Effect of a Multimodal Integrative Intervention on Quality of Recovery After Laparoscopic Colorectal Cancer Surgery: A Single-Center, Single-Blind, Pragmatic Randomized Controlled Trial

Effect of a Multimodal Integrative Intervention on Quality of Recovery After Laparoscopic Colorectal Cancer Surgery: A Single-Center, Single-Blind, Pragmatic Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of a Multimodal Integrative Intervention on Quality of Recovery After Laparoscopic Colorectal Cancer Surgery: A Single-Center, Single-Blind, Pragmatic Randomized Controlled Trial Jiayi Ren, Qiuyu Yang, Haoxiang He, Jin Li, Hang Gao, Chen Yang, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9250570/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Despite the minimally invasive nature of laparoscopic colorectal surgery, postoperative recovery is frequently compromised by pain, fatigue, and delayed gastrointestinal function. Current rehabilitation strategies largely rely on unimodal approaches, and evidence for structured multimodal protocols is limited. This study aimed to evaluate whether a multimodal integrative intervention—comprising electroacupuncture, abdominal massage, structured breathing training, and early ambulation—improves the quality of recovery in patients undergoing laparoscopic surgery for stage I–III colorectal cancer. Methods This single-center, single-blind, parallel-group, pragmatic randomized controlled trial randomized 105 patients to either a multimodal intervention or standard care. The intervention group received electroacupuncture and breathing training from postoperative day 1 to 7, with abdominal massage and supervised progressive ambulation added from postoperative day 4 to 7. The control group received standard postoperative care. The primary outcome was the trajectory of the Quality of Recovery-15 (QoR-15) score assessed at postoperative days 3, 7, and 30. Statistical analyses followed a modified intention-to-treat principle. Results Of 105 randomized patients, 90 (45 per group) were included in the final analysis. A significant group-by-time interaction was observed for QoR-15 scores (P = 0.043). While no significant between-group differences were found at postoperative days 3 or 7, the intervention group demonstrated significantly higher QoR-15 scores at postoperative day 30 (mean difference 11.33; 95% confidence interval 3.41 to 19.26; P = 0.005). Secondary outcomes, including pain intensity and perceived exertion, also favored the intervention group. No serious intervention-related adverse events were reported. Conclusions A multimodal integrative intervention significantly enhances the mid-to-long-term quality of recovery (at 30 days) after laparoscopic colorectal cancer surgery, despite no significant differences in the immediate postoperative period. These findings support the real-world effectiveness of integrating structured multimodal rehabilitation into standard perioperative care pathways. Trial Registration ChiCTR2400085191.Registered on June 3, 2024. Multimodal Integrative Intervention Colorectal Cancer Surgery Randomized Controlled Trial electroacupuncture abdominal massage exercise therapy Figures Figure 1 Figure 2 Figure 3 1. Introduction Colorectal cancer (CRC) remains one of the most prevalent malignancies worldwide ( 1 ). While laparoscopic surgery has become the standard approach owing to its minimally invasive nature, the postoperative course is frequently complicated by acute pain, profound fatigue, impaired functional capacity, and delayed gastrointestinal motility ( 2 , 3 ). These distressing symptoms not only hinder early mobilization but also cumulatively compromise the patient’s overall Quality of Recovery (QoR), potentially adversely influencing long-term clinical outcomes. Enhanced Recovery After Surgery (ERAS) protocols have substantially improved perioperative outcomes by integrating evidence-based strategies, including early mobilization and multimodal analgesia( 4 ). Recent evidence underscores that effective ERAS pathways not only improve short-term clinical outcomes but may also facilitate the timely initiation of subsequent oncological treatments( 5 , 6 ).However, the effectiveness of standardized ERAS pathways is often attenuated in heterogeneous populations, particularly older adults or frail individuals who struggle to tolerate uniform early mobilization targets( 7 , 8 ). Conventional postoperative ambulation protocols largely rely on "one-size-fits-all" instructions, often lacking individualized, symptom-titrated strategies to safely guide physical activity. Furthermore, the potential of integrating non-pharmacological modalities—such as electroacupuncture and massage therapy—to alleviate the very symptoms (pain and fatigue) that impede early mobilization within ERAS frameworks highlights a critical gap in contemporary perioperative research. In recent years, complementary and integrative medicine (such as acupuncture and massage) has gained increasing attention and utilization in surgical settings to alleviate postoperative discomforts and promote holistic recovery( 9 ). Furthermore, techniques like transcutaneous electrical acupoint stimulation (TEAS) have shown significant promise in managing postoperative pain and accelerating gastrointestinal recovery in various abdominal surgeries ( 10 ). Building upon this emerging evidence, structured multimodal integrative interventions may overcome these limitations by simultaneously targeting multiple physiological and symptomatic pathways ( 11 , 12 ). Electroacupuncture has been shown to exert robust analgesic and anti-inflammatory effects while enhancing gastrointestinal motility via autonomic regulation( 13 – 15 ). Concurrently, abdominal massage can augment local circulation and stimulate peristalsis through neuro-reflexive mechanisms( 16 , 17 ). We hypothesized that if these symptom-relieving therapies are strategically combined with a stepwise, symptom-guided exercise protocol (utilizing objective pain and fatigue thresholds), they would act synergistically. This integrated approach could proactively alleviate postoperative symptoms, thereby enabling patients to safely achieve their functional recovery milestones. Despite this biologically plausible rationale, high-quality randomized controlled trials evaluating such coordinated, stepwise integrative modalities are scarce. Given the complex and interactive nature of this multi-component rehabilitation package, isolating the specific efficacy of individual modalities against sham controls does not reflect real-world clinical practice. Therefore, we conducted a single-blind, pragmatic randomized controlled trial (pRCT) to evaluate the overall clinical effectiveness of a multimodal integrative intervention—comprising electroacupuncture, abdominal massage, structured breathing training, and symptom-titrated supervised progressive ambulation—would significantly improve the trajectory of postoperative recovery quality, as measured by the QoR-15, in patients undergoing laparoscopic colorectal cancer surgery compared with standard postoperative care alone. 2 .Methods 2.1. Study Design and Ethics: We conducted a single-center, single-blind, two-group, parallel, superiority pragmatic randomized controlled trial. The pragmatic design was chosen to evaluate the intervention’s effectiveness under real-world clinical conditions, where these multimodal therapies are delivered as an integrated care package rather than isolated components. The study was approved by the Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Approval No. 2024-1494-077-01) and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. This trial was registered at the Chinese Clinical Trial Registry (ChiCTR2400085191) on June 3, 2024, prior to patient enrollment. The study was reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) extension for pragmatic trials. 2.2. Participants: We consecutively enrolled adult patients (aged > 18 years, ASA physical status I–III) scheduled for elective laparoscopic resection of colonic or upper rectal cancer, without conversion, and who provided written informed consent. We excluded patients undergoing resection for mid/low rectal cancer, total/proctocolectomy, complex/combined procedures, or stoma creation. Patients who required intraoperative conversion to open surgery, experienced severe intraoperative complications, used epidural anesthesia/analgesia, had a cardiac pacemaker, needle allergy, or prior acupuncture experience were subsequently excluded prior to the initiation of postoperative interventions. 2.3. Randomization and Blinding: An independent statistician generated the randomization sequence using a computer-based random number generator in SPSS (version 26.0). Participants were allocated in a 1:1 ratio to either the multimodal integrative intervention or standard postoperative care group. Stratified block randomization was employed to ensure prognostic balance across key baseline covariates, including AJCC tumor stage, age, and sex. Allocation concealment was maintained using sequentially numbered, opaque, sealed envelopes (SNOSE). After baseline assessment and written informed consent were obtained, a research nurse uninvolved in enrollment or outcome evaluation opened the envelope to assign the participant. Given the behavioral nature of the interventions, blinding of participants and therapists was not feasible. To reduce performance bias, participants were told that the study compared two postoperative recovery approaches, without revealing specific components or hypotheses. They were instructed not to discuss treatment details with assessors. Surgical and ward staff remained unaware of group assignment, though they had access to standard medical records. Outcome assessors and the data analyst were blinded throughout the study. All outcomes were assessed at scheduled time points by trained blinded personnel. Adverse events requiring intervention were managed by the unblinded therapist per protocol, without unblinding the outcome assessors, thus preserving data integrity. These procedures were implemented to minimize selection, performance, and detection bias. 2.4. Interventions: Participants were randomly assigned to either the intervention group (multimodal integrative intervention plus standard postoperative care) or the control group (standard postoperative care alone). The components and procedures of each group are summarized in Table 1 , and the day-by-day intervention schedule across postoperative days 1–7 (POD1–POD7) is provided in Table 2 . 2.4.1. Intervention Group (Multimodal Integrative Intervention) Patients in the intervention group received a structured program consisting of electroacupuncture, abdominal massage (Tuina, Mo Fa technique), and exercise therapy (structured breathing training and early ambulation) , in addition to standard postoperative care. Electroacupuncture : Practitioner Qualification: Electroacupuncture sessions were conducted by licensed acupuncturists with a minimum of 5 years of clinical experience. Procedure: Sterile, single-use acupuncture needles (length: 35 mm; diameter: 0.40 mm; Qizhou, Suzhou Zhongjing Life Technology Co., Ltd., China) were used. Based on a consensus protocol developed by experts in the field, the acupoints Zusanli (ST-36) and Hegu (LI-4) were selected for their efficacy in alleviating postoperative pain, abdominal distension, and promoting gastrointestinal function. Needles were inserted perpendicularly to a depth of approximately 20–30 mm, adjusted according to individual patient's body constitution. The achievement of de qi, a sensation of soreness, numbness, or distension considered indicative of effective needling, was sought. Electroacupuncture Parameters: Following needle insertion, an SDZ-III electronic acupuncture device (Suzhou Medical Appliance Factory, China) was connected. Electrical stimulation was delivered at a continuous waveform with a frequency of 100 Hz. The intensity was adjusted to a level tolerable to the patient without causing muscle twitching or discomfort. Duration and Frequency: Each electroacupuncture session lasted for 20 minutes. Treatment commenced on postoperative day 1 and was administered once daily until postoperative day 7, resulting in a total of 7 sessions. Abdominal Massage : Practitioner Qualification: Abdominal massage was performed by certified massage therapists. Procedure: The intervention consisted of gentle clockwise abdominal rubbing (Mo Fa). The manipulation was applied over the abdominal region with light pressure, ensuring the patient experienced no pain or significant discomfort. Duration and Frequency: Sessions lasted 10 minutes, administered twice daily from postoperative days 4 to 7. Exercise Therapy : The exercise protocol included two components: Structured Breathing Training: Patients were guided to perform diaphragmatic breathing exercises. Each session lasted for 5 minutes and was performed twice daily throughout the intervention period (postoperative days 1-7). Early Ambulation Plan: A graded activity plan was implemented: Postoperative Days 1-3: Patients were encouraged to maintain a semi-Fowler's position in bed and perform active ankle and limb movements. Postoperative Days 4-7: Supervised progressive ambulation was added to the regimen. During the initial sessions, the walking duration was set to a target of 5 minutes, with a minimum acceptable duration of 2 minutes to accommodate early postoperative frailty. The daily duration was subsequently increased by 2-3 minutes per session, aiming for 10-15 minutes by POD 7. Crucially, the titration of walking time was not arbitrary but strictly guided by predefined tolerance criteria based on real-time assessments: an acceptable modified Borg Rating of Perceived Exertion score of ≤ 3 (Moderate) and a Visual Analog Scale (VAS) pain score of ≤ 4. If a patient exceeded these thresholds, the session was interrupted or maintained at the previous tolerated duration. Table 1. Intervention protocol details Component Intervention Group (Multimodal Integrative Care) Control Group (Standard Postoperative Care) Basis of Care Received all components of Standard Postoperative Care based on institutional ERAS protocols, plus the following integrative therapies. Received standard postoperative care only(based on institutional ERAS protocols). Electroacupuncture NA › Practitioner Licensed acupuncturists with ≥5 years of experience. › Acupoints Bilateral Zusanli (ST-36), Hegu (LI-4). › Needle Specification Sterile, single-use needles (0.40 mm × 35 mm; Qizhou, Suzhou Zhongjing Life Technology Co., Ltd., China). › Depth / Technique ~20-30 mm depth; de qi sensation sought. › Electroacupuncture Device Hwato SDZ-III electronic acupuncture device (Suzhou Medical Appliance Factory, China) . NA › Waveform / Frequency Continuous wave, 100 Hz. › Session Duration & Frequency 20 minutes, once daily. › Period Postoperative days 1 to 7 (Total: 7 sessions). Abdominal Massage (Tuina) NA › Practitioner Certified tuina massage therapists. › Technique Gentle clockwise abdominal rubbing (Mo Fa). › Pressure Light pressure, ensuring no pain. › Session Duration & Frequency 10 minutes, twice daily. › Period Postoperative days 4 to 7. Exercise Therapy › Breathing Training Diaphragmatic breathing (Structured Breathing Training), 5 minutes, twice daily. No structured breathing training. General verbal encouragement for early mobilization was provided. › Ambulation Plan Days 4-7: Symptom-titrated supervised progressive ambulation, twice daily. • Target: 5-15 mins/session (minimum acceptable: 2 mins). • Titration criteria: Strictly guided by daily safety thresholds (Modified Borg score ≤ 3 and VAS pain score ≤ 4). No structured ambulation plan. Table 2. Intervention Schedule Postoperative Days (POD) Electroacupuncture Breathing Training Abdominal Massage (Tuina) Early Ambulation Days 1-3 ✔ Daily (20 minutes) ✔ Twice daily (5 minutes) - - Days 4-7 ✔ Daily 20 minutes) ✔ Twice daily (5 minutes) ✔ Twice daily (10 minutes) ✔ Twice daily (Target: 5–15 mins) 2.4.2 . Control group (Standard Postoperative Care) Patients in the control group received standard postoperative care based on institutional Enhanced Recovery After Surgery (ERAS) protocols, which included standardized pharmacologic pain management (e.g., patient-controlled analgesia with opioids or scheduled non-steroidal anti-inflammatory drugs), routine vital signs monitoring, fluid management, and general verbal encouragement for early mobilization. They did not receive any form of electroacupuncture, abdominal massage, or the structured breathing training and early ambulation plan provided to the intervention group.Importantly, all patients in both groups received a highly standardized multimodal analgesia protocol per institutional ERAS guidelines to minimize potential confounding from disparate pain management strategies. 2.5. Outcome Measures: Primary Outcome The primary outcome was the patient-centred Quality of Recovery-15 (QoR-15) score, a validated questionnaire that comprehensively assesses recovery after surgery. The QoR-15 includes 15 items covering five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Total scores range from 0 to 150, with higher scores indicating better recovery. (18)A score of ≥118(19) was defined as indicating good recovery, and the minimal clinically important difference (MCID) was set at 6.0(20). QoR-15 scores were assessed on postoperative day 3 (POD3), day 7 (POD7), and day 30 (POD30) to capture short- to medium-term recovery dynamics following laparoscopic colorectal cancer surgery. The QoR-15 is widely recognized as a patient-reported outcome (PRO) tool in clinical recovery assessments. Secondary Outcomes Secondary outcomes included pain intensity, muscle strength, perceived exertion, and functional exercise capacity. Pain intensity was assessed using the Visual Analog Scale (VAS; 0-10). Muscle strength was evaluated using the Medical Research Council (MRC) scale (0-5), where 0 indicates no visible or palpable muscle contraction and 5 indicates normal strength. Assessments were performed by trained assessors according to a standardized protocol on postoperative days (POD) 3, 7, and 30.Perceived exertion was evaluated using the Modified Borg Scale (0-10), and functional capacity was objectively assessed using the 6-minute walk test (6MWT). As early mobilization may be restricted in the immediate postoperative period, formal assessments of perceived exertion (Borg) and functional capacity (6MWT) were conducted on POD7 and POD30. (Note: The real-time, daily VAS and Borg scores utilized exclusively for the titration of the early ambulation plan on POD 4-7 were recorded in nursing charts for safety monitoring and adherence tracking, distinct from these formal secondary outcome assessments). 2.6. Sample Size Calculation: The sample size calculation was based on the primary outcome, the QoR-15 score on postoperative day 3. Although the primary analysis assessed the overall recovery trajectory, the sample size was conservatively powered based on the early critical time point of POD3.POD3 was selected because it reflects early global recovery beyond the immediate post-anesthesia period and has been used as a primary time point in perioperative recovery trials employing QoR-15(21). Based on published QoR-15 data in laparoscopic colorectal surgery and related recovery studies, together with our clinical experience, the expected mean (SD) POD3 QoR-15 score in the control group was 110 (12)(22, 23) .A between-group difference of 6.0 points was considered clinically meaningful (MCID) (18-20) , corresponding to a standardized effect size (Cohen’s d) of 0.50. Using a two-sided independent-samples t-test with an α level of 0.05, 80% power, and a 1:1 allocation ratio, G*Power software (version 3.1.9.7) indicated that 36 participants were required per group. To achieve a final evaluable sample of 90 participants (45 per group) after accounting for potential post-randomization exclusions and dropouts, we ultimately randomized a total of 105 patients. This final sample size was more than adequate to detect the prespecified clinically meaningful difference. 2.7. Statistical Analysis All analyses were conducted according to a modified intention-to-treat (mITT) principle, including all randomized participants with available outcome data. Descriptive statistics were utilized to summarize baseline characteristics, adverse events, and adherence to the progressive ambulation protocol (e.g., achievement of target duration and protocol interruptions).All statistical analyses were performed using SPSS version 24.0. Continuous variables were assessed for normality using the Shapiro-Wilk test. Data are presented as mean ± standard deviation for normally distributed variables or median (interquartile range) for non-normally distributed variables. Categorical variables are presented as frequencies (percentages) and were compared using chi-square tests. Baseline characteristics were compared between groups using independent-samples t tests or Mann–Whitney U tests for continuous variables, and χ² tests or Fisher’s exact tests for categorical variables, as appropriate. For longitudinal outcomes, including QoR-15 scores, postoperative pain intensity (VAS), muscle strength, Borg Rating of Perceived Exertion scores, 6-minute walk test (6MWT) distance, and the percentage of predicted 6MWT distance, linear mixed-effects models were used to account for within-subject correlations over time. Each model included fixed effects for group (intervention vs control), time, and their interaction, along with a subject-specific random intercept to account for within-subject correlations. This likelihood-based approach naturally handles missing data under the missing-at-random (MAR) assumption.When a significant group-by-time interaction was detected, between-group comparisons were performed at each time point using estimated marginal means. In the absence of a significant interaction, main effects of group and time were interpreted. Post hoc pairwise comparisons were adjusted for multiple testing using the Bonferroni method. Results from mixed-effects models are reported as estimated marginal means with standard errors (SE), along with mean differences, 95% confidence intervals (CI), and corresponding P values. All statistical tests were two-sided, and a P value < 0.05 was considered statistically significant. 3. Results 3.1. Participant Flow A total of 198 patients were assessed for eligibility, of whom 105 were randomized to the intervention group (n = 53) or the control group (n = 52). After randomization, two participants in the intervention group did not receive the allocated intervention due to intraoperative complications (n = 1) or withdrawal of consent (n = 1). During follow-up, six participants in the intervention group and seven in the control group discontinued the intervention or were lost to follow-up for the primary outcome. Ultimately, 45 participants in each group had at least one post-baseline assessment of the primary outcome and were included in the mITT analysis. The detailed reasons for exclusion after randomization are presented in the CONSORT flow diagram (Fig. 1 ). 3.2. Baseline Data Baseline demographic and clinical characteristics were highly comparable between the two groups ( Table 3 ). No statistically significant differences were observed in age, sex distribution, height, weight, or body mass index (all P > 0.05), indicating successful randomization and balanced group characteristics at baseline.Furthermore, baseline adherence to the standard institutional ERAS elements was comparable between the two groups. Table 3 Baseline characteristics of participants Characteristic Intervention Group(n = 45) Control Group(n = 45) P value Age (y) 72(61, 80) 70(61, 78) 0.399 Sex, n (%) Female 22(48.9) 19(42.2) 0.525 Male 23(51.1) 26(57.8) 0.525 Height 166(158, 172) 166(162, 171) 0.662 Weight 65.9(11.3) 64.7(10.9) 0.615 Body mass index (kg/m²) 24.3(3.9) 23.4(3.2) 0.255 3.3. Intervention Adherence and Safety The multimodal integrative intervention, particularly the symptom-titrated progressive ambulation protocol, was well tolerated. By POD 7, 38 patients (84.4%) in the intervention group successfully achieved the target walking duration of 10–15 minutes per session. Protocol interruptions or failure to progress due to predefined intolerance criteria occurred in 7 patients. The primary reasons for limiting walking duration were postoperative wound pain (VAS > 4, n = 3) and intolerable fatigue (Modified Borg > 3, n = 4). Notably, all these patients safely maintained their previously tolerated durations. No serious intervention-related adverse events (e.g., severe bleeding, falls, or anastomotic leakage) were reported in either group.A few minor incidents, such as transient mild bruising at the acupuncture sites or mild muscle soreness after massage, were noted but resolved spontaneously without requiring medical intervention or protocol discontinuation. 3.4. Primary Outcome Quality of Recovery-15 (QoR-15) Scores Quality of recovery was assessed using the QoR-15 questionnaire at POD3, POD7, and POD30. Linear mixed-effects model analysis demonstrated a significant group-by-time interaction (P = 0.043), indicating different postoperative recovery trajectories between the two groups. A significant main effect of time was observed (P < 0.001), whereas the main effect of group did not reach statistical significance (P = 0.053). Post hoc Bonferroni-adjusted comparisons showed no significant between-group differences at POD3 or POD7; however, QoR-15 scores were significantly higher in the intervention group at POD30 (mean difference = 11.33, 95% CI 3.41 to 19.26; P = 0.005), suggesting a delayed but robust enhancement in overall recovery quality (Fig. 2 ). 3.5. Secondary Outcomes Pain Intensity (VAS Scores) Postoperative pain intensity assessed by VAS showed significant main effects of group (P = 0.003) and time (P < 0.001), with no significant group-by-time interaction (P = 0.465) in the linear mixed-effects model. Overall, VAS scores were lower in the intervention group. Between-group differences were not significant at POD3 but were significant at POD7 (mean difference = − 1.11, 95% CI − 1.89 to − 0.33; P = 0.006) and POD30 (mean difference = − 1.24, 95% CI − 2.02 to − 0.47; P = 0.002). Muscle Strength The linear mixed-effects model for muscle strength showed a significant main effect of time (P < 0.001) but not group (P = 0.216). Interestingly, the intervention group exhibited slightly lower muscle strength than the control group at POD 3 (mean difference = − 0.24, 95% CI − 0.48 to − 0.01; P = 0.039). However, this transient difference dissipated, with no significant between-group differences observed at POD 7 or POD 30 ( Table 4 ). Borg Scores Perceived exertion assessed by the Borg score showed significant main effects of group (P < 0.001) and time (P < 0.001), with no significant group-by-time interaction (P = 0.089) in the linear mixed-effects model. Overall, Borg scores were lower in the intervention group. Between-group differences were significant at POD7 (mean difference = − 1.42, 95% CI − 2.19 to − 0.66; P < 0.001) and POD30 (mean difference = − 1.87, 95% CI − 2.63 to − 1.10; P < 0.001). 6-Minute Walk Test Functional capacity assessed by the six-minute walk test showed significant main effects of group (P = 0.021) and time (P < 0.001), with no significant group-by-time interaction (P = 0.154) in the linear mixed-effects model. Overall, 6MWT distance was greater in the intervention group. Between-group differences were not significant at POD7 but were significant at POD30 (mean difference = 53.33 m, 95% CI 15.15 to 91.52; P = 0.007). Percentage of Predicted 6MWT Distance The percentage of predicted 6MWT distance showed significant main effects of group (P = 0.003) and time (P < 0.001), with no significant group-by-time interaction (P = 0.128) in the linear mixed-effects model. Overall, the percentage of predicted 6MWT distance was higher in the intervention group. Between-group differences were not significant at POD7 but were significant at POD30 (mean difference = 0.106, 95% CI 0.045 to 0.166; P = 0.001). Table 4. Comparison of Secondary Outcomes Between Groups Across Different Time Points Outcome Measure Time Control (EM mean ± SE) Intervention (EM mean ± SE) Mean difference (95% CI) P value QoR-15 POD3 83.98 ± 2.83 86.42 ± 2.83 2.44 (−5.48 to 10.37) 0.543 POD7 100.67 ± 2.83 108.20 ± 2.83 7.53 (−0.40 to 15.46) 0.062 POD30 114.02 ± 2.83 125.36 ± 2.83 11.33 (3.41 to 19.26) 0.005 VAS Score POD3 5.76 ± 0.27 5.02 ± 0.27 −0.73 (−1.49 to 0.02) 0.057 POD7 3.84 ± 0.28 2.73 ± 0.28 −1.11 (−1.89 to −0.33) 0.006 POD30 2.36 ± 0.28 1.11 ± 0.28 −1.24 (−2.02 to −0.47) 0.002 Muscle Strength POD3 3.56 ± 0.08 3.31 ± 0.08 −0.24 (−0.48 to −0.01) 0.039 POD7 4.13 ± 0.08 4.00 ± 0.08 −0.13 (−0.37 to 0.10) 0.258 POD30 4.71 ± 0.08 4.73 ± 0.08 0.02 (−0.21 to 0.25) 0.850 Borg Score POD7 5.89 ± 0.27 4.47 ± 0.27 −1.42 (−2.19 to −0.66) <0.001 POD30 3.34 ± 0.27 1.48 ± 0.27 −1.87 (−2.63 to −1.10) <0.001 6MWT POD7 247.29 ± 13.66 272.56 ± 13.66 25.27 (−12.92 to 63.45) 0.193 POD30 401.27 ± 13.66 454.60 ± 13.66 53.33 (15.15 to 91.52) 0.007 Proportion of predicted 6MWT distance POD7 0.419 ± 0.022 0.473 ± 0.022 0.054 (−0.007 to 0.115) 0.080 POD30 0.682 ± 0.022 0.788 ± 0.022 0.106 (0.045 to 0.166) 0.001 Mean differences are presented as intervention minus control. Estimated marginal means and between-group differences were derived from linear mixed-effects models with Bonferroni-adjusted post hoc comparisons. Estimated marginal means were derived from linear mixed-effects models. 3.6. Adverse Events No serious adverse events related to the multimodal integrative intervention were reported during the study period. Among participants included in the modified intention-to-treat analysis, three individuals in the intervention group (6.7%) reported minor, transient discomfort associated with electroacupuncture; these events did not require additional intervention or lead to treatment discontinuation. No adverse events were reported in association with the abdominal massage or exercise therapy components. 4. Discussion The present single-blind, randomized controlled trial demonstrates that a structured multimodal integrative intervention confers significant, long-term benefits on postoperative recovery following laparoscopic colorectal cancer surgery. While previous studies have independently reported beneficial effects of single interventions, evidence supporting the efficacy of structured multimodal integrative protocols remains limited(24, 25). Our study is among the first to evaluate a stepwise, symptom-titrated multimodal strategy. The primary finding was a significant alteration in the trajectory of postoperative recovery (group-by-time interaction for QoR-15 scores). Compared with standard postoperative care, patients receiving the integrative intervention exhibited a delayed but robust and clinically meaningful improvement in overall recovery quality at postoperative day 30, accompanied by sustained reductions in pain and fatigue, and enhanced functional capacity. Interestingly, we observed no significant between-group differences in the primary outcome (QoR-15) at POD 3 or POD 7. This phenomenon likely reflects the overwhelming physiological impact of acute surgical trauma and systemic inflammatory responses during the immediate postoperative phase, which may mask the early benefits of rehabilitation interventions. Furthermore, it is worth noting that the actual mean QoR-15 score of the control group on POD 3 in our study (approximately 84) was lower than the anticipated score of 110 used in our initial sample size calculation. This discrepancy may be further attributed to the specific clinical characteristics of our cohort. Our study included a substantial proportion of middle-aged and elderly patients undergoing major laparoscopic colorectal resections, who might experience more profound acute surgical stress, fatigue, and delayed early functional return. Differences in baseline demographics and institutional perioperative care pathways compared to previous literature may also contribute to this lower early recovery trajectory. Nevertheless, the substantial and statistically significant group-by-time interaction observed throughout the trial indicates that our initial sample size provided sufficient statistical power to detect the true therapeutic effect of the multimodal integrative intervention. However, the significant divergence at POD 30 suggests a "legacy effect" or delayed functional compensation. By aggressively managing early postoperative pain and fatigue through electroacupuncture and abdominal massage, and safely maintaining physical conditioning via titrated ambulation, the integrative intervention preserved the patients' physiological reserves. This preservation translated into accelerated medium-to-long-term recovery once the acute surgical stress subsided. These accelerated recovery milestones align with the broader objectives of ERAS pathways. Similar benefits of structured recovery pathways on expediting gastrointestinal function and overall recovery have been prominently observed in other real-world cohorts of stage II–III colorectal cancer patients(6). By integrating electroacupuncture and massage into the ERAS framework, our study provides a novel non-pharmacological strategy to further optimize these clinical outcomes. The superiority of the multimodal approach stems from the synergistic physiological mechanisms of its components. Electroacupuncture and abdominal massage have been widely documented to modulate autonomic nervous system balance, suppress inflammatory pathways, and promote gastrointestinal motility(26-30). Consistent with our findings, recent trials have demonstrated that repeated or multi-period applications of acupoint stimulation can significantly reduce postoperative nausea, vomiting, and pain in patients undergoing laparoscopic surgeries(31).By effectively reducing pain (VAS) and perceived exertion (Borg), these passive modalities created an optimal "physiological window" for active exercise. Notably, our results showed a transient, slightly lower muscle strength in the intervention group at POD 3. While the exact physiological mechanism remains unclear, this temporary dip may be attributed to two potential factors. First, executing intensive early ambulation during the acute catabolic phase of surgical stress initially demands high energy expenditure, which can transiently exacerbate peripheral muscle fatigue in gastrointestinal surgery patients(32). Second, recent evidence highlights that interventions like electroacupuncture and massage significantly enhance parasympathetic (vagal) tone(33), inducing an immediate and profound systemic muscle relaxation (34). This therapy-induced parasympathetic dominance might acutely reduce peak voluntary muscle contraction force during testing. Importantly, rather than an adverse effect, this early subtle difference was fully resolved by POD 7, eventually translating into significantly superior functional capacity (6MWT) by POD 30. A critical innovation of this trial is the implementation of the symptom-titrated progressive ambulation protocol. While various physical and respiratory prehabilitation strategies have been explored to enhance recovery(35, 36), conventional ERAS postoperative mobilization pathways frequently face low adherence rates due to generalized "one-size-fits-all" targets that fail to accommodate individual postoperative frailty(32). By contrast, our protocol strictly utilized real-time objective thresholds (VAS ≤ 4 and Modified Borg ≤ 3) to guide walking duration. This individualized approach resulted in an exceptionally high adherence rate, with 84.4% of patients successfully achieving the 10-15 minute ambulation target by POD 7 without any serious adverse events. This provides compelling evidence that early mobilization, when properly titrated against objective symptom limits, is highly feasible and safe even in patients recovering from major abdominal surgery. Despite the significant findings, our study has several limitations. First, owing to the pragmatic design and the complex nature of the multimodal intervention (which combines physical stimulation with active functional exercises), implementing a credible sham control and achieving double-blinding were practically unfeasible. Consequently, we cannot entirely rule out placebo effects or the influence of increased therapist attention. However, our primary objective was to evaluate the real-world clinical effectiveness of this comprehensive ERAS add-on package rather than isolating the mechanistic efficacy of single modalities. Furthermore, potential bias was minimized by strictly blinding both the outcome assessors and data analysts. Second, we did not collect preoperative baseline measurements for functional and patient-reported outcomes, such as the 6MWT and QoR-15. As a result, we could not calculate the exact percentage of return to preoperative baseline status for individual patients. Nevertheless, our rigorous randomization process ensured that demographic and clinical characteristics were highly balanced between the two groups, substantially mitigating the risk of baseline confounding. Third, although a standardized multimodal analgesia protocol was strictly implemented, we did not precisely quantify total postoperative opioid or overall analgesic consumption. Future studies should incorporate these specific metrics to further validate the potential opioid-sparing effects of this integrative intervention. Fourth, as a single-center trial, the generalizability of our results to broader populations and different clinical settings may be limited. Finally, the follow-up period was relatively short, focusing primarily on early-to-mid-term recovery milestones. Therefore, the ultimate long-term impact of this multimodal intervention on oncological outcomes and cancer survival remains unknown and warrants further longitudinal research. 5. Conclusions In conclusion, the implementation of a structured multimodal integrative intervention—comprising electroacupuncture, abdominal massage, breathing training, and early ambulation—did not yield a statistically significant improvement in early postoperative recovery (POD 3 and 7) compared to standard care. However, it significantly enhanced the medium-term quality of recovery at POD 30. These findings suggest that while the acute surgical trauma and physiological stress may mask the immediate benefits of the intervention, its legacy effects play a crucial role in facilitating a better convalescence at one month postoperatively. Clinicians should consider setting realistic expectations for patients regarding the timeline of recovery benefits when applying this multimodal approach. Abbreviations 6MWT 6-minute walk test AJCC American Joint Committee on Cancer ASA American Society of Anesthesiologists BMI Body mass index CI Confidence interval CONSORT Consolidated Standards of Reporting Trials CRC Colorectal cancer EM mean Estimated marginal means ERAS Enhanced Recovery After Surgery LI-4 Hegu acupoint MCID Minimal clinically important difference mITT Modified intention-to-treat MRC Medical Research Council POD Postoperative day PRO Patient-reported outcome QoR Quality of Recovery QoR-15 15-item Quality of Recovery RCT Randomized controlled trial SD Standard deviation SE Standard error SNOSE Sequentially numbered, opaque, sealed envelopes ST-36 Zusanli acupoint TEAS Transcutaneous electrical acupoint stimulation VAS Visual Analog Scale Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Approval No. 2024-1494-077-01) and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to patient privacy and confidentiality, but are available from the corresponding author (Jiming Tao) on reasonable request. Competing interests The authors declare that they have no competing interests. Trial protocol and statistical analysis plan The full trial protocol and statistical analysis plan are accessible via the Chinese Clinical Trial Registry (Registration number: ChiCTR2400085191). Further details or additional materials are available from the corresponding author upon reasonable request. Funding This study was supported by the Shanghai Municipal Health System Key Support Discipline—Rehabilitation Medicine (No. 2023ZDFC0301), the Shanghai University of Traditional Chinese Medicine Science and Technology Development Project (Natural Science Category; 23KFL009), and the Shanghai University of Traditional Chinese Medicine Affiliated Shuguang Hospital Siming Fund (SGKJ-202509).The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors' contributions JR, QY, and HH contributed equally to this work and should be considered co-first authors. JT, JR, and HH conceived and designed the study; JR, HH, QY, and CC recruited and followed up the patients; QY analysed and interpreted the data; JT, JR, and HH were responsible for study monitoring; QY accessed and was responsible for the raw data associated with the study, and JR was responsible for data verification; QY performed the statistical analysis; JR and HH drafted the manuscript; HG, JL, CC, CY, YC, MK and YW critically revised the important intellectual content of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all the participants and the medical staff at Shuguang Hospital for their support during the study. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209–49. Lavikainen LI, Guyatt GH, Sallinen VJ, Karanicolas PJ, Couban RJ, Singh T, et al. Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery. Ann Surg. 2024;279(2):213–25. Islami F, Goding Sauer A, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018;68(1):31–54. Rosa F, Longo F, Pozzo C, Strippoli A, Quero G, Fiorillo C, et al. Enhanced recovery after surgery (ERAS) versus standard recovery for gastric cancer patients: The evidences and the issues. Surg Oncol. 2022;41:101727. Pang Q, Duan L, Jiang Y, Liu H. Oncologic and long-term outcomes of enhanced recovery after surgery in cancer surgeries - a systematic review. World J Surg Oncol. 2021;19(1):191. Wang B, Wu Z, Zhang R, Chen Y, Dong J, Qi X. Retrospective analysis of safety and efficacy of enhanced recovery pathways in stage II-III colorectal cancer patients submitted to surgery and adjuvant therapy. World J Surg Oncol. 2021;19(1):99. Molenaar CJL, van Rooijen SJ, Fokkenrood HJP, Roumen RMH, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database of Systematic Reviews. 2022;2022(5). Onerup A, Li Y, Afshari K, Angenete E, de la Croix H, Ehrencrona C, et al. Long-term results of a short‐term home‐based pre‐ and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG‐C): a randomized clinical trial. Colorectal Dis. 2024;26(3):545–53. Lederer AK, Samstag Y, Simmet T, Syrovets T, Huber R. Complementary medicine usage in surgery: a cross-sectional survey in Germany. BMC Complement Med Ther. 2022;22(1):263. Chang XL, Liu XM, An LX, Zheng JY, Zhang K. Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial. BMC Complement Med Ther. 2023;23(1):253. Bisch SP, Jago CA, Kalogera E, Ganshorn H, Meyer LA, Ramirez PT, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol. 2021;161(1):46–55. Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M et al. Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer. JAMA Surg. 2020;155(3). Li X, Kou Z, Liu R, Zhou Z, Mei J, Yan W. Transcutaneous Electrical Acupoint Stimulation Improves Postoperative Nutrition and Promotes Early Recovery of Gastrointestinal Function in Patients with Colorectal Cancer. Comb Chem High Throughput Screen. 2025;28(1):64–73. Wang Y, Wang L, Ni X, Jiang M, Zhao L. Effect of acupuncture therapy for postoperative gastrointestinal dysfunction in gastric and colorectal cancers: an umbrella review. Front Oncol. 2024;14. Zhou T, Wang S, Fan BJ, Zhang LX, Hu SH, Hou W. Clinical efficacy of acupuncture in treating postoperative gastrointestinal dysfunction of colorectal cancer, a systematic review and Meta analysis. Zhen Ci Yan Jiu. 2024;49(2):208–19. Dai N, He Q, Liu X, Fang M, Xiong M, Li X, et al. Therapeutic massage/Tuina for treatment of functional dyspepsia: a systematic review and meta-analysis of randomized controlled trials. Qual Life Res. 2023;32(3):653–67. Huang SY, Chiao CY, Chien LY. Effectiveness of abdominal massage on chronic constipation in adults: A systematic review and meta-analysis. Int J Nurs Stud. 2025;161:104936. Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology. 2013;118(6):1332–40. Myles PS, Myles DB. An Updated Minimal Clinically Important Difference for the QoR-15 Scale. Anesthesiology. 2021;135(5):934–5. Myles PS, Myles DB, Galagher W, Chew C, MacDonald N, Dennis A. Minimal Clinically Important Difference for Three Quality of Recovery Scales. Anesthesiology. 2016;125(1):39–45. Admiraal M, Hermanns H, Hermanides J, Wensing C, Meinsma SL, Wartenberg HCH, et al. Study protocol for the TRUSt trial: a pragmatic randomised controlled trial comparing the standard of care with a transitional pain service for patients at risk of chronic postsurgical pain undergoing surgery. BMJ Open. 2021;11(8):e049676. Xu Y, He L, Liu S, Zhang C, Ai Y. Intraoperative intravenous low-dose esketamine improves quality of early recovery after laparoscopic radical resection of colorectal cancer: A prospective, randomized controlled trial. PLoS ONE. 2023;18(6):e0286590. Zheng L, Lu Y, Lu X, You L, Yu C, Lai J et al. Intrathecal Morphine for Enhanced Recovery After Laparoscopic Colorectal Surgery: A Randomized Clinical Trial. JAMA Surg. 2025. Cao LX, Chen ZQ, Jiang Z, Chen QC, Fan XH, Xia SJ, et al. Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery. World J Gastroenterol. 2020;26(23):3271–82. Lv X, Hou A, Han S, Cao J, Lou J, Li H, et al. Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged ≥ 65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial. J Clin Anesth. 2024;99:111670. Kim KH, Lee MS, Choi TY, Kim TH. Acupuncture for symptomatic gastroparesis. Cochrane Database Syst Rev. 2018;12(12):Cd009676. Liang X, Yang JA, Yang JB, Wang X, Yang Y. Evaluation of abdominal massage as a non-pharmacological modality to restore gut microbiota and duodenal barrier function in a rat model of functional dyspepsia. Technol Health Care. 2025:9287329251363139. Wang Y, Xu J, Bao R, Li Z. Massage for gastrointestinal function among participants after abdominal surgery: A protocol for systematic review and meta-analysis. Med (Baltim). 2021;100(49):e28087. Wang Q, Lin J, Yang P, Liang Y, Lu D, Wang K, et al. Effect of Massage on the TLR4 Signalling Pathway in Rats with Neuropathic Pain. Pain Res Manag. 2020;2020:8309745. Liu S, Fu W, Fu J, Chen G, He Y, Zheng T, et al. Electroacupuncture alleviates intestinal inflammation via a distinct neuro-immune signal pathway in the treatment of postoperative ileus. Biomed Pharmacother. 2024;173:116387. Jin LD, Lei W, Xu J, Xing L, Shen YH, Lin SF, et al. Effect of single or multi-period use of transcutaneous acupoint electrical stimulation on postoperative nausea and vomiting in patients undergoing gynecological laparoscopic surgery: a prospective randomized double-blind trial. BMC Complement Med Ther. 2025;25(1):110. Zhang L, Wu Q, Wang X, Zhu X, Shi Y, Wu CJ. Factors impacting early mobilization according to the Enhanced Recovery After Surgery guideline following gastrointestinal surgery: A prospective study. Geriatr Gerontol Int. 2024;24(2):234–9. He J, Huang R, Ouyang J, Zhao G, Zhong M. Muscarinic Receptor-Mediated Electroacupuncture Modulation of Reactive Enteric Glial Cells Ameliorates Postoperative Ileus. J Inflamm Res. 2025;18:17057–72. Mat Isar NEN, Abdul Halim MHZ, Ong MLY. Acute massage stimulates parasympathetic activation after a single exhaustive muscle contraction exercise. J Bodyw Mov Ther. 2022;30:105–11. Bausys A, Luksta M, Anglickiene G, Maneikiene VV, Kryzauskas M, Rybakovas A, et al. Effect of home-based prehabilitation on postoperative complications after surgery for gastric cancer: randomized clinical trial. Br J Surg. 2023;110(12):1800–7. Jin B, Yao M, Shen W, Fu L, Liu P, Zheng X, et al. Effect of post-extubation high-flow nasal cannula combined with respiratory training versus conventional oxygen therapy on postoperative pulmonary complications in patients after major abdominal surgery: protocol for a single-centre randomized controlled trial. Trials. 2023;24(1):396. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviews received at journal 12 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 31 Mar, 2026 Editor assigned by journal 30 Mar, 2026 Submission checks completed at journal 29 Mar, 2026 First submitted to journal 28 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9250570","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":616832208,"identity":"4dac22f8-23c4-4ba3-8dbb-e9c6916de6b1","order_by":0,"name":"Jiayi Ren","email":"","orcid":"","institution":"Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jiayi","middleName":"","lastName":"Ren","suffix":""},{"id":616832210,"identity":"b34cdc40-c947-4cf3-9519-209c8d69a377","order_by":1,"name":"Qiuyu Yang","email":"","orcid":"","institution":"Shuguang Hospital 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07:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9250570/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9250570/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106189895,"identity":"2e3f9088-d00c-44ba-bb1d-82591b3790e4","added_by":"auto","created_at":"2026-04-05 17:11:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50492,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT Flow Diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9250570/v1/5da07d4792958d9ab54c3721.png"},{"id":106189896,"identity":"e312817e-854e-43ba-84df-5c1dcd91240e","added_by":"auto","created_at":"2026-04-05 17:11:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37097,"visible":true,"origin":"","legend":"\u003cp\u003eQoR-15 Scores Over Time (EM mean ± SE)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9250570/v1/a2594510e243fb9a0b184eb3.png"},{"id":106189897,"identity":"1b733e19-99a5-498a-863e-c4e6a2610497","added_by":"auto","created_at":"2026-04-05 17:11:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":109451,"visible":true,"origin":"","legend":"\u003cp\u003eSecondary Outcomes (EM mean ± SE)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9250570/v1/70864475958fc27e2373486c.png"},{"id":106403141,"identity":"47c28b3d-3deb-47ef-8c97-337fd2631e2a","added_by":"auto","created_at":"2026-04-08 09:13:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2675669,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9250570/v1/e27669c6-0433-4311-b11f-23fa6250f26b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of a Multimodal Integrative Intervention on Quality of Recovery After Laparoscopic Colorectal Cancer Surgery: A Single-Center, Single-Blind, Pragmatic Randomized Controlled Trial","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eColorectal cancer (CRC) remains one of the most prevalent malignancies worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). While laparoscopic surgery has become the standard approach owing to its minimally invasive nature, the postoperative course is frequently complicated by acute pain, profound fatigue, impaired functional capacity, and delayed gastrointestinal motility (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These distressing symptoms not only hinder early mobilization but also cumulatively compromise the patient\u0026rsquo;s overall Quality of Recovery (QoR), potentially adversely influencing long-term clinical outcomes.\u003c/p\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols have substantially improved perioperative outcomes by integrating evidence-based strategies, including early mobilization and multimodal analgesia(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Recent evidence underscores that effective ERAS pathways not only improve short-term clinical outcomes but may also facilitate the timely initiation of subsequent oncological treatments(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).However, the effectiveness of standardized ERAS pathways is often attenuated in heterogeneous populations, particularly older adults or frail individuals who struggle to tolerate uniform early mobilization targets(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Conventional postoperative ambulation protocols largely rely on \"one-size-fits-all\" instructions, often lacking individualized, symptom-titrated strategies to safely guide physical activity. Furthermore, the potential of integrating non-pharmacological modalities\u0026mdash;such as electroacupuncture and massage therapy\u0026mdash;to alleviate the very symptoms (pain and fatigue) that impede early mobilization within ERAS frameworks highlights a critical gap in contemporary perioperative research.\u003c/p\u003e \u003cp\u003eIn recent years, complementary and integrative medicine (such as acupuncture and massage) has gained increasing attention and utilization in surgical settings to alleviate postoperative discomforts and promote holistic recovery(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Furthermore, techniques like transcutaneous electrical acupoint stimulation (TEAS) have shown significant promise in managing postoperative pain and accelerating gastrointestinal recovery in various abdominal surgeries (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Building upon this emerging evidence, structured multimodal integrative interventions may overcome these limitations by simultaneously targeting multiple physiological and symptomatic pathways (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Electroacupuncture has been shown to exert robust analgesic and anti-inflammatory effects while enhancing gastrointestinal motility via autonomic regulation(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Concurrently, abdominal massage can augment local circulation and stimulate peristalsis through neuro-reflexive mechanisms(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). We hypothesized that if these symptom-relieving therapies are strategically combined with a stepwise, symptom-guided exercise protocol (utilizing objective pain and fatigue thresholds), they would act synergistically. This integrated approach could proactively alleviate postoperative symptoms, thereby enabling patients to safely achieve their functional recovery milestones.\u003c/p\u003e \u003cp\u003eDespite this biologically plausible rationale, high-quality randomized controlled trials evaluating such coordinated, stepwise integrative modalities are scarce. Given the complex and interactive nature of this multi-component rehabilitation package, isolating the specific efficacy of individual modalities against sham controls does not reflect real-world clinical practice. Therefore, we conducted a single-blind, pragmatic randomized controlled trial (pRCT) to evaluate the overall clinical effectiveness of a multimodal integrative intervention\u0026mdash;comprising electroacupuncture, abdominal massage, structured breathing training, and symptom-titrated supervised progressive ambulation\u0026mdash;would significantly improve the trajectory of postoperative recovery quality, as measured by the QoR-15, in patients undergoing laparoscopic colorectal cancer surgery compared with standard postoperative care alone.\u003c/p\u003e"},{"header":"2 .Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Ethics:\u003c/h2\u003e \u003cp\u003eWe conducted a single-center, single-blind, two-group, parallel, superiority pragmatic randomized controlled trial. The pragmatic design was chosen to evaluate the intervention\u0026rsquo;s effectiveness under real-world clinical conditions, where these multimodal therapies are delivered as an integrated care package rather than isolated components. The study was approved by the Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Approval No. 2024-1494-077-01) and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. This trial was registered at the Chinese Clinical Trial Registry (ChiCTR2400085191) on June 3, 2024, prior to patient enrollment. The study was reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) extension for pragmatic trials.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Participants:\u003c/h2\u003e \u003cp\u003eWe consecutively enrolled adult patients (aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years, ASA physical status I\u0026ndash;III) scheduled for elective laparoscopic resection of colonic or upper rectal cancer, without conversion, and who provided written informed consent. We excluded patients undergoing resection for mid/low rectal cancer, total/proctocolectomy, complex/combined procedures, or stoma creation. Patients who required intraoperative conversion to open surgery, experienced severe intraoperative complications, used epidural anesthesia/analgesia, had a cardiac pacemaker, needle allergy, or prior acupuncture experience were subsequently excluded prior to the initiation of postoperative interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Randomization and Blinding:\u003c/h2\u003e \u003cp\u003eAn independent statistician generated the randomization sequence using a computer-based random number generator in SPSS (version 26.0). Participants were allocated in a 1:1 ratio to either the multimodal integrative intervention or standard postoperative care group. Stratified block randomization was employed to ensure prognostic balance across key baseline covariates, including AJCC tumor stage, age, and sex.\u003c/p\u003e \u003cp\u003eAllocation concealment was maintained using sequentially numbered, opaque, sealed envelopes (SNOSE). After baseline assessment and written informed consent were obtained, a research nurse uninvolved in enrollment or outcome evaluation opened the envelope to assign the participant.\u003c/p\u003e \u003cp\u003eGiven the behavioral nature of the interventions, blinding of participants and therapists was not feasible. To reduce performance bias, participants were told that the study compared two postoperative recovery approaches, without revealing specific components or hypotheses. They were instructed not to discuss treatment details with assessors. Surgical and ward staff remained unaware of group assignment, though they had access to standard medical records.\u003c/p\u003e \u003cp\u003eOutcome assessors and the data analyst were blinded throughout the study. All outcomes were assessed at scheduled time points by trained blinded personnel. Adverse events requiring intervention were managed by the unblinded therapist per protocol, without unblinding the outcome assessors, thus preserving data integrity. These procedures were implemented to minimize selection, performance, and detection bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Interventions:\u003c/h2\u003e \u003cp\u003eParticipants were randomly assigned to either the intervention group (multimodal integrative intervention plus standard postoperative care) or the control group (standard postoperative care alone). The components and procedures of each group are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the day-by-day intervention schedule across postoperative days 1\u0026ndash;7 (POD1\u0026ndash;POD7) is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1. Intervention Group (Multimodal Integrative Intervention)\u003c/h2\u003e \u003cp\u003ePatients in the intervention group received a structured program consisting of \u003cb\u003eelectroacupuncture, abdominal massage (Tuina, Mo Fa technique), and exercise therapy (structured breathing training and early ambulation)\u003c/b\u003e, in addition to standard postoperative care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eElectroacupuncture\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePractitioner Qualification: Electroacupuncture sessions were conducted by licensed acupuncturists with a minimum of 5 years of clinical experience.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProcedure: Sterile, single-use acupuncture needles (length: 35 mm; diameter: 0.40 mm; Qizhou, Suzhou Zhongjing Life Technology Co., Ltd., China) were used. Based on a consensus protocol developed by experts in the field, the acupoints Zusanli (ST-36) and Hegu (LI-4) were selected for their efficacy in alleviating postoperative pain, abdominal distension, and promoting gastrointestinal function. Needles were inserted perpendicularly to a depth of approximately 20\u0026ndash;30 mm, adjusted according to individual patient's body constitution. The achievement of de qi, a sensation of soreness, numbness, or distension considered indicative of effective needling, was sought.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eElectroacupuncture Parameters: Following needle insertion, an SDZ-III electronic acupuncture device (Suzhou Medical Appliance Factory, China) was connected. Electrical stimulation was delivered at a continuous waveform with a frequency of 100 Hz. The intensity was adjusted to a level tolerable to the patient without causing muscle twitching or discomfort.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDuration and Frequency: Each electroacupuncture session lasted for 20 minutes. Treatment commenced on postoperative day 1 and was administered once daily until postoperative day 7, resulting in a total of 7 sessions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAbdominal Massage\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePractitioner Qualification: Abdominal massage was performed by certified massage therapists.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProcedure: The intervention consisted of gentle clockwise abdominal rubbing (Mo Fa). The manipulation was applied over the abdominal region with light pressure, ensuring the patient experienced no pain or significant discomfort.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDuration and Frequency: Sessions lasted 10 minutes, administered twice daily from postoperative days 4 to 7.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eExercise Therapy\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exercise protocol included two components:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStructured Breathing Training: Patients were guided to perform diaphragmatic breathing exercises. Each session lasted for 5 minutes and was performed twice daily throughout the intervention period (postoperative days 1-7).\u003c/li\u003e\n \u003cli\u003eEarly Ambulation Plan: A graded activity plan was implemented:\u003c/li\u003e\n \u003cli\u003ePostoperative Days 1-3: Patients were encouraged to maintain a semi-Fowler\u0026apos;s position in bed and perform active ankle and limb movements.\u003c/li\u003e\n \u003cli\u003ePostoperative Days 4-7: Supervised progressive ambulation was added to the regimen. During the initial sessions, the walking duration was set to a target of 5 minutes, with a minimum acceptable duration of 2 minutes to accommodate early postoperative frailty. The daily duration was subsequently increased by 2-3 minutes per session, aiming for 10-15 minutes by POD 7. Crucially, the titration of walking time was not arbitrary but strictly guided by predefined tolerance criteria based on real-time assessments: an acceptable modified Borg Rating of Perceived Exertion score of \u0026le; 3 (Moderate) and a Visual Analog Scale (VAS) pain score of \u0026le; 4. If a patient exceeded these thresholds, the session was interrupted or maintained at the previous tolerated duration.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 1. Intervention protocol details\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"581\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComponent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Multimodal Integrative Care)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Standard Postoperative Care)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBasis of Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eReceived all components of Standard Postoperative Care based on institutional ERAS protocols, \u003cstrong\u003eplus\u003c/strong\u003e the following integrative therapies.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003eReceived\u0026nbsp;standard postoperative care\u0026nbsp;only(based on institutional ERAS protocols).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElectroacupuncture\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eLicensed acupuncturists with \u0026ge;5 years of experience.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Acupoints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eBilateral Zusanli (ST-36), Hegu (LI-4).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Needle Specification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eSterile, single-use needles (0.40 mm \u0026times; 35 mm; Qizhou, Suzhou Zhongjing Life Technology Co., Ltd., China).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Depth / Technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e~20-30 mm depth;\u0026nbsp;de qi\u0026nbsp;sensation sought.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; \u003cstrong\u003eElectroacupuncture Device\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHwato SDZ-III electronic acupuncture device (Suzhou Medical Appliance Factory, China)\u003c/strong\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 210px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Waveform / Frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eContinuous wave, 100 Hz.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Session Duration \u0026amp; Frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e20 minutes, once daily.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative days 1 to 7 (Total: 7 sessions).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbdominal Massage (Tuina)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eCertified tuina massage therapists.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eGentle clockwise abdominal rubbing (Mo Fa).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eLight pressure, ensuring no pain.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Session Duration \u0026amp; Frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e10 minutes, twice daily.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative days 4 to 7.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Breathing Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003eDiaphragmatic breathing (Structured Breathing Training), 5 minutes, twice daily. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003eNo structured breathing training. General verbal encouragement for early mobilization was provided.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026rsaquo; Ambulation Plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays 4-7:\u003c/strong\u003e\u0026nbsp; Symptom-titrated supervised progressive ambulation, twice daily.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Target: 5-15 mins/session (minimum acceptable: 2 mins).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Titration criteria: Strictly guided by daily safety thresholds (Modified Borg score \u0026le; 3 and VAS pain score \u0026le; 4).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003eNo structured ambulation plan.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Intervention Schedule\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"604\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Days\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(POD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElectroacupuncture\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreathing Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbdominal Massage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Tuina)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly Ambulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays 1-3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e✔ Daily\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(20 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e✔ Twice daily\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(5 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays 4-7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e✔ Daily\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e✔\u0026nbsp;Twice daily\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(5 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e✔\u0026nbsp;Twice daily (10 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e✔\u0026nbsp;Twice daily (Target: 5\u0026ndash;15 mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.2\u003c/strong\u003e\u003cstrong\u003e. Control group (Standard Postoperative Care)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients in the control group received standard postoperative care based on institutional Enhanced Recovery After Surgery (ERAS) protocols, which included standardized pharmacologic pain management (e.g., patient-controlled analgesia with opioids or scheduled non-steroidal anti-inflammatory drugs), routine vital signs monitoring, fluid management, and general verbal encouragement for early mobilization. They did not receive any form of electroacupuncture, abdominal massage, or the structured breathing training and early ambulation plan provided to the intervention group.Importantly, all patients in both groups received a highly standardized multimodal analgesia protocol per institutional ERAS guidelines to minimize potential confounding from disparate pain management strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Outcome Measures:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the patient-centred Quality of Recovery-15 (QoR-15) score, a validated questionnaire that comprehensively assesses recovery after surgery. The QoR-15 includes 15 items covering five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Total scores range from 0 to 150, with higher scores indicating better recovery. (18)A score of \u0026ge;118(19) was defined as indicating good recovery, and the minimal clinically important difference (MCID) was set at 6.0(20). QoR-15 scores were assessed on postoperative day 3 (POD3), day 7 (POD7), and day 30 (POD30) to capture short- to medium-term recovery dynamics following laparoscopic colorectal cancer surgery. The QoR-15 is widely recognized as a patient-reported outcome (PRO) tool in clinical recovery assessments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSecondary outcomes included pain intensity, muscle strength, perceived exertion, and functional exercise capacity. Pain intensity was assessed using the Visual Analog Scale (VAS; 0-10). Muscle strength was evaluated using the Medical Research Council (MRC) scale (0-5), where 0 indicates no visible or palpable muscle contraction and 5 indicates normal strength. Assessments were performed by trained assessors according to a standardized protocol on postoperative days (POD) 3, 7, and 30.Perceived exertion was evaluated using the Modified Borg Scale (0-10), and functional capacity was objectively assessed using the 6-minute walk test (6MWT). As early mobilization may be restricted in the immediate postoperative period, formal assessments of perceived exertion (Borg) and functional capacity (6MWT) were conducted on POD7 and POD30. (Note: The real-time, daily VAS and Borg scores utilized exclusively for the titration of the early ambulation plan on POD 4-7 were recorded in nursing charts for safety monitoring and adherence tracking, distinct from these formal secondary outcome assessments).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6. Sample Size Calculation:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size calculation was based on the primary outcome, the QoR-15 score on postoperative day 3. Although the primary analysis assessed the overall recovery trajectory, the sample size was conservatively powered based on the early critical time point of POD3.POD3 was selected because it reflects early global recovery beyond the immediate post-anesthesia period and has been used as a primary time point in perioperative recovery trials employing QoR-15(21).\u0026nbsp;Based on published QoR-15 data in laparoscopic colorectal surgery and related recovery studies, together with our clinical experience, the expected mean (SD) POD3 QoR-15 score in the control group was 110 (12)(22, 23)\u0026nbsp;.A between-group difference of 6.0 points was considered clinically meaningful (MCID)\u0026nbsp;(18-20)\u0026nbsp;, corresponding to a standardized effect size (Cohen\u0026rsquo;s d) of 0.50. Using a two-sided independent-samples t-test with an \u0026alpha; level of 0.05, 80% power, and a 1:1 allocation ratio, G*Power software (version 3.1.9.7) indicated that 36 participants were required per group. To achieve a final evaluable sample of 90 participants (45 per group) after accounting for potential post-randomization exclusions and dropouts, we ultimately randomized a total of 105 patients. This final sample size was more than adequate to detect the prespecified clinically meaningful difference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7. Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted according to a modified intention-to-treat (mITT) principle, including all randomized participants with available outcome data. Descriptive statistics were utilized to summarize baseline characteristics, adverse events, and adherence to the progressive ambulation protocol (e.g., achievement of target duration and protocol interruptions).All statistical analyses were performed using SPSS version 24.0. Continuous variables were assessed for normality using the Shapiro-Wilk test. Data are presented as mean \u0026plusmn; standard deviation for normally distributed variables or median (interquartile range) for non-normally distributed variables. Categorical variables are presented as frequencies (percentages) and were compared using chi-square tests. Baseline characteristics were compared between groups using independent-samples t tests or Mann\u0026ndash;Whitney U tests for continuous variables, and \u0026chi;\u0026sup2; tests or Fisher\u0026rsquo;s exact tests for categorical variables, as appropriate.\u003c/p\u003e\n\u003cp\u003eFor longitudinal outcomes, including QoR-15 scores, postoperative pain intensity (VAS), muscle strength, Borg Rating of Perceived Exertion scores, 6-minute walk test (6MWT) distance, and the percentage of predicted 6MWT distance, linear mixed-effects models were used to account for within-subject correlations over time. Each model included fixed effects for group (intervention vs control), time, and their interaction, along with a subject-specific random intercept to account for within-subject correlations. This likelihood-based approach naturally handles missing data under the missing-at-random (MAR) assumption.When a significant group-by-time interaction was detected, between-group comparisons were performed at each time point using estimated marginal means. In the absence of a significant interaction, main effects of group and time were interpreted. Post hoc pairwise comparisons were adjusted for multiple testing using the Bonferroni method. Results from mixed-effects models are reported as estimated marginal means with standard errors (SE), along with mean differences, 95% confidence intervals (CI), and corresponding P values.\u003c/p\u003e\n\u003cp\u003eAll statistical tests were two-sided, and a P value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participant Flow\u003c/h2\u003e \u003cp\u003eA total of 198 patients were assessed for eligibility, of whom 105 were randomized to the intervention group (n\u0026thinsp;=\u0026thinsp;53) or the control group (n\u0026thinsp;=\u0026thinsp;52). After randomization, two participants in the intervention group did not receive the allocated intervention due to intraoperative complications (n\u0026thinsp;=\u0026thinsp;1) or withdrawal of consent (n\u0026thinsp;=\u0026thinsp;1). During follow-up, six participants in the intervention group and seven in the control group discontinued the intervention or were lost to follow-up for the primary outcome. Ultimately, 45 participants in each group had at least one post-baseline assessment of the primary outcome and were included in the mITT analysis. The detailed reasons for exclusion after randomization are presented in the CONSORT flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Baseline Data\u003c/h2\u003e \u003cp\u003e \u003cb\u003eBaseline demographic and clinical characteristics were highly comparable between the two groups (\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e). No statistically significant differences were observed in age, sex distribution, height, weight, or body mass index (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating successful randomization and balanced group characteristics at baseline.Furthermore, baseline adherence to the standard institutional ERAS elements was comparable between the two groups.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention Group(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(61, 80)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70(61, 78)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e22(48.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e19(42.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.525\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e23(51.1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e26(57.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.525\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e166(158, 172)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e166(162, 171)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.662\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e65.9(11.3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64.7(10.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.615\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e24.3(3.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e23.4(3.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.255\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Intervention Adherence and Safety\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe multimodal integrative intervention, particularly the symptom-titrated progressive ambulation protocol, was well tolerated. By POD 7, 38 patients (84.4%) in the intervention group successfully achieved the target walking duration of 10\u0026ndash;15 minutes per session. Protocol interruptions or failure to progress due to predefined intolerance criteria occurred in 7 patients. The primary reasons for limiting walking duration were postoperative wound pain (VAS\u0026thinsp;\u0026gt;\u0026thinsp;4, n\u0026thinsp;=\u0026thinsp;3) and intolerable fatigue (Modified Borg\u0026thinsp;\u0026gt;\u0026thinsp;3, n\u0026thinsp;=\u0026thinsp;4). Notably, all these patients safely maintained their previously tolerated durations. No serious intervention-related adverse events (e.g., severe bleeding, falls, or anastomotic leakage) were reported in either group.A few minor incidents, such as transient mild bruising at the acupuncture sites or mild muscle soreness after massage, were noted but resolved spontaneously without requiring medical intervention or protocol discontinuation.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Primary Outcome\u003c/h2\u003e \u003cp\u003e \u003cb\u003eQuality of Recovery-15 (QoR-15) Scores\u003c/b\u003e \u003c/p\u003e \u003cp\u003eQuality of recovery was assessed using the QoR-15 questionnaire at POD3, POD7, and POD30. Linear mixed-effects model analysis demonstrated a significant group-by-time interaction (P\u0026thinsp;=\u0026thinsp;0.043), indicating different postoperative recovery trajectories between the two groups. A significant main effect of time was observed (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas the main effect of group did not reach statistical significance (P\u0026thinsp;=\u0026thinsp;0.053).\u003c/p\u003e \u003cp\u003ePost hoc Bonferroni-adjusted comparisons showed no significant between-group differences at POD3 or POD7; however, QoR-15 scores were significantly higher in the intervention group at POD30 (mean difference\u0026thinsp;=\u0026thinsp;11.33, 95% CI 3.41 to 19.26; P\u0026thinsp;=\u0026thinsp;0.005), suggesting a delayed but robust enhancement in overall recovery quality (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Secondary Outcomes\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePain Intensity (VAS Scores)\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePostoperative pain intensity assessed by VAS showed significant main effects of group (P\u0026thinsp;=\u0026thinsp;0.003) and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no significant group-by-time interaction (P\u0026thinsp;=\u0026thinsp;0.465) in the linear mixed-effects model. Overall, VAS scores were lower in the intervention group. Between-group differences were not significant at POD3 but were significant at POD7 (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.11, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;1.89 to \u0026minus;\u0026thinsp;0.33; P\u0026thinsp;=\u0026thinsp;0.006) and POD30 (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.24, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;2.02 to \u0026minus;\u0026thinsp;0.47; P\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMuscle Strength\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe linear mixed-effects model for muscle strength showed a significant main effect of time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) but not group (P\u0026thinsp;=\u0026thinsp;0.216). Interestingly, the intervention group exhibited slightly lower muscle strength than the control group at POD 3 (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.24, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;0.48 to \u0026minus;\u0026thinsp;0.01; P\u0026thinsp;=\u0026thinsp;0.039). However, this transient difference dissipated, with no significant between-group differences observed at POD 7 or POD 30 (\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBorg Scores\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePerceived exertion assessed by the Borg score showed significant main effects of group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no significant group-by-time interaction (P\u0026thinsp;=\u0026thinsp;0.089) in the linear mixed-effects model. Overall, Borg scores were lower in the intervention group. Between-group differences were significant at POD7 (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.42, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;2.19 to \u0026minus;\u0026thinsp;0.66; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and POD30 (mean difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.87, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;2.63 to \u0026minus;\u0026thinsp;1.10; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e6-Minute Walk Test\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eFunctional capacity assessed by the six-minute walk test showed significant main effects of group (P\u0026thinsp;=\u0026thinsp;0.021) and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no significant group-by-time interaction (P\u0026thinsp;=\u0026thinsp;0.154) in the linear mixed-effects model. Overall, 6MWT distance was greater in the intervention group. Between-group differences were not significant at POD7 but were significant at POD30 (mean difference\u0026thinsp;=\u0026thinsp;53.33 m, 95% CI 15.15 to 91.52; P\u0026thinsp;=\u0026thinsp;0.007).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePercentage of Predicted 6MWT Distance\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe percentage of predicted 6MWT distance showed significant main effects of group (P\u0026thinsp;=\u0026thinsp;0.003) and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with no significant group-by-time interaction (P\u0026thinsp;=\u0026thinsp;0.128) in the linear mixed-effects model. Overall, the percentage of predicted 6MWT distance was higher in the intervention group. Between-group differences were not significant at POD7 but were significant at POD30 (mean difference\u0026thinsp;=\u0026thinsp;0.106, 95% CI 0.045 to 0.166; P\u0026thinsp;=\u0026thinsp;0.001).\u003c/b\u003e \u003c/p\u003e \n\u003cp\u003eTable 4. Comparison of Secondary Outcomes Between Groups Across Different Time Points\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"549\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003eOutcome Measure\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003eTime\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003eControl (EM mean \u0026plusmn; SE)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003eIntervention (EM mean \u0026plusmn; SE)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eMean difference (95% CI)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003eP value\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 92px;\"\u003eQoR-15\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e83.98\u0026nbsp;\u0026plusmn;\u0026nbsp;2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e86.42 \u0026plusmn; 2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e2.44 (\u0026minus;5.48 to 10.37)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.543\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e100.67 \u0026plusmn; 2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e108.20 \u0026plusmn; 2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e7.53 (\u0026minus;0.40 to 15.46)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.062\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e114.02 \u0026plusmn; 2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e125.36 \u0026plusmn; 2.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e11.33 (3.41 to 19.26)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.005\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 92px;\"\u003eVAS Score\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e5.76 \u0026plusmn; 0.27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e5.02 \u0026plusmn; 0.27 \u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;0.73 (\u0026minus;1.49 to 0.02)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.057\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e3.84 \u0026plusmn; 0.28\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e2.73 \u0026plusmn; 0.28\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;1.11 (\u0026minus;1.89 to \u0026minus;0.33)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.006\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e2.36 \u0026plusmn; 0.28\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e1.11 \u0026plusmn; 0.28\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;1.24 (\u0026minus;2.02 to \u0026minus;0.47)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.002\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 92px;\"\u003eMuscle Strength\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e3.56 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e3.31 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;0.24 (\u0026minus;0.48 to \u0026minus;0.01)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.039\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e4.13 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e4.00 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;0.13 (\u0026minus;0.37 to 0.10)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.258\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e4.71 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e4.73 \u0026plusmn; 0.08\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e0.02 (\u0026minus;0.21 to 0.25)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.850\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 92px;\"\u003eBorg Score\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e5.89 \u0026plusmn; 0.27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e4.47 \u0026plusmn; 0.27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;1.42 (\u0026minus;2.19 to \u0026minus;0.66)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u0026lt;0.001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e3.34 \u0026plusmn; 0.27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e1.48 \u0026plusmn; 0.27\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u0026minus;1.87 (\u0026minus;2.63 to \u0026minus;1.10)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u0026lt;0.001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 92px;\"\u003e6MWT\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e247.29 \u0026plusmn; 13.66\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e272.56 \u0026plusmn; 13.66\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e25.27 (\u0026minus;12.92 to 63.45)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.193\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e401.27 \u0026plusmn; 13.66\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e454.60 \u0026plusmn; 13.66\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e53.33 (15.15 to 91.52)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.007\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 92px;\"\u003eProportion of predicted 6MWT distance\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD7\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e0.419 \u0026plusmn; 0.022\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e0.473 \u0026plusmn; 0.022\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e0.054 (\u0026minus;0.007 to 0.115)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.080\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003ePOD30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e0.682 \u0026plusmn; 0.022\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e0.788 \u0026plusmn; 0.022\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e0.106 (0.045 to 0.166)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e0.001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMean differences are presented as intervention minus control.\u003c/p\u003e\n\u003cp\u003eEstimated marginal means and between-group differences were derived from linear mixed-effects models with Bonferroni-adjusted post hoc comparisons.\u003c/p\u003e\n\u003cp\u003eEstimated marginal means were derived from linear mixed-effects models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6. Adverse Events\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo serious adverse events related to the multimodal integrative intervention were reported during the study period. Among participants included in the modified intention-to-treat analysis, three individuals in the intervention group (6.7%) reported minor, transient discomfort associated with electroacupuncture; these events did not require additional intervention or lead to treatment discontinuation. No adverse events were reported in association with the abdominal massage or exercise therapy components.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present single-blind, randomized controlled trial demonstrates that a structured multimodal integrative intervention confers significant, long-term benefits on postoperative recovery following laparoscopic colorectal cancer surgery. While previous studies have independently reported beneficial effects of single interventions, evidence supporting the efficacy of structured multimodal integrative protocols remains limited(24, 25). Our study is among the first to evaluate a stepwise, symptom-titrated multimodal strategy. The primary finding was a significant alteration in the trajectory of postoperative recovery (group-by-time interaction for QoR-15 scores). Compared with standard postoperative care, patients receiving the integrative intervention exhibited a delayed but robust and clinically meaningful improvement in overall recovery quality at postoperative day 30, accompanied by sustained reductions in pain and fatigue, and enhanced functional capacity.\u003c/p\u003e\n\u003cp\u003eInterestingly, we observed no significant between-group differences in the primary outcome (QoR-15) at POD 3 or POD 7. This phenomenon likely reflects the overwhelming physiological impact of acute surgical trauma and systemic inflammatory responses during the immediate postoperative phase, which may mask the early benefits of rehabilitation interventions. Furthermore, it is worth noting that the actual mean QoR-15 score of the control group on POD 3 in our study (approximately 84) was lower than the anticipated score of 110 used in our initial sample size calculation. This discrepancy may be further attributed to the specific clinical characteristics of our cohort. Our study included a substantial proportion of middle-aged and elderly patients undergoing major laparoscopic colorectal resections, who might experience more profound acute surgical stress, fatigue, and delayed early functional return. Differences in baseline demographics and institutional perioperative care pathways compared to previous literature may also contribute to this lower early recovery trajectory. Nevertheless, the substantial and statistically significant group-by-time interaction observed throughout the trial indicates that our initial sample size provided sufficient statistical power to detect the true therapeutic effect of the multimodal integrative intervention. However, the significant divergence at POD 30 suggests a \u0026quot;legacy effect\u0026quot; or delayed functional compensation. By aggressively managing early postoperative pain and fatigue through electroacupuncture and abdominal massage, and safely maintaining physical conditioning via titrated ambulation, the integrative intervention preserved the patients\u0026apos; physiological reserves. This preservation translated into accelerated medium-to-long-term recovery once the acute surgical stress subsided. These accelerated recovery milestones align with the broader objectives of ERAS pathways. Similar benefits of structured recovery pathways on expediting gastrointestinal function and overall recovery have been prominently observed in other real-world cohorts of stage II\u0026ndash;III colorectal cancer patients(6). By integrating electroacupuncture and massage into the ERAS framework, our study provides a novel non-pharmacological strategy to further optimize these clinical outcomes.\u003c/p\u003e\n\u003cp\u003eThe superiority of the multimodal approach stems from the synergistic physiological mechanisms of its components. Electroacupuncture and abdominal massage have been widely documented to modulate autonomic nervous system balance, suppress inflammatory pathways, and promote gastrointestinal motility(26-30).\u0026nbsp;Consistent with our findings, recent trials have demonstrated that repeated or multi-period applications of acupoint stimulation can significantly reduce postoperative nausea, vomiting, and pain in patients undergoing laparoscopic surgeries(31).By effectively reducing pain (VAS) and perceived exertion (Borg), these passive modalities created an optimal \u0026quot;physiological window\u0026quot; for active exercise. Notably, our results showed a transient, slightly lower muscle strength in the intervention group at POD 3. While the exact physiological mechanism remains unclear, this temporary dip may be attributed to two potential factors. First, executing intensive early ambulation during the acute catabolic phase of surgical stress initially demands high energy expenditure, which can transiently exacerbate peripheral muscle fatigue in gastrointestinal surgery patients(32). Second, recent evidence highlights that interventions like electroacupuncture and massage significantly enhance parasympathetic (vagal) tone(33), inducing an immediate and profound systemic muscle relaxation\u0026nbsp;(34). This therapy-induced parasympathetic dominance might acutely reduce peak voluntary muscle contraction force during testing. Importantly, rather than an adverse effect, this early subtle difference was fully resolved by POD 7, eventually translating into significantly superior functional capacity (6MWT) by POD 30.\u003c/p\u003e\n\u003cp\u003eA critical innovation of this trial is the implementation of the symptom-titrated progressive ambulation protocol. While various physical and respiratory prehabilitation strategies have been explored to enhance recovery(35, 36), conventional ERAS postoperative mobilization pathways frequently face low adherence rates due to generalized \u0026quot;one-size-fits-all\u0026quot; targets that fail to accommodate individual postoperative frailty(32). By contrast, our protocol strictly utilized real-time objective thresholds (VAS \u0026le; 4 and Modified Borg \u0026le; 3) to guide walking duration. This individualized approach resulted in an exceptionally high adherence rate, with 84.4% of patients successfully achieving the 10-15 minute ambulation target by POD 7 without any serious adverse events. This provides compelling evidence that early mobilization, when properly titrated against objective symptom limits, is highly feasible and safe even in patients recovering from major abdominal surgery.\u003c/p\u003e\n\u003cp\u003eDespite the significant findings, our study has several limitations. First, owing to the pragmatic design and the complex nature of the multimodal intervention (which combines physical stimulation with active functional exercises), implementing a credible sham control and achieving double-blinding were practically unfeasible. Consequently, we cannot entirely rule out placebo effects or the influence of increased therapist attention. However, our primary objective was to evaluate the real-world clinical effectiveness of this comprehensive ERAS add-on package rather than isolating the mechanistic efficacy of single modalities. Furthermore, potential bias was minimized by strictly blinding both the outcome assessors and data analysts. Second, we did not collect preoperative baseline measurements for functional and patient-reported outcomes, such as the 6MWT and QoR-15. As a result, we could not calculate the exact percentage of return to preoperative baseline status for individual patients. Nevertheless, our rigorous randomization process ensured that demographic and clinical characteristics were highly balanced between the two groups, substantially mitigating the risk of baseline confounding. Third, although a standardized multimodal analgesia protocol was strictly implemented, we did not precisely quantify total postoperative opioid or overall analgesic consumption. Future studies should incorporate these specific metrics to further validate the potential opioid-sparing effects of this integrative intervention. Fourth, as a single-center trial, the generalizability of our results to broader populations and different clinical settings may be limited. Finally, the follow-up period was relatively short, focusing primarily on early-to-mid-term recovery milestones. Therefore, the ultimate long-term impact of this multimodal intervention on oncological outcomes and cancer survival remains unknown and warrants further longitudinal research.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn conclusion, the implementation of a structured multimodal integrative intervention\u0026mdash;comprising electroacupuncture, abdominal massage, breathing training, and early ambulation\u0026mdash;did not yield a statistically significant improvement in early postoperative recovery (POD 3 and 7) compared to standard care. However, it significantly enhanced the medium-term quality of recovery at POD 30. These findings suggest that while the acute surgical trauma and physiological stress may mask the immediate benefits of the intervention, its legacy effects play a crucial role in facilitating a better convalescence at one month postoperatively. Clinicians should consider setting realistic expectations for patients regarding the timeline of recovery benefits when applying this multimodal approach.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e6MWT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e6-minute walk test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAJCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Joint Committee on Cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCONSORT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Standards of Reporting Trials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eColorectal cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEM mean\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEstimated marginal means\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnhanced Recovery After Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLI-4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHegu acupoint\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimal clinically important difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emITT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModified intention-to-treat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative day\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-reported outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Recovery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoR-15\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e15-item Quality of Recovery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard error\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSNOSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSequentially numbered, opaque, sealed envelopes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST-36\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eZusanli acupoint\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTEAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTranscutaneous electrical acupoint stimulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual Analog Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Approval No. 2024-1494-077-01) and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to patient privacy and confidentiality, but are available from the corresponding author (Jiming Tao) on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial protocol and statistical analysis plan\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe full trial protocol and statistical analysis plan are accessible via the Chinese Clinical Trial Registry (Registration number: ChiCTR2400085191). Further details or additional materials are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Shanghai Municipal Health System Key Support Discipline\u0026mdash;Rehabilitation Medicine (No. 2023ZDFC0301), the Shanghai University of Traditional Chinese Medicine Science and Technology Development Project (Natural Science Category; 23KFL009), and the Shanghai University of Traditional Chinese Medicine Affiliated Shuguang Hospital Siming Fund (SGKJ-202509).The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJR, QY, and HH contributed equally to this work and should be considered co-first authors. JT, JR, and HH conceived and designed the study; JR, HH, QY, and CC recruited and followed up the patients; QY analysed and interpreted the data; JT, JR, and HH were responsible for study monitoring; QY accessed and was responsible for the raw data associated with the study, and JR was responsible for data verification; QY performed the statistical analysis; JR and HH drafted the manuscript; HG, JL, CC, CY, YC, MK and YW critically revised the important intellectual content of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants and the medical staff at Shuguang Hospital for their support during the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database of Systematic Reviews. 2022;2022(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnerup A, Li Y, Afshari K, Angenete E, de la Croix H, Ehrencrona C, et al. Long-term results of a short‐term home‐based pre‐ and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG‐C): a randomized clinical trial. Colorectal Dis. 2024;26(3):545\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLederer AK, Samstag Y, Simmet T, Syrovets T, Huber R. Complementary medicine usage in surgery: a cross-sectional survey in Germany. BMC Complement Med Ther. 2022;22(1):263.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang XL, Liu XM, An LX, Zheng JY, Zhang K. Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial. BMC Complement Med Ther. 2023;23(1):253.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBisch SP, Jago CA, Kalogera E, Ganshorn H, Meyer LA, Ramirez PT, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol. 2021;161(1):46\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M et al. Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer. JAMA Surg. 2020;155(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Kou Z, Liu R, Zhou Z, Mei J, Yan W. 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Minimal Clinically Important Difference for Three Quality of Recovery Scales. Anesthesiology. 2016;125(1):39\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdmiraal M, Hermanns H, Hermanides J, Wensing C, Meinsma SL, Wartenberg HCH, et al. Study protocol for the TRUSt trial: a pragmatic randomised controlled trial comparing the standard of care with a transitional pain service for patients at risk of chronic postsurgical pain undergoing surgery. BMJ Open. 2021;11(8):e049676.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Y, He L, Liu S, Zhang C, Ai Y. Intraoperative intravenous low-dose esketamine improves quality of early recovery after laparoscopic radical resection of colorectal cancer: A prospective, randomized controlled trial. PLoS ONE. 2023;18(6):e0286590.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng L, Lu Y, Lu X, You L, Yu C, Lai J et al. Intrathecal Morphine for Enhanced Recovery After Laparoscopic Colorectal Surgery: A Randomized Clinical Trial. JAMA Surg. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao LX, Chen ZQ, Jiang Z, Chen QC, Fan XH, Xia SJ, et al. Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery. World J Gastroenterol. 2020;26(23):3271\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLv X, Hou A, Han S, Cao J, Lou J, Li H, et al. Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial. J Clin Anesth. 2024;99:111670.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim KH, Lee MS, Choi TY, Kim TH. Acupuncture for symptomatic gastroparesis. Cochrane Database Syst Rev. 2018;12(12):Cd009676.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang X, Yang JA, Yang JB, Wang X, Yang Y. Evaluation of abdominal massage as a non-pharmacological modality to restore gut microbiota and duodenal barrier function in a rat model of functional dyspepsia. Technol Health Care. 2025:9287329251363139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Xu J, Bao R, Li Z. Massage for gastrointestinal function among participants after abdominal surgery: A protocol for systematic review and meta-analysis. Med (Baltim). 2021;100(49):e28087.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Q, Lin J, Yang P, Liang Y, Lu D, Wang K, et al. Effect of Massage on the TLR4 Signalling Pathway in Rats with Neuropathic Pain. Pain Res Manag. 2020;2020:8309745.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu S, Fu W, Fu J, Chen G, He Y, Zheng T, et al. Electroacupuncture alleviates intestinal inflammation via a distinct neuro-immune signal pathway in the treatment of postoperative ileus. Biomed Pharmacother. 2024;173:116387.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin LD, Lei W, Xu J, Xing L, Shen YH, Lin SF, et al. Effect of single or multi-period use of transcutaneous acupoint electrical stimulation on postoperative nausea and vomiting in patients undergoing gynecological laparoscopic surgery: a prospective randomized double-blind trial. BMC Complement Med Ther. 2025;25(1):110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Wu Q, Wang X, Zhu X, Shi Y, Wu CJ. Factors impacting early mobilization according to the Enhanced Recovery After Surgery guideline following gastrointestinal surgery: A prospective study. Geriatr Gerontol Int. 2024;24(2):234\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe J, Huang R, Ouyang J, Zhao G, Zhong M. Muscarinic Receptor-Mediated Electroacupuncture Modulation of Reactive Enteric Glial Cells Ameliorates Postoperative Ileus. J Inflamm Res. 2025;18:17057\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMat Isar NEN, Abdul Halim MHZ, Ong MLY. Acute massage stimulates parasympathetic activation after a single exhaustive muscle contraction exercise. J Bodyw Mov Ther. 2022;30:105\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBausys A, Luksta M, Anglickiene G, Maneikiene VV, Kryzauskas M, Rybakovas A, et al. Effect of home-based prehabilitation on postoperative complications after surgery for gastric cancer: randomized clinical trial. Br J Surg. 2023;110(12):1800\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin B, Yao M, Shen W, Fu L, Liu P, Zheng X, et al. Effect of post-extubation high-flow nasal cannula combined with respiratory training versus conventional oxygen therapy on postoperative pulmonary complications in patients after major abdominal surgery: protocol for a single-centre randomized controlled trial. Trials. 2023;24(1):396.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multimodal Integrative Intervention, Colorectal Cancer Surgery, Randomized Controlled Trial, electroacupuncture, abdominal massage, exercise therapy","lastPublishedDoi":"10.21203/rs.3.rs-9250570/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9250570/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite the minimally invasive nature of laparoscopic colorectal surgery, postoperative recovery is frequently compromised by pain, fatigue, and delayed gastrointestinal function. Current rehabilitation strategies largely rely on unimodal approaches, and evidence for structured multimodal protocols is limited. This study aimed to evaluate whether a multimodal integrative intervention\u0026mdash;comprising electroacupuncture, abdominal massage, structured breathing training, and early ambulation\u0026mdash;improves the quality of recovery in patients undergoing laparoscopic surgery for stage I\u0026ndash;III colorectal cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-center, single-blind, parallel-group, pragmatic randomized controlled trial randomized 105 patients to either a multimodal intervention or standard care. The intervention group received electroacupuncture and breathing training from postoperative day 1 to 7, with abdominal massage and supervised progressive ambulation added from postoperative day 4 to 7. The control group received standard postoperative care. The primary outcome was the trajectory of the Quality of Recovery-15 (QoR-15) score assessed at postoperative days 3, 7, and 30. Statistical analyses followed a modified intention-to-treat principle.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 105 randomized patients, 90 (45 per group) were included in the final analysis. A significant group-by-time interaction was observed for QoR-15 scores (P\u0026thinsp;=\u0026thinsp;0.043). While no significant between-group differences were found at postoperative days 3 or 7, the intervention group demonstrated significantly higher QoR-15 scores at postoperative day 30 (mean difference 11.33; 95% confidence interval 3.41 to 19.26; P\u0026thinsp;=\u0026thinsp;0.005). Secondary outcomes, including pain intensity and perceived exertion, also favored the intervention group. No serious intervention-related adverse events were reported.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA multimodal integrative intervention significantly enhances the mid-to-long-term quality of recovery (at 30 days) after laparoscopic colorectal cancer surgery, despite no significant differences in the immediate postoperative period. These findings support the real-world effectiveness of integrating structured multimodal rehabilitation into standard perioperative care pathways.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eChiCTR2400085191.Registered on June 3, 2024.\u003c/p\u003e","manuscriptTitle":"Effect of a Multimodal Integrative Intervention on Quality of Recovery After Laparoscopic Colorectal Cancer Surgery: A Single-Center, Single-Blind, Pragmatic Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-05 17:11:45","doi":"10.21203/rs.3.rs-9250570/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"160041477391780702171296875116791365181","date":"2026-05-11T06:34:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95398891127800940614946762872769506818","date":"2026-05-07T13:42:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167454019375234541227934457450466141867","date":"2026-04-25T03:13:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-12T21:15:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295307992661257292719616293344608709183","date":"2026-04-02T20:56:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-31T10:47:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T16:35:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T00:17:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2026-03-28T07:19:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b491f105-623f-40f9-8d8c-5a0d2f6ea615","owner":[],"postedDate":"April 5th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"160041477391780702171296875116791365181","date":"2026-05-11T06:34:38+00:00","index":306,"fulltext":""},{"type":"reviewerAgreed","content":"95398891127800940614946762872769506818","date":"2026-05-07T13:42:58+00:00","index":301,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-05T17:11:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-05 17:11:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9250570","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9250570","identity":"rs-9250570","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}