuret al., 2007), indicating that the functions of the sym-pathetic and parasympathetic nervous systems werealtered. Knowing that the HRV of IBS patients mightdiffer from those without functional GI disorders,nurses could use this indicator to measure the altera-tion of ANS.

Stress is known to increase visceral sensitivity in IBSpatients (Whitehead, Crowell, Robinson, Heller, &Schuster, 1992). Up to 60% of U.S. patients with IBSreport a number of extraintestinal symptoms includingpsychological distress, sleep disruption, and fatigue(Sykes, Blanchard, Lackner, Keefer, & Krasner, 2003).In Korea, 40%90% of IBS patients were reported tohave psychological symptoms (Lee, 2006). Patientswith IBS have significantly higher levels of depressionthan the patients with other bowel-related diseasessuch as ulcerative colitis (Han et al., 2006; Hong,

2004).Conventional therapy for the chronic and recurringsymptoms of IBS consists mainly of the use of


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A total of 59 women were randomly assigned to thetwo study groups; 11 dropped out before study com-pletion. Six of them failed to provide follow-up data.Table 1 is the consolidated standards of reporting trials(CONSORT) diagram. Study subjects were 42 adultwomen with IBS who understood the purposes of the

study and agreed to participate by signing a writtenconsent form. Subjects were assessed for their IBSsymptoms by using Rome III criteria. A computerizedadaptive randomization procedure was used to assignthe women to the study groups; both the KHA andS-KHA groups consisted of 21 participants.

Measurements

Primary Variables

Assessing Symptoms of IBSThis study adopted the IBS module, which wasabstracted from the Rome III Questionnaire developedby Drossman (2006) on the basis of Rome III (trans-lated by the Korean Society of Gastrointestinal Motilityin 2007). Cronbach's in this study was .75. The IBSmodule consisted of 10 items.

control group. The KHA group showed balanced skintemperature in symmetric body areas, as measured bydigital infrared thermographic imaging (Shin et al.,2009).

Regarding the effect of acupuncture on bowel symp-toms, Xiao and Liu (2004) conducted a study in which

percutaneous electrostimulation was performed on 24diarrhea-dominant IBS patients twice a week for 8weeks. In each session, the stimulation was applied tocrucial spots of the body meridian channel for 30 min-utes. The results showed that the sensory threshold ofthe rectum was increased and the frequency of defeca-tion and abdominal pain were significantly decreased,suggesting that percutaneous electrostimulation waseffective for alleviating the symptoms of IBS.

Because few studies have been conducted on theeffect of KHA in terms of IBS and previous studiesmeasured only subjective items, this study intended totest the effect of KHA by using objective measure-ments, such as HRV. In previous studies, significantlydifferent outcomes were obtained by excluding thecontrol group from any treatment, and there were veryfew rigorous trials using experimental methods.Therefore, a two-group experimental study was under-taken in this investigation. The intervention groupreceived the KHA, whereas the control group receiveda sham-KHA (S-KHA) procedure.

Purpose

The purpose of this article was to identify the effect ofKHA on Korean young single students with IBS. Thisstudy had two aims: (1) to document the role of KHAon changes in bowel symptoms and (2) to assess theinfluence of KHA on stress levels, mental health, andfunctional balance of the ANS in patients sufferingfrom IBS.

MethodsWomen with IBS were recruited through university andcommunity advertisements in Seoul, Korea. Inclusioncriteria consisted of women who were at least 18 years

old, had a diagnosis of IBS from a physician, and couldspeak Korean. The exclusion criteria consisted of car-diovascular diseases (hypertension, arrhythmia,ischemic heart diseases); diseases related to the kidney(renal insufficiency), liver, lungs, GI tract, and endo-crine system (diabetes, thyroid disease); cancer (stom-ach and uterine cancer); past abdominal surgery; andmental and neurological disorders. Women with cer-tain other comorbidities or medication use were alsoexcluded. Everyone with depressive symptoms wasexcluded from the study. Women with any injury or

inflammatory and infectious disease in their handswere also excluded.

TABLE 1. Study Consolidate Standards ofReporting Trials (CONSORT) Table

Assessed for Eligibility N 253

Excluded,n 194

Reason,n

Did not meet inclusion criteria 114

Chose not to participate 80

Randomized,n 59

KHA S-KHA

Randomized,n 30 29

Received full intervention,n 25 23

Received partial intervention,n 5 6

Reason,nToo busy 5 5

Health problem 1

Complete follow-up 21 21

No follow-up,n 4 2

Reason,n

Too busy 3 2

Unable to contact 1

Analyzed,n 21 21

Notes. KHA Korean hand acupuncture; S-KHA sham

Korean hand acupuncture.


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was measured as the total score of mental health dividedby 90 (the total number of items); the scores rangedbetween 0 and 4. Cronbach's in this study was .87.

Heart Rate VariabilityFor the measurement of HRV, the SA-3000P HRV

device (Medicore Co. Ltd, Seoul, Republic of Korea)was used. It is approved by the appropriate Koreanregulatory agency. The subjects were seated on chairs,and their HRV was measured for 5 minutes by attach-ing electrodes on the left and right wrists and leftankle. To control any factors that might influenceHRV, the subjects were instructed not to smoke, drinkcoffee, or exercise for 1 hour before HRV measure-ment. Also, collecting data during academic mid-termor final examination periods was prohibited to rule outacademic stress.

During HRV measurement, the temperature andhumidity of the room were maintained at certain levelsto present a refreshing atmosphere. Measures includedstandard deviation of RR (SDRR) intervals, physicalstress index, total power, very low frequency, LF, HF,normalized LF (LF/LFHF), normalized HF (HF/LFHF), and LF/HF.

Time domain HRV measures were computed on thebasis of RR interval and differences in RR intervals.parasympathetic nervous system (PSNS) activity wasassessed with spectral HF and ln HF. Mixed sympa-thetic nervous system (SNS) and PSNS activity was

measured with timed domain measure SDRR intervalsand LF. SNS/PSNS balance was indexed in the fre-quency domain LF/HF. In a study of young Koreancollege women, SDRR intervals ranged between 43and 44, LF between 334 and 348, HF between 517and 593, and LF/HF between 1.24 and 1.91 (Kwak,Kim, & Shim, 2009).

InterventionThe intervention period consisted of eight KHA ses-sions, which were conducted twice a week for 4weeks from June 2009 to January 2010. If a disease

is generated in a body, a reflex is shown on the bodysurface along the organic reflex system and at thattime, KHA intends to heal the disease not by apply-ing acupuncture directly to the body, but by apply-ing it onto the reflection point of the body surface(Yu, 1994). There are two micromeridians, or KiMeks (Im Ki Mek and Dok Ki Mek), that connect allthe energy systems of internal organs (Shin et al.,2009) and 12 Ki Meks that correspond to the energyof different internal organs.

Ki Meks have several spots that correspond to certain

parts of the internal organs. Spots are used by directlystimulating the corresponding body part and by stimu-lating the Ki Meks that correspond to the abdominal

Bowel Symptom Severity ScaleThe study adopted the Bowel Symptom Severity Scale,which was developed by Boyce et al. (2000) and thentranslated into Korean by Yang (2004). It includedeight bowel symptoms related to IBS for the last 7days, such as loose stool, hard stool, abdominal pain,

diarrhea, bloating, urgency to defecate, constipation,and abdominal discomfort.

Frequency, distress, and disability related to bowelsymptoms were scored for each symptom. The score forbowel symptom frequency ranged from 5 to 40 points,because each symptom could be rated for 1 to 5 points;for distress and disability, 0 to 4 points were assignedfor each symptom. The total score was 0 to 32 pointsand higher totals indicate more severe symptoms. In aprevious research, Cronbach's was .92 (Boyce et al.,2000), whereas Cronbach's in this study was 0.93.

Subsequent Variables

StressFor the measurement of stress, the translated versionof Global Assessment of Recent Stress by Koh (1988)(that was originally developed by Linn, 1985, to evalu-ate the perceived stress during the period of 1 week)was used. The instrument is based on a 10-point scale:0 (no stress) to 9 points (severely stressful state). Theinstrument contained eight items on job, work, pres-sure from personal relations, change in personal

relations, disease, financial status, daily life, andchanges in daily life that are perceived as general stress.At the time the instrument was developed, the testretest reliability was r .81 (Linn, 1985) whereas 0.82was obtained in this study. In a study of Korean youngwomen with IBS, stress level ranged between 29 and33 points (Park & Lim, 2008; Park & Shin, 2009).

Mental HealthThis study used the Symptom Checklist90Revision,Korean version adapted for use in Korea by Kim,Kim, and Won (1984) from Derogatis's (1977)

Symptom Checklist90Revision to standardize andconstruct the criteria for diagnosing adults with mentalhealth conditions. This instrument is composed of 90items related to nine types of symptomssomatiza-tion, obsessivecompulsive, interpersonal sensitivity,depression, anxiety, hostility, phobic anxiety, paranoidideation, and psychoticismand asks subjects to ratethe degree of the symptom experienced by the subjectduring the past 7 days. Each item is rated on a 5-pointscale: 0 never, 1 slightly, 2moderately, 3 seri-ously, and 4 very seriously; a higher score indicated

worse mental health (score range: 048).The Global Severity Index is often used to measure theoverall distress level. The stress level of the participants


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area of certain internal organs (Yu, 1994). There were16 KHA reflection spots that were applied to the KHAgroup, including the spots in Im Ki Mek (A8, A12,A16), Dok Ki Meck (B19, B24), spleen Ki Mek (F19),stomach Ki Mek (E8, E12), large intestine Ki Mek (D1,D2, D5, D6, D7), and spots that corresponded to the

large intestine (E21, E22, E24) (see Figure 1).For the S-KHA group, 16 spots that were unrelated

to the crucial energy spots received acupuncture.Because there are no sham needles used in Korea,were set in nontherapeutic points. For KHA, womenwashed their hands; the areas where acupuncture nee-dles would be inserted were cleaned using an alcoholswab. Needles were inserted on both palms at an inser-tion depth of less than 1 mm. The needles used weredisposable stainless steel.

For the treatment, a professional KHA acupunctur-ist who was registered with the Korean HandAcupuncture Therapy Board and had at least 4 yearsexperience applied KHA to each subject for 25 minutesin each point. All KHA acupuncturists use the samepoints because they receive standardized training. Onlyone acupuncturist worked for this project. She received40 hours training for the study protocol.

Data AnalysisThe data were analyzed using SAS v9.0 (SAS Institute,Cary, NC). Descriptive statistics were used to analyzethe demographic data. For the verification of homoge-

neity in both groups, a chi-square test and t-test were

conducted. Mean score and standard deviation werecalculated for bowel symptoms, mental health, stress,and HRV. To assess the differences between the KHAand S-KHA groups from pretreatment to posttreat-ment, a paired ttest was conducted.

Ethical ConsiderationsThe study protocol was reviewed and approved by thecommittee on Human Subjects Review Board at EwhaWomans University, Seoul, Korea. The potential par-ticipants were given both verbal information and awritten summary of the study before being asked toparticipate in the study. The potential participantswere told by the investigator that participation in thisstudy was voluntary. Informed consent was obtainedfrom all subjects. Study numbers were given to all thesubjects to protect their privacy. Only the principalinvestigator had access to the subject identifier andstudy number. After collection, data were stored in alocked cabinet. Follow-up for both groups wasconducted to avoid attrition, and $20 was offered asan incentive to those who completed the final follow-up questionnaire and HRV test to reduce attritionrates.

Results

DemographicsThe demographic characteristics of the subjects in the

homogeneity test are shown in Table 2. The average

FIGURE 1. Spots on the hand, which regulate bowel symptoms and correspond to points in the large intestine. A spotsof Im Ki Mek; B spots of Dok Ki Mek; D large intestine Ki Mek; E stomach Ki Mek; E21, E22, E24 spots that cor-respond to the large intestine; F spleen Ki Mek.


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age of the KHA group was 22 years and that of theS-KHA group was 21 years. There was no significantdifference in the body mass index between groups; thebody mass index of the KHA group was 19.71, where-as the S-KHA group's was 20.46. The subjects of bothgroups were single and students. Regardless of thepresence of abdominal pain and discomfort, most sub-

jects in both groups did not visit a medical institutionafter receiving the diagnosis of IBS, nor did they exer-cise regularly. At baseline, there were no significantdifferences in demographic characteristics of KHA andS-KHA groups.

Effect of KHA on Primary VariablesThe change in bowel symptom severity in KHA andS-KHA groups before and after KHA treatment isshown in Table 3. The KHA group experienced sig-nificant reduction of the frequency in loose stool (p

.023) and abdominal discomfort (p

.001). Some ofthe perceived difficulties, such as distress caused byabdominal pain (p .048), bloating (p .048), and

abdominal discomfort (p .031), caused by bowelsymptoms were significantly reduced in the KHAgroup. Disability as expressed by abdominal pain(p .033), bloating (p .009), and abdominal dis-comfort (p .003) showed a significant decrease inthe KHA group compared with the S-KHA group.

Effect of KHA on Subsequent VariablesThe change in mental health and stress among theKHA and S-KHA groups before and after KHA treat-ment is shown in Table 4. There were no significantdifferences in the stress level and indicators of mentalhealth. The change in HRV among the KHA andS-KHA groups before and after KHA treatment isdescribed in Table 5. No significant difference wasnoted among the indicators of HRV between the KHAgroup and the S-KHA group.

DiscussionThis study was conducted to test the effectiveness ofKHA in terms of bowel symptoms of Korean singlewomen with IBS as well as their mental health, stress,and HRV. After receiving eight sessions of KHA for 4weeks, the subjects in the intervention groupexperienced significant decreases in the frequency ofloose stool and abdominal pain. Distress and perceiveddisability caused by abdominal pain, bloating, andabdominal discomfort were also significantly reducedin the intervention group. No adverse effects were

reported by either group; however, KHA was not effec-tive in terms of stress control or promoting mentalhealth and did not result in any difference in HRV,which was an objective and physiological index forboth groups.

One of the principles of KHA is that the stimulationof the Ki Meks of the organs leads to the regulation ofthe functions of internal organs. Use of acupuncture,which is also believed to regulate the GI system bystimulating the ANS, was supported by larger studiesconducted in the past. For example, in a recent rand-omized sham-controlled trial (n 29), the intervention

group experienced significant improvement of abdom-inal pain, discomfort, intestinal gas, bloating, and stoolconsistency after receiving acupuncture treatmenttwice a week for 4 weeks (Anastasi, McMahon, &Kim, 2009). Xiao and Liu (2004) also reportedimprovement of looseness in stool, abdominaldiscomfort, abdominal pain, and bloating with the useof acupuncture.

These findings were partially supported by a largerstudy conducted by Lembo et al. (2009). After receiv-ing acupuncture treatment for IBS symptoms twice a

week for 3 weeks (N

230), the subjects in bothexperimental and sham acupuncture groups showedsignificant improvement in their bowel symptoms.

TABLE 2. Baseline Demographics (N 42)KHA

(n 21)S-KHA

(n 21) p

Age, M (SD), y 22.26 (3.23) 21.48 (2.73) .232

BMI, M (SD) 19.71 (2.14) 20.46 (1.52) .072

Not married 21 (100) 21 (100)

Education,n (%) 0.252

High school 15 (71.4) 19 (90.5)

Junior college 1 (4.8) 0 (0)

University 5 (23.8) 2 (9.5)

Visit to clinics,n (%) .830

None 14 (66.8) 13 (61.9)

1 5 (23.8) 4 (19.0)

2 1 (4.7) 2 (9.5)

3 1 (4.7) 1 (4.7)

More than 5 0 (0) 1 (4.7)

Employment,n (%) .147

Professionals 2 (9.5) 0 (0)

Students 19 (90.5) 21 (100)

Exercise,n (%) .792

None 14 (66.7) 13 (61.9)

Less than 1/week 2 (9.5) 2 (9.5)

(N 42) 23/week 5 (23.8) 5 (23.8)

45/week 0 1 (4.7)

Note. BMI body mass index; KHA Korean hand acupunc-ture; S-KHA sham Korean hand acupuncture.


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TABLE 3. Baseline and Change Scores on Bowel Symptoms (N 42)

Measures Groups

Pretest Posttest

pM SD M SD

Loose stools

Frequency KHA 2.38 0.86 1.8 0.7 .023*

S-KHA 1.67 0.73 1.81 0.75 .535

Distress KHA 2.29 0.96 1.95 0.69 .203

S-KHA 1.71 0.72 1.57 0.68 .510

Disability KHA 2.10 0.94 1.55 0.83 .056

S-KHA 1.57 0.75 1.62 0.92 .855

Hard stools

Frequency KHA 1.65 0.67 1.43 0.51 .243

S-KHA 1.48 0.51 1.62 0.80 .497

Distress KHA 1.5 0.51 1.33 0.48 .291

S-KHA 1.48 0.60 1.29 0.46 .258Disability KHA 1.35 0.59 1.19 0.40 .320

S-KHA 1.38 0.59 1.24 0.44 .378

Abdominal pain

Frequency KHA 2.24 1.00 1.9 0.79 .234

S-KHA 1.86 0.73 2.05 0.80 .426

Distress (N 42) KHA 2.43 0.93 1.9 0.72 .048*

S-KHA 1.95 1.02 2 0.63 .857

Disability KHA 2.38 0.67 1.9 0.72 .033*

S-KHA 1.90 1.04 1.67 0.73 .397

DiarrheaFrequency KHA 1.38 0.59 1.5 0.61 .528

S-KHA 1.05 0.22 1.48 0.68 .011*

Distress KHA 1.48 0.98 1.3 0.47 .466

S-KHA 1.19 0.68 1.24 0.54 .803

Disability KHA 1.33 0.58 1.35 0.59 .928

S-KHA 1.19 0.68 1.29 0.72 .661

Bloating

Frequency KHA 2.24 0.89 2 0.97 .419

S-KHA 1.90 0.70 1.90 0.94 1

Distress KHA 2.43 0.87 1.9 0.79 .048*

S-KHA 1.95 0.80 1.90 0.70 .839

Disability KHA 2.48 0.87 1.7 0.92 .009*

S-KHA 1.90 0.83 1.71 0.72 .431

Urgency

Frequency KHA 1.95 0.92 1.65 0.67 .236

S-KHA 1.86 0.96 1.81 0.60 .849

Distress KHA 1.71 0.90 1.65 0.59 .788

S-KHA 1.81 1.12 1.81 0.68 1

Disability KHA 1.71 0.90 1.55 0.83 .546

S-KHA 1.76 1.14 1.67 0.66 .742

(continues)


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In the study by Xiao and Liu (2004), the interventiongroup received acupuncture twice per week for 8weeks, whereas in the present study, the intervention

group received acupuncture twice per week for 4weeks. In Xiao and Liu's (2004) study, the reduction ofpsychological symptoms could have been due to thereduction of IBS symptoms. Other explanations sug-gested by Xiao and Liu (2004) was that they might havestimulated the spots related to mental disorders duringthe intervention. In any case, the influence of KHA oracupuncture on psychological symptoms should bereevaluated considering the intervention dose.

KHA can cause artificial physical stimulation. In thecase of an experimental study, a two-group designhelps reduce biased judgments while enabling the

measurement of a certain effect and reduction of attri-tion among the patients. This study has shown thatKHA is an effective option for treating IBS symptoms.Further study is warranted as to how best to incorpo-rate this intervention into clinical practice and thecommunity. There is a need for further research on theeffectiveness of KHA in women with IBS using morediverse physiological indices. To eliminate potentialplacebo effects in the study, including an S-KHAgroup, wherein application of KHA to areas not asso-ciated with bowel symptoms occurs, is essential. The

effect of S-KHA in this study was a lack of reductionin symptoms; thus, S-KHA should be considered inother KHA studies as a control.

This might be explained with high placebo responsesof IBS subjects. In clinical studies to determine theeffect of medication for IBS symptoms, placebo effects

were reported between 30% and 80% in the controlgroup (Choi, 2006).

Because IBS is a chronic, functional disease, manypatients with IBS seek CAM for IBS symptom manage-ment. Valid evidence for CAM use is vital informationfor nurses because they can direct IBS patients to cost-effective care based on this evidence. There is conflict-ing evidence for different CAM modalities for IBSsymptoms. For example, cognitivebehavioral psycho-logical therapy (Boyce et al., 2000) was shown toreduce the IBS symptoms whereas reflexology (Tovey,2002) did not show statistically significant reduction of

bowel symptoms in an intervention group. Obtainingevidence for various types of CAM modalities such asKHA will benefit IBS patients by providing moreoptions for care. Nurses who are familiar with KHAcould advise IBS patients who seek supplemental ther-apy because of economic reasons, or because of sideeffects from or intolerance to medications used in con-ventional therapy.

In this study, the use of KHA was not effective onpsychological symptoms and stress levels among IBSsubjects. Previous studies that used acupuncture for IBS

subjects reported decreased anxiety and depression lev-els (Xiao & Liu, 2004). The differences could have beencaused by the dosage of intervention in the two studies.

TABLE 3. Baseline and Change Scores on Bowel Symptoms (N 42) (Continued)

Measures Groups

Pretest Posttest

pM SD M SD

Constipation

Frequency KHA 1.7 0.57 1.48 0.60 .229

S-KHA 1.71 0.56 1.38 0.50 .048*

Distress KHA 1.75 0.72 1.38 0.59 .081

S-KHA 1.57 0.75 1.29 0.56 .169

Disability KHA 1.45 0.83 1.33 0.58 .605

S-KHA 1.43 0.60 1.19 0.40 .139

Abdominal discomfort

Frequency KHA 2.9 0.94 1.9 0.72 .001*

S-KHA 2.14 0.91 1.9 0.72 .300

Distress KHA 2.71 0.90 2.1 0.85 .031*

S-KHA 2.24 0.94 1.86 0.65 .137Disability KHA 2.71 0.90 2.1 1.85 .003*

S-KHA 2.14 0.96 1.76 0.77 .165

Note. There were no statistically significant baseline differences in the outcomes of interest by treatment group. KHA Korean hand

acupuncture; S-KHA sham Korean hand acupuncture.

*p .05.


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LimitationsThe study limitations involve the small sample sizeand lack of follow-up on the long-term effects of

KHA treatment after the intervention. Excludingparticipants with depression would have been a biasbecause some IBS patients tend toward depression.

It is recommended that other studies be conductedto obtain a larger sample size and promote the studythrough a longer intervention period with appropri-

ate controls such as depressive symptoms.Excluding men with IBS and exclusively includingunmarried women are also limitations. Most of the

TABLE 4. Baseline and Change Scores on Mental Health and Stress

Measures

Pretest Posttest

pM SD M SD

Somatization

KHA 13.08 8.13 8.44 6.89 0.172S-KHA 11.83 6.43 10.74 7.33 0.517

Obsessivecompulsive

KHA 14.23 6.92 11.42 6.84 0.122

S-KHA 12.91 7.70 12.09 6.74 0.810

Interpersonal sensitivity

KHA 10.92 6.99 9.00 7.59 0.964

S-KHA 8.74 5.75 7.77 6.36 0.848

Depression

KHA 14.58 8.78 13.81 10.25 0.686

S-KHA 13.83 8.55 13.30 9.99 0.969

Anxiety

KHA 10.04 6.55 8.04 6.59 0.848

S-KHA 8.57 6.91 7.96 7.91 0.964

Hostility

KHA 4.69 3.41 4.15 4.46 0.454

S-KHA 4.09 3.60 4.00 4.09 0.418

Phobic anxiety

KHA 3.88 4.84 2.58 3.69 0.119

S-KHA 2.35 4.17 1.83 3.08 0.639

Paranoid ideation

KHA 3.88 3.56 3.23 4.06 0.721

S-KHA 2.57 3.45 2.78 3.09 0.534

Psychoticism

KHA 8.27 4.66 6.46 5.46 0.174

S-KHA 5.43 5.26 4.30 4.88 0.912

GSI

KHA 1.01 0.44 0.96 0.59 0.784

S-KHA 0.91 0.55 0.80 0.50 0.524

Stress

KHA 31.19 8.09 30.95 11.37 0.938

S-KHA 27.52 8.9 25.29 10.94 0.472

Note. GSI Global Severity Index; KHA Korean hand acupuncture; S-KHA sham Korean hand acupuncture.


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subjects were students. Selective sampling limits thegeneralizability of these study results. In addition, thisstudy verified the effect of KHA through 4-week treat-ment; it is recommended that the therapy be evaluatedin terms of frequency, distress, and discomfort of IBSbowel symptoms over a longer time period.

ConclusionsKorean hand acupuncture was effective in reducing

bowel symptoms such as looseness of stool, bloating,abdominal discomfort, and abdominal pain amongKorean young women with IBS. However, it was not

TABLE 5. Baseline and Change Scores on Heart Rate Variability

Measures

Pretest Posttest

pM SD M SD

SDRR

KHA 48.84 14.97 49.82 18.84 0.602S-KHA 45.60 15.11 42.01 17.99 0.174

PSI

KHA 32.64 25.08 33.74 35.04 0.279

S-KHA 33.86 16.49 56.17 56.52 0.148

TP

KHA 1666.91 1185.85 2082.85 1734.63 0.314

S-KHA 1806.56 1628.56 1537.66 1200.24 0.033

VLF

KHA 668.26 504.13 834.32 675.25 0.632

S-KHA 884.75 848.62 658.72 488.91 0.103

LF

KHA 554.70 380.30 750.77 876.75 0.331

S-KHA 585.72 667.92 556.55 748.74 0.170

HF

KHA 443.95 441.33 497.76 565.54 0.945

S-KHA 336.09 267.07 322.38 279.01 0.073

LFNorm

KHA 61.63 18.07 64.03 16.62 0.959

S-KHA 58.67 15.89 60.97 18.39 0.253

HFNorm

KHA 38.37 18.07 35.97 16.62 0.959

S-KHA 41.33 15.89 39.03 18.39 0.253

LF/HF

KHA 2.87 3.68 2.91 3.62 0.661

S-KHA 2.00 1.77 2.32 2.10 0.199

Note. HF high frequency; HFNorm LF/LFHF; HF/LFHF; KHA Korean hand acupuncture group; LF low frequency; LF/HF

low frequency/high frequency normalized HF; LFNorm normalized LF; PSI physical stress index; S-KHA sham Korean hand

acupuncture group; SDRR standard deviation of RR intervals; TP total power; VLF very low frequency.

effective in relieving psychological symptoms, stresslevels, and HRV.

Repeated studies with larger samples using diverseage groups or multisite studies are necessary to evalu-ate the effectiveness of KHA in women with IBS.Although regulating the Ki Meks of organs and corre-sponding spots of the large intestine by stimulationinfluenced some bowel symptoms, its influence on psy-chological symptoms and HRV should be further stud-

ied. Designing an intervention to regulate the Ki Meksto reduce psychological symptoms such as depression,anxiety, and stress levels could be done in the future.


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