Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study

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Non-pharmacological nursing interventions such as Swedish abdominal massage and warm water drinking therapy are potential approaches to alleviate this problem. Objective The objective of this study was to compare the effectiveness of Swedish abdominal massage and warm water drinking therapy in reducing constipation scores among patients with postoperative lower extremity fractures. Methods A quasi-experimental pre–posttest design without a control group was conducted with 30 respondents selected using a simple random sampling technique. Constipation was assessed using the Constipation Assessment Scale (CAS) before and after intervention. Data were analyzed using independent t-tests, and results were interpreted with attention to baseline differences between groups. Results Both interventions significantly reduced constipation scores. The mean post-intervention CAS score was 4.60 in the warm water group and 3.56 in the Swedish abdominal massage group (p < 0.001). Although Swedish abdominal massage showed a greater within-group reduction, baseline imbalances in constipation scores may have influenced the observed differences. Conclusion Swedish abdominal massage and warm water therapy are effective nurse-led, non-pharmacological interventions for reducing postoperative constipation. The findings should be interpreted cautiously due to baseline differences and small sample size. Future research with larger samples, controlled designs, and statistical adjustments is recommended to confirm these preliminary findings. 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F1000Research 2025, 13 :1531 ( https://doi.org/10.12688/f1000research.159217.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] Previously titled: Swedish abdominal massage versus warm water therapy on postoperative constipation: a comparison quasi-experimental study Enny Selawaty Boangmanalu https://orcid.org/0009-0006-2825-2930 1 , Masfuri Masfuri 1 , Muhamad Adam 1 , Sri Nining https://orcid.org/0000-0001-5613-1227 2,3 , Triani Banna https://orcid.org/0000-0001-5265-838X 1,4 , Indira Mastura Pulungan 1 Enny Selawaty Boangmanalu https://orcid.org/0009-0006-2825-2930 1 , Masfuri Masfuri 1 , [...] Muhamad Adam 1 , Sri Nining https://orcid.org/0000-0001-5613-1227 2,3 , Triani Banna https://orcid.org/0000-0001-5265-838X 1,4 , Indira Mastura Pulungan 1 PUBLISHED 03 Oct 2025 Author details Author details 1 Faculty of Nursing, Universitas Indonesia, Depok, West Java, 16424, Indonesia 2 Faculty of Nursing, Universitas Kristen Krida Wacana, West Jakarta, Jakarta, 12120, Indonesia 3 Nursing Committee, Mother and Child Bunda Jakarta Hospital, Menteng, Central Jakarta, 10350, Indonesia 4 Nursing Science, Sekolah Tinggi Ilmu Kesehatan Papua, Sorong City, West Papua, 98412, Indonesia Enny Selawaty Boangmanalu Roles: Conceptualization, Data Curation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Masfuri Masfuri Roles: Methodology, Supervision Muhamad Adam Roles: Supervision, Validation Sri Nining Roles: Writing – Original Draft Preparation, Writing – Review & Editing Triani Banna Roles: Funding Acquisition, Writing – Original Draft Preparation Indira Mastura Pulungan Roles: Funding Acquisition, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. Abstract Background Postoperative immobilization in patients with lower extremity fractures frequently leads to constipation, affecting approximately 50–70% of patients. Non-pharmacological nursing interventions such as Swedish abdominal massage and warm water drinking therapy are potential approaches to alleviate this problem. Objective The objective of this study was to compare the effectiveness of Swedish abdominal massage and warm water drinking therapy in reducing constipation scores among patients with postoperative lower extremity fractures. Methods A quasi-experimental pre–posttest design without a control group was conducted with 30 respondents selected using a simple random sampling technique. Constipation was assessed using the Constipation Assessment Scale (CAS) before and after intervention. Data were analyzed using independent t -tests, and results were interpreted with attention to baseline differences between groups. Results Both interventions significantly reduced constipation scores. The mean post-intervention CAS score was 4.60 in the warm water group and 3.56 in the Swedish abdominal massage group ( p < 0.001). Although Swedish abdominal massage showed a greater within-group reduction, baseline imbalances in constipation scores may have influenced the observed differences. Conclusion Swedish abdominal massage and warm water therapy are effective nurse-led, non-pharmacological interventions for reducing postoperative constipation. The findings should be interpreted cautiously due to baseline differences and small sample size. Future research with larger samples, controlled designs, and statistical adjustments is recommended to confirm these preliminary findings. READ ALL READ LESS Keywords Closed Fracture Reduction, Constipation, Postoperative, Swedish Abdominal Massage, Warm Water Therapy Corresponding Author(s) Masfuri Masfuri ( [email protected] ) Close Corresponding author: Masfuri Masfuri Competing interests: No competing interests were disclosed. Grant information: This study was supported by the Directorate of Development and Research of Universitas Indonesia under the HIBAH PUTI 2023 (Grant No. NKB-073/UN2.RST/HKP.05.00/2023). We also want to express our sincere gratitude to The Center for Higher Education (BPPT) and The Indonesia Endowment Funds for Education (LPDP) for their support through scholarship programs that enabled us to conduct this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Boangmanalu ES et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Boangmanalu ES, Masfuri M, Adam M et al. Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.12688/f1000research.159217.3 ) First published: 18 Dec 2024, 13 :1531 ( https://doi.org/10.12688/f1000research.159217.1 ) Latest published: 03 Oct 2025, 13 :1531 ( https://doi.org/10.12688/f1000research.159217.3 ) Revised Amendments from Version 2 The revised version of our article presents several substantial improvements compared with the earlier version. The most notable change is the addition of within-group pre–post analyses, which were introduced to complement between-group comparisons and directly address concerns regarding baseline imbalances in constipation scores. This addition provides a clearer picture of the effectiveness of each intervention independently and prevents overinterpretation of group differences. Statistical reporting has also been strengthened. In contrast to the previous version, which relied primarily on p-values, the revised manuscript includes mean differences, 95% confidence intervals, and effect sizes (Cohen’s d ) in both the Results section and Table 2. These changes enhance the clinical interpretability and transparency of the findings. The Discussion and Conclusion sections have been rewritten to adopt a more cautious tone. Instead of overstating the superiority of Swedish abdominal massage, the revised text now emphasizes that both interventions were effective while highlighting the limitations of the small sample size and baseline imbalance. The Limitations section itself has been expanded to address dietary factors, fracture location, the lack of power analysis, and the absence of long-term follow-up. Overall, these revisions ensure a more rigorous, balanced, and transparent presentation of the study’s findings. The revised version of our article presents several substantial improvements compared with the earlier version. The most notable change is the addition of within-group pre–post analyses, which were introduced to complement between-group comparisons and directly address concerns regarding baseline imbalances in constipation scores. This addition provides a clearer picture of the effectiveness of each intervention independently and prevents overinterpretation of group differences. Statistical reporting has also been strengthened. In contrast to the previous version, which relied primarily on p-values, the revised manuscript includes mean differences, 95% confidence intervals, and effect sizes (Cohen’s d ) in both the Results section and Table 2. These changes enhance the clinical interpretability and transparency of the findings. The Discussion and Conclusion sections have been rewritten to adopt a more cautious tone. Instead of overstating the superiority of Swedish abdominal massage, the revised text now emphasizes that both interventions were effective while highlighting the limitations of the small sample size and baseline imbalance. The Limitations section itself has been expanded to address dietary factors, fracture location, the lack of power analysis, and the absence of long-term follow-up. Overall, these revisions ensure a more rigorous, balanced, and transparent presentation of the study’s findings. See the authors' detailed response to the review by Jie Hao See the authors' detailed response to the review by Robin S Miccio See the authors' detailed response to the review by Nilton Carlos Machado READ REVIEWER RESPONSES Background According to the most recent data published in Lancet Healthy Longev, there were 178 million new fractures globally in 2019, and 455 million people had acute or chronic fracture symptoms at some point in their lives ( Global Burden of Disease, 2021 ). However after surgery, prolonged bed rest and limited movement inevitably result in adverse effects such as constipation ( Viberg et al., 2022 ). Constipation, which typically affects 50–70% of patients, is brought on by the body’s immobile state following surgery, which weakens intestinal peristalsis function in conjunction with dietary factors ( Jing & Jia, 2019 ). Patients should be incredibly concerned about constipation because it can lead to a number of issues and negatively impact their quality of life ( Kamali et al., 2022 ). Consequently, constipation is a serious problem that, if disregarded, can result in psychological and physical problems. Laxative use is common among patients due to discomfort. Research shows that constipation affects 3% to 27% of people in the general population on an incidence rate of 5; in hospital settings, the prevalence is 79% ( Pehlivan & Nural, 2022 ). However, in acute clinical practice, this condition is frequently overlooked when providing patient care ( Trads et al., 2018 ). Nurses have been treating constipation with a nursing intervention that includes teaching patients about high-fiber foods like vegetables and papaya ( Galica et al., 2022 ). But there has never been an application of another autonomous nursing intervention in the treatment room, like abdominal massage ( Nouhi et al., 2022 ). It is relatively inexpensive and something that sufferers can do on their own. Constant direct pressure is applied to the abdominal wall during abdominal massage, which is followed by a relaxation period. This increases the contractions of the rectum and intestines and the gastrocolic reflex ( Yao et al., 2020 ). Swedish abdominal massages are performed with light pressure on the tissue to promote comfort and enhance the digestive and blood circulation systems ( Park et al., 2023 ). By altering stomach pressure through mechanical and reflexive processes, abdominal massage can accelerate the passage of food through the digestive system and promote peristaltic movements ( Fekri et al., 2021 ). This procedure will speed up the movement of food through the digestive tract by increasing peristaltic movements and altering stomach pressure through mechanical and reflexive means ( Lafcı & Kaşikçi, 2023 ). To fill the stomach capacity, water is a good option. Using warm water as a complementary therapy is recommended ( Kilroe et al., 2024 ). The effects of hydrostatic, hydrodynamic, and warmth can promote relaxation and better blood circulation. The body responds to water to prevent, correct, and improve human health status, which makes water therapy one of the natural healing systems ( Asmaa Sayed et al., 2018 ). Warm water consumption will quicken the body’s temperature regulation process because it requires less energy. Constipation will speed up the defecation process by using warm water to soften the stool ( Parsons et al., 2022 ). The aim of this study is to compare the effectiveness of drinking warm water and Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. Methods Study design This research used quasi-experimental and pre-posttest designs without control group. This research was conducted at the Idaman Regional Public Hospital, Banjarbaru, South Kalimantan, Indonesia from May 10 th to June 30 th 2023. Participants The sample was 30 respondents selected using simple random technique. Determination of the sample size of each group is determined by calculating the paired numerical comparative formula. The sample in this research selected randomly using a lottery. Randomization is done by lottery, which makes a list of all subjects to be studied, gives a number code to each item to be investigated, writes the code on a small paper, rolls up each paper, puts the rolled paper into a container then shakes or shakes the container and takes one by one the roll. If you get an odd number, the warm water consumption intervention will be carried out while if you get an even number, you will enter the Swedish abdominal massage intervention. The inclusion criteria were: (1) all post-operative orthopedic surgery patients with lower extremity fractures (fractures of the femur, pelvis, tibia, fibula, ankle, and pedis), (2) patients with casts, (3) post-operative orthopedic surgery patients with ORIF, (4) patients aged 17-60 years, (5) compos-mentis patient, (5) patients with post-operative day 1 (after 1×24 hours/POD 1), (6) patients with a Barthel index score ≤ 8 (severe dependence), (7) patients receiving a standard diet from the hospital. Instrument This research used demographic questionnaire and the Constipation Assessment Scale (CAS) questionnaire to assess the patients’ constipation levels before and after the intervention. We used the Constipation Assessment Scale (CAS) that develop by McMillan and Williams and translated into Indonesian version by Suwandi. The valid CAS instrument in the Indonesian version consists of eight questions ( Suwandi, 2017 ). Intervention The sample was split into two intervention groups: group 2 got a Swedish abdominal massage, and group 1 drank warm water. 500 ml of warm water in a glass was consumed by group 1 at a temperature of 31.5°C. For three days, they drank the water as soon as they woke up and before breakfast. They were then permitted to eat breakfast 30 to 45 minutes after they had finished drinking. Over the course of three days, the second group, which was given a Swedish abdominal massage, had their abdominal muscles massaged for fifteen to twenty minutes. The moment when the respondents woke up, they were received this massage. It is recommended that patients refrain from eating breakfast following the intervention; however, they are permitted to consume food 30 to 45 minutes following the procedure. Every intervention was examined over the course of three days; the pretest was given prior to the intervention, and the post test was given following the third day of the intervention. The first time the respondent was able to defecate was used to calculate the defecation time. Data collection The data were collected by the researchers. Questionnaires were distributed to each group before and after intervention. Data analysis Descriptive statistical tests were used to measure demographic data or respondents’ characteristics. Data analysis was done with Windows-based IBM SPSS (Version 26.0) ( IBM Corp, 2024 ). The data were normally distributed according to Shapiro-Wilk (p≥0.05), so the independent t-test was used to measure constipation scores. The data were normally distributed according to Shapiro-Wilk (p≥0.05), so the independent t-test was used to measure constipation scores. Results The participants’ characteristics such as age, gender, types of analgetics and constipation score were collected at baseline on Table 1 . Table 1. Respondent’s characteristics. Characteristics Warm water drinking therapy (n = 15) Swedish abdominal massage (n = 15) Total (n = 30) n % n % n % Sex Female 4 26.66% 6 40% 10 33.3% Male 11 73.33% 9 60% 20 66.6% Age Mean (SD) 28.93 (14.97) Mean (SD) 31.53 (16.16) Types of analgetic Non-opioid 15 100% 15 100% 30 100% Constipation Score Before Mean (SD) 8.40 (2.41) Mean (SD) 10.13 (1.80) After Mean (SD) 4.60 (0.91) Mean (SD) 3.60 (0.63) According to this study, the majority of respondents—11 (73.3%) and nine (60%), respectively—were men who participated in the warm water intervention group and the Swedish abdominal massage intervention group. The first intervention group’s average age was 28.93 years, while the second intervention group’s average age was 31.53 years. The first intervention group’s confidence interval fell between 17 and 60 years, while the second intervention group’s confidence interval fell between 17 and 58 years. In both groups, non-opioid analgesics were used 100% of the time as analgesics. Prior to the intervention, the group receiving a Swedish abdominal massage had a higher mean constipation score than the group drinking warm water. On the other hand, the Swedish abdominal massage intervention group had a lower mean constipation score following the intervention. The statistical test found significant differences between the two intervention groups’ respondent characteristics (gender, age, and type of analgesic; p>0.05), but not between the groups’ pre- and post-intervention characteristics. Constipation scores of the warm water drinking therapy group and the swedish abdominal massage group The difference in constipation score was measured by looking at the mean score of the drinking warm water group and the Swedish abdominal massage group on Table 2 . Table 2. Constipation scores of the warm water drinking therapy group (n = 15) and the swedish abdominal massage group (n = 15). Group Pre-test Mean (SD) Post-test Mean (SD) Mean Difference 95% CI of Difference p-value Effect Size (Cohen’s d) Warm water drinking therapy 8.40 (2.41) 4.60 (0.91) 3.80 [2.50 – 5.10] <0.001 2.09 Swedish abdominal massage 10.13 (1.80) 3.60 (0.63) 6.53 [5.56 – 7.50] <0.001 4.84 * Significant at p<0.05. The within-group analysis demonstrated that both interventions significantly reduced constipation scores. In the warm water group, the mean CAS score decreased from 8.40 (SD = 2.41) to 4.60 (SD = 0.91), t (14) = xx, p < 0.001, Cohen’s d = 2.09, 95% CI [2.50–5.10]. Similarly, the Swedish abdominal massage group showed a reduction from 10.13 (SD = 1.80) to 3.60 (SD = 0.63), t (14) = xx, p < 0.001, Cohen’s d = 4.84, 95% CI [5.56–7.50]. Between-group comparisons indicated a greater mean reduction in constipation scores in the massage group (mean difference = 6.53, 95% CI [5.56–7.50]) compared to the warm water group (mean difference = 3.80, 95% CI [2.50–5.10]). However, the baseline imbalance in constipation scores (10.13 vs. 8.40) may have influenced these results, and therefore the interpretation of superiority between groups should be made cautiously. Discussion Both Swedish abdominal massage and warm water therapy were effective in reducing postoperative constipation scores. Within-group analyses confirmed significant reductions for both interventions, each with large effect sizes. Although the Swedish abdominal massage group demonstrated a greater mean reduction, this finding should be interpreted with caution because the baseline constipation scores were higher in this group. The imbalance at baseline may have provided a greater potential for improvement, and the small sample size further limits the strength of between-group comparisons. In addition to being an effective treatment for constipation, a Swedish abdominal massage can also lessen the degree of straining, anal pain, and bloating, as well as the degree of incomplete bowel emptying ( Choi et al., 2021 ). By strengthening the abdominal muscles and encouraging intestinal peristalsis, massage can improve the digestive system’s efficiency, improving quality of life ratings and resulting in better-consistent stools ( Durmuş İskender & Çalışkan, 2022 ). Abdominal massage can stimulate afferent neuron stretch receptors in the luminal wall, which contract the intestinal muscles above the pressure point and relax them below, thereby generating peristaltic waves ( Aydinli & Karadağ, 2023 ; Faghihi et al., 2021 ; Keely & Barrett, 2022 ). This physiological mechanism supports the observed clinical improvements. For three days in a row, consuming 500 ml of warm water first thing in the morning can intensify the gastric effect and heighten the feeling of passing gas ( Kilroe et al., 2024 ). The best time to trigger the gastrocolic reflex is in the morning. This reflex happens when the extrinsic autonomic nerve, which is responsible for promoting colonic motility and large amplitude propagation (HAPCs) to ward off constipation, contracts the stomach when it reaches a specific volume (500 ml) ( Al-Kharraz et al., 2023 ). One to three glasses of water a day can help trigger the gastric reflex. Utilizing warm water is a complementary therapy. The warm, hydrostatic, and hydrodynamic effects can promote relaxation and better blood circulation ( Asmaa Sayed et al., 2018 ). Significant results were found in the majority of research studies that used warm water consumption at different volumes in conjunction with Swedish abdominal massage. The hypothesis posits that upon food entry, the large intestine experiences mass movements primarily due to the gastrocolic reflex ( Bellini et al., 2021 ). This reflex is facilitated by gastrin and parasympathetic innervation, which travel from the stomach to the large intestine ( Chatip et al., 2024 ). The urge to urinate frequently follows this reflex, which is most noticeable in many people after their first meal of the day. Therefore, a reflex is triggered to move the contents of the digestive tract farther along when new food enters, making room for the incoming food ( Gu et al., 2023 ). The remaining small intestine’s contents are moved into the large intestine by the gastroileal reflex, and the defecation reflex is triggered by the gastrocolic reflex, which pushes the large intestine’s contents into the rectum. This is so that the digestive system can function more efficiently. Peristalsis, or the stimulation of intestinal peristaltic movements, is strengthened by abdominal massage and is consistent with the findings of previous studies ( Karaaslan et al., 2024 ). Previous studies have also described the physiological mechanisms underlying these effects. With the help of gastrin from the stomach and the extrinsic autonomic nerve, direct stimulation of the abdominal muscles can induce peristalsis and the gastrocolon, which causes the colon’s mass to accelerate and the stomach’s contractions to strongen ( Chatip et al., 2024 ). A gastroileal reflex will result in the movement of the remaining contents of the small intestine to the large intestine by forcing the chyme into the duodenum through strong peristaltic movements ( Durmuş İskender & Çalışkan, 2022 ). This will speed up the absorption process in the intestine. A colon’s contents will be forced into the rectum, a gastrocolon effect will be produced, stretch receptors in the rectal wall will be stimulated, and a feeling of defecation will be produced through good intestinal motility ( Artale et al., 2023 ). These mechanisms help to explain the observed improvements in constipation scores in both intervention groups, although our study was not designed to measure physiological parameters directly. Overall, both interventions are feasible nurse-led strategies, but the findings must be interpreted with caution. The small sample size (n = 30), the absence of power analysis, and baseline imbalance are important limitations that restrict generalizability. Future studies should employ larger samples, rigorous randomization, and appropriate statistical adjustments such as ANCOVA to minimize baseline differences and confirm these preliminary findings. Conclusion Both Swedish abdominal massage and warm water therapy significantly improved constipation symptoms in postoperative patients with lower extremity fractures. Swedish abdominal massage showed a greater reduction within its group; however, this result should be interpreted with caution due to baseline differences, the small sample size, and other contextual limitations. Despite respondents following hospital dietary guidelines, fiber intake and food portions were not calculated, which may have influenced outcomes. Furthermore, fracture location may have affected mobilization, with distal fractures allowing easier mobilization compared to proximal fractures. Overall, both interventions may be considered as feasible, nurse-led strategies to complement pharmacological management of postoperative constipation. Larger, adequately powered studies with longer follow-up and more comprehensive control of confounding factors (such as diet and mobilization) are warranted to confirm these findings and guide evidence-based postoperative care protocols. Ethical consideration This research was approved by the Ethics Commission of Idaman Regional Public Hospital, Banjarbaru with number No. RS00214/KEPK-RSDI/04/2023 on May 1 st 2023. Before conducting the research, the researcher explained to the respondents about the objectives, procedures, and expectations of this research in person verbal and written. The respondents were asked to provide their written consent in an informed consent by signing before participating in this research. The respondents were also assured that their involvement was voluntary and were informed of their right to withdraw from the study at any time without facing any penalties. Data availability Underlying data Fighshare: Swedish Abdominal Massage versus Warm Water Therapy on Postoperative Constipation: A Comparison Quasi Experimental Study: 10.6084/m9.figshare.27764655.v2 ( Boangmanalu, 2024 ). This project contains the following underlying data Click or tap here to enter text. 1. SPO of Water Consumption 2. SPO of Abdominal Massage 3. SPSS Output 4. All Data consist of all raw data underlying data before analysis in SPSS file Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Extended data Fighshare: Swedish Abdominal Massage versus Warm Water Therapy on Postoperative Constipation: A Comparison Quasi Experimental Study: 10.6084/m9.figshare.27764655.v2 ( Boangmanalu, 2024 ). This project contains the following extended dataClick or tap here to enter text.: 1. Consort cheklist 2. Research instrument 3. Informed Consent 4. Research explanation Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Reporting guidelines Fighshare: CONSORT checklist for Swedish Abdominal Massage versus Warm Water Therapy on Postoperative Constipation: A Comparison Quasi Experimental Study: 10.6084/m9.figshare.27764655.v2 ( Boangmanalu, 2024 ). Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements This study was successfully conducted with the support of various parties. We want to thank the hospital where the study was carried out and the Faculty of Nursing, University of Indonesia. We also extend our gratitude to all participants and their families for their support in making this study possible. 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Close Report a concern Comment ADD YOUR COMMENT Author details Author details 1 Faculty of Nursing, Universitas Indonesia, Depok, West Java, 16424, Indonesia 2 Faculty of Nursing, Universitas Kristen Krida Wacana, West Jakarta, Jakarta, 12120, Indonesia 3 Nursing Committee, Mother and Child Bunda Jakarta Hospital, Menteng, Central Jakarta, 10350, Indonesia 4 Nursing Science, Sekolah Tinggi Ilmu Kesehatan Papua, Sorong City, West Papua, 98412, Indonesia Enny Selawaty Boangmanalu Roles: Conceptualization, Data Curation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Masfuri Masfuri Roles: Methodology, Supervision Muhamad Adam Roles: Supervision, Validation Sri Nining Roles: Writing – Original Draft Preparation, Writing – Review & Editing Triani Banna Roles: Funding Acquisition, Writing – Original Draft Preparation Indira Mastura Pulungan Roles: Funding Acquisition, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information This study was supported by the Directorate of Development and Research of Universitas Indonesia under the HIBAH PUTI 2023 (Grant No. NKB-073/UN2.RST/HKP.05.00/2023). We also want to express our sincere gratitude to The Center for Higher Education (BPPT) and The Indonesia Endowment Funds for Education (LPDP) for their support through scholarship programs that enabled us to conduct this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) version 3 Revised Published: 03 Oct 2025, 13:1531 https://doi.org/10.12688/f1000research.159217.3 version 2 Revised Published: 23 Jun 2025, 13:1531 https://doi.org/10.12688/f1000research.159217.2 version 1 Published: 18 Dec 2024, 13:1531 https://doi.org/10.12688/f1000research.159217.1 Copyright © 2025 Boangmanalu ES et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Boangmanalu ES, Masfuri M, Adam M et al. Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.12688/f1000research.159217.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 23 Jun 2025 Revised Views 0 Cite How to cite this report: Hao J. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395120 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395120 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Aug 2025 Jie Hao , University of Nebraska Medical Center, Omaha, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.183692.r395120 The manuscript entitled "Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study" has been reviewed. The manuscript explores a relevant and practical nursing intervention—Swedish abdominal massage versus warm water therapy—for managing postoperative constipation in ... Continue reading READ ALL The manuscript entitled "Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study" has been reviewed. The manuscript explores a relevant and practical nursing intervention—Swedish abdominal massage versus warm water therapy—for managing postoperative constipation in patients with lower extremity fractures. The topic is of clinical interest, particularly given the high incidence of postoperative constipation and the need for non-pharmacological, nurse-led interventions. The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. The conclusion that "Swedish abdominal massage was noticeably more successful" may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Physical therapy, rehabilitation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hao J. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395120 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395120 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 03 Oct 2025 Sri Nining , Faculty of Nursing, Universitas Kristen Krida Wacana, West Jakarta, 12120, Indonesia 03 Oct 2025 Author Response Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences ... Continue reading Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. Response: Thank you for pointing this out. We have revised the Discussion section to highlight this limitation. We now explicitly state that the baseline imbalance may have influenced the results, and that the observed superiority of Swedish abdominal massage should be interpreted cautiously. In addition, within-group pre-post analyses were added to the Results section to provide a clearer picture of intervention effectiveness. We also recommend the use of ANCOVA or stratified randomization in future studies to minimize baseline variability. Comment 2 The conclusion that “Swedish abdominal massage was noticeably more successful” may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. Response: We agree with this comment. The statement in the Discussion and Conclusion sections has been revised to a more cautious interpretation. We now emphasize that both interventions were effective, with Swedish abdominal massage showing greater within-group reduction, but superiority cannot be firmly concluded due to baseline differences and the small sample size. Comment 3 The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. Response: We have acknowledged the small sample size as a key limitation in the Discussion section and clarified that it reduces statistical power and generalizability. To strengthen the findings, we have now reported effect sizes (Cohen’s d ) and 95% confidence intervals in the Results section and revised Table 2 accordingly. These additions provide greater clarity regarding the clinical significance of the results. Comment 4 The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Response: This has been addressed in the revised Results section and Table 2, where we now include 95% confidence intervals and effect sizes for both interventions. The narrative has also been updated to interpret these findings more appropriately. Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. Response: Thank you for pointing this out. We have revised the Discussion section to highlight this limitation. We now explicitly state that the baseline imbalance may have influenced the results, and that the observed superiority of Swedish abdominal massage should be interpreted cautiously. In addition, within-group pre-post analyses were added to the Results section to provide a clearer picture of intervention effectiveness. We also recommend the use of ANCOVA or stratified randomization in future studies to minimize baseline variability. Comment 2 The conclusion that “Swedish abdominal massage was noticeably more successful” may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. Response: We agree with this comment. The statement in the Discussion and Conclusion sections has been revised to a more cautious interpretation. We now emphasize that both interventions were effective, with Swedish abdominal massage showing greater within-group reduction, but superiority cannot be firmly concluded due to baseline differences and the small sample size. Comment 3 The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. Response: We have acknowledged the small sample size as a key limitation in the Discussion section and clarified that it reduces statistical power and generalizability. To strengthen the findings, we have now reported effect sizes (Cohen’s d ) and 95% confidence intervals in the Results section and revised Table 2 accordingly. These additions provide greater clarity regarding the clinical significance of the results. Comment 4 The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Response: This has been addressed in the revised Results section and Table 2, where we now include 95% confidence intervals and effect sizes for both interventions. The narrative has also been updated to interpret these findings more appropriately. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 03 Oct 2025 Sri Nining , Faculty of Nursing, Universitas Kristen Krida Wacana, West Jakarta, 12120, Indonesia 03 Oct 2025 Author Response Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences ... Continue reading Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. Response: Thank you for pointing this out. We have revised the Discussion section to highlight this limitation. We now explicitly state that the baseline imbalance may have influenced the results, and that the observed superiority of Swedish abdominal massage should be interpreted cautiously. In addition, within-group pre-post analyses were added to the Results section to provide a clearer picture of intervention effectiveness. We also recommend the use of ANCOVA or stratified randomization in future studies to minimize baseline variability. Comment 2 The conclusion that “Swedish abdominal massage was noticeably more successful” may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. Response: We agree with this comment. The statement in the Discussion and Conclusion sections has been revised to a more cautious interpretation. We now emphasize that both interventions were effective, with Swedish abdominal massage showing greater within-group reduction, but superiority cannot be firmly concluded due to baseline differences and the small sample size. Comment 3 The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. Response: We have acknowledged the small sample size as a key limitation in the Discussion section and clarified that it reduces statistical power and generalizability. To strengthen the findings, we have now reported effect sizes (Cohen’s d ) and 95% confidence intervals in the Results section and revised Table 2 accordingly. These additions provide greater clarity regarding the clinical significance of the results. Comment 4 The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Response: This has been addressed in the revised Results section and Table 2, where we now include 95% confidence intervals and effect sizes for both interventions. The narrative has also been updated to interpret these findings more appropriately. Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. Response: Thank you for pointing this out. We have revised the Discussion section to highlight this limitation. We now explicitly state that the baseline imbalance may have influenced the results, and that the observed superiority of Swedish abdominal massage should be interpreted cautiously. In addition, within-group pre-post analyses were added to the Results section to provide a clearer picture of intervention effectiveness. We also recommend the use of ANCOVA or stratified randomization in future studies to minimize baseline variability. Comment 2 The conclusion that “Swedish abdominal massage was noticeably more successful” may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. Response: We agree with this comment. The statement in the Discussion and Conclusion sections has been revised to a more cautious interpretation. We now emphasize that both interventions were effective, with Swedish abdominal massage showing greater within-group reduction, but superiority cannot be firmly concluded due to baseline differences and the small sample size. Comment 3 The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. Response: We have acknowledged the small sample size as a key limitation in the Discussion section and clarified that it reduces statistical power and generalizability. To strengthen the findings, we have now reported effect sizes (Cohen’s d ) and 95% confidence intervals in the Results section and revised Table 2 accordingly. These additions provide greater clarity regarding the clinical significance of the results. Comment 4 The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Response: This has been addressed in the revised Results section and Table 2, where we now include 95% confidence intervals and effect sizes for both interventions. The narrative has also been updated to interpret these findings more appropriately. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Huriani E. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395119 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395119 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Aug 2025 Emil Huriani , Faculty of Nursing, Universitas Andalas, Padang, West Sumatra, Indonesia Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.183692.r395119 Thank you for the opportunity to review this manuscript. Overall, this is a well-conducted study. There are several extents need to be executed to make the conclusion of the study is readable and acceptable. Background ... Continue reading READ ALL Thank you for the opportunity to review this manuscript. Overall, this is a well-conducted study. There are several extents need to be executed to make the conclusion of the study is readable and acceptable. Background Background does not explain well the magnitude of the problem, the urgency of the research, and the state of the art based on the available literature. The researcher does not reveal the novelty of the research. The application of abdominal massage to overcome constipation has been widely documented in references. The author has not explained the advancement revealed through this research. I'm a little confused because in the background of the study, the researchers stated that an intervention involving "teaching patients about high-fiber foods like vegetables and papaya" could relieve constipation. In contrast, the researchers tested the effect of using warm water therapy to relieve constipation. Another confusing statement is "Constipation will speed up the defecation process by using warm water to soften the stool.". What do you mean with this statement? The authors need to explain why they chose to compare abdominal massage and warm water therapy in this study. Methods Participants Regarding randomization, researchers do not need to explain the lottery process in detail. Were there any exclusion criteria for selecting respondents? Please provide these. Was there any control over the type of anesthesia used, whether spinal or general? Instruments What is the validity and reliability of the CAS score after being translated into a bahasa? In intervention section, it is stated “Over the course of three days, the second group, which was given a Swedish abdominal massage, ‘had their abdominal muscles massaged for fifteen to twenty minutes.” Then, what was done during the first three days. Researchers recorded the first time the respondent was able to defecate to calculate the defecation time. I couldn't find this data in the results table. Data Analysis There is a repetition of sentences at the end of this section. Ethical approval It's important to explain the ethics protocol and how researchers meet the ethical aspects of health research. Has the research protocol received ethical approval from the appropriate agency? Results Researchers need to provide data on laxative use because laxative use is often used to treat constipation and the Barthel index score because this score describes the level of dependency and the level of ability to carry out activities. Before continuing to statistical test on differences of CAS score after the intervention between the two respondents’ groups, authors must go first with homogeneity test of CAS score before the intervention between the two respondents’ groups as well as homogeneity tests for respondent characteristics (age and gender). When the CAS scores before the intervention in both groups were found to be homogeneous, then the statistical test can be continued by comparing the CAS scores after the intervention. Otherwise, if the data at the baseline were not homogeneous, the researcher should go with a statistical test that was appropriate for non-homogeneous data. The research results are not in sync with the SPSS output in the Extended data related to participants’ characteristics such as age and gender. The extended data provided shows repetitions on analysis of research data and the results are different between the initial analysis and the subsequent analysis. In Table 2 dan its narration, it is confusing when you are presenting the difference constipation score, but still there are constipation scores both pre-test and post-test of both groups of respondents. Discussion. The first sentence in the discussion is not supported by adequate statistical analysis. Furthermore, the authors need to elaborate on the main effects observed in this study before discussing other benefits of the intervention being tested. Conclusion I also emphasize the research conclusions. The conclusion does not explicitly convey the final results of the research that has been conducted. The statement "The protocol of drinking warm water and Swedish abdominal massage immediately after waking up effectively reduces constipation scores on postoperative lower extremity fracture patients and can be used to adjuvant therapy" has not answered the aim of comparing the effectiveness of drinking warm water and Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. Moreover, the recommendations given do not correspond to the research conclusions. Perhaps, the authors can improve this manuscript so that it can present clear research results and contain elements of novelty, described well and clearly, so that it can be acceptable and readable. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Cardiovascular Nursing I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Huriani E. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395119 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395119 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Machado NC. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r394054 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-394054 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 08 Aug 2025 Nilton Carlos Machado , São Paulo State University, São Paulo, Brazil Approved VIEWS 0 https://doi.org/10.5256/f1000research.183692.r394054 The authors accepted and ... Continue reading READ ALL The authors accepted and did the correction solicited. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pediatric Gastroenterology, Hepatology and Nutrition. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Machado NC. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r394054 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-394054 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 18 Dec 2024 Views 0 Cite How to cite this report: Miccio RS. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357284 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357284 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Feb 2025 Robin S Miccio , Rutgers University, Newark, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174914.r357284 Overall, this is a wonderful study. My biggest concern is with the strong statement in the conclusion: “The results showed that Swedish abdominal massage was noticeably more successful than warm water drinking therapy in reducing the constipation score.” The heterogeneity ... Continue reading READ ALL Overall, this is a wonderful study. My biggest concern is with the strong statement in the conclusion: “The results showed that Swedish abdominal massage was noticeably more successful than warm water drinking therapy in reducing the constipation score.” The heterogeneity between groups at baseline makes this statement not entirely true. The authors note that “the statistical test found significant differences between the two intervention groups’ respondent characteristics (gender, age, and type of analgesic; p>0.05).” If the groups were significantly different at baseline, we are not comparing apples to apples. I’m a bit confused with p>0.05 – if p is greater than 0.05 that usually means that there is NO significant difference between groups? Would statisticians consider Levine’s Test to determine whether the assumption of homogeneity of variance is met? If there truly are differences at baseline, is another statistical test more appropriate to compare groups (like mixed-effects models)? If this is not possible, I think you can only compare pre and post data within groups (not between). It would also be good to note the limitations of a small sample size and report the effect size. Please note I am not a statistician, but thinking these areas need to be addressed. More information should be included about the groups. Such as: was the control group able to drink hot beverages during the intervention (i.e. tea or coffee), what about water consumption at baseline and throughout? Did the patients use laxatives at all? What other pain meds were used during the intervention (even non-opiate pain meds can cause constipation). From a massage therapist perspective, would be helpful to report details on the massage intervention – how was massage applied: over clothes/on skin, what techniques, what position was the patient in, who performed the massage and what was their training? Lastly, the way the aim is worded is confusing. I think the word “versus” or “against” may help clarify. It is also in the end of the Intro. Example correction: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Massage therapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Miccio RS. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357284 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357284 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Sep 2025 Enny Selawaty Boangmanalu , Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia 10 Sep 2025 Author Response Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, ... Continue reading Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, and type of analgesic; p>0.05) indicate that there was no significant difference between the two intervention groups—those receiving warm water therapy and those receiving Swedish abdominal massage. This conclusion is supported by the statistical tests (p-value > 0.05; α ≥ 0.05), which demonstrate no significant variance between the groups. The homogeneity of variance was tested using the chi-square test and Levene’s test, confirming that the groups were comparable at baseline. 2. Respon: The homogeneity of respondent characteristics was tested using the chi-square test and Levine’s test. These tests confirmed that the assumption of homogeneity of variance was met, allowing for valid comparisons between the intervention groups. We acknowledge that alternative statistical methods, such as mixed-effects models, may provide further insight, particularly if baseline differences were present. Additionally, we recognize the importance of discussing the limitations of our sample size and reporting the effect size for a more comprehensive analysis. 3. Respon: In the warm water therapy group, participants consumed 500 ml of warm water (temperature: approximately 31°C) each morning before breakfast. No other hot beverages (such as tea or coffee) were permitted during the intervention. Participants were allowed to eat breakfast 30-45 minutes after consuming the warm water. To minimize confounding factors, only non-opioid analgesics were used during the study, and no participants were given laxatives. The Swedish abdominal massage was performed directly on the skin, involving specific abdominal muscle movements. Each massage session lasted 15-20 minutes and was conducted daily for three consecutive days immediately after waking up. Patients remained in a supine position during the massage and were instructed to delay breakfast for 30-45 minutes post-intervention. The massages were administered by trained nurses, in accordance with their professional scope of practice under national nursing regulations. 4. Respon: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. We accept your advice, we have revised our article Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, and type of analgesic; p>0.05) indicate that there was no significant difference between the two intervention groups—those receiving warm water therapy and those receiving Swedish abdominal massage. This conclusion is supported by the statistical tests (p-value > 0.05; α ≥ 0.05), which demonstrate no significant variance between the groups. The homogeneity of variance was tested using the chi-square test and Levene’s test, confirming that the groups were comparable at baseline. 2. Respon: The homogeneity of respondent characteristics was tested using the chi-square test and Levine’s test. These tests confirmed that the assumption of homogeneity of variance was met, allowing for valid comparisons between the intervention groups. We acknowledge that alternative statistical methods, such as mixed-effects models, may provide further insight, particularly if baseline differences were present. Additionally, we recognize the importance of discussing the limitations of our sample size and reporting the effect size for a more comprehensive analysis. 3. Respon: In the warm water therapy group, participants consumed 500 ml of warm water (temperature: approximately 31°C) each morning before breakfast. No other hot beverages (such as tea or coffee) were permitted during the intervention. Participants were allowed to eat breakfast 30-45 minutes after consuming the warm water. To minimize confounding factors, only non-opioid analgesics were used during the study, and no participants were given laxatives. The Swedish abdominal massage was performed directly on the skin, involving specific abdominal muscle movements. Each massage session lasted 15-20 minutes and was conducted daily for three consecutive days immediately after waking up. Patients remained in a supine position during the massage and were instructed to delay breakfast for 30-45 minutes post-intervention. The massages were administered by trained nurses, in accordance with their professional scope of practice under national nursing regulations. 4. Respon: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. We accept your advice, we have revised our article Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Sep 2025 Enny Selawaty Boangmanalu , Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia 10 Sep 2025 Author Response Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, ... Continue reading Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, and type of analgesic; p>0.05) indicate that there was no significant difference between the two intervention groups—those receiving warm water therapy and those receiving Swedish abdominal massage. This conclusion is supported by the statistical tests (p-value > 0.05; α ≥ 0.05), which demonstrate no significant variance between the groups. The homogeneity of variance was tested using the chi-square test and Levene’s test, confirming that the groups were comparable at baseline. 2. Respon: The homogeneity of respondent characteristics was tested using the chi-square test and Levine’s test. These tests confirmed that the assumption of homogeneity of variance was met, allowing for valid comparisons between the intervention groups. We acknowledge that alternative statistical methods, such as mixed-effects models, may provide further insight, particularly if baseline differences were present. Additionally, we recognize the importance of discussing the limitations of our sample size and reporting the effect size for a more comprehensive analysis. 3. Respon: In the warm water therapy group, participants consumed 500 ml of warm water (temperature: approximately 31°C) each morning before breakfast. No other hot beverages (such as tea or coffee) were permitted during the intervention. Participants were allowed to eat breakfast 30-45 minutes after consuming the warm water. To minimize confounding factors, only non-opioid analgesics were used during the study, and no participants were given laxatives. The Swedish abdominal massage was performed directly on the skin, involving specific abdominal muscle movements. Each massage session lasted 15-20 minutes and was conducted daily for three consecutive days immediately after waking up. Patients remained in a supine position during the massage and were instructed to delay breakfast for 30-45 minutes post-intervention. The massages were administered by trained nurses, in accordance with their professional scope of practice under national nursing regulations. 4. Respon: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. We accept your advice, we have revised our article Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, and type of analgesic; p>0.05) indicate that there was no significant difference between the two intervention groups—those receiving warm water therapy and those receiving Swedish abdominal massage. This conclusion is supported by the statistical tests (p-value > 0.05; α ≥ 0.05), which demonstrate no significant variance between the groups. The homogeneity of variance was tested using the chi-square test and Levene’s test, confirming that the groups were comparable at baseline. 2. Respon: The homogeneity of respondent characteristics was tested using the chi-square test and Levine’s test. These tests confirmed that the assumption of homogeneity of variance was met, allowing for valid comparisons between the intervention groups. We acknowledge that alternative statistical methods, such as mixed-effects models, may provide further insight, particularly if baseline differences were present. Additionally, we recognize the importance of discussing the limitations of our sample size and reporting the effect size for a more comprehensive analysis. 3. Respon: In the warm water therapy group, participants consumed 500 ml of warm water (temperature: approximately 31°C) each morning before breakfast. No other hot beverages (such as tea or coffee) were permitted during the intervention. Participants were allowed to eat breakfast 30-45 minutes after consuming the warm water. To minimize confounding factors, only non-opioid analgesics were used during the study, and no participants were given laxatives. The Swedish abdominal massage was performed directly on the skin, involving specific abdominal muscle movements. Each massage session lasted 15-20 minutes and was conducted daily for three consecutive days immediately after waking up. Patients remained in a supine position during the massage and were instructed to delay breakfast for 30-45 minutes post-intervention. The massages were administered by trained nurses, in accordance with their professional scope of practice under national nursing regulations. 4. Respon: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. We accept your advice, we have revised our article Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Machado NC. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357292 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357292 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Jan 2025 Nilton Carlos Machado , São Paulo State University, São Paulo, Brazil Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174914.r357292 The authors present an enjoyable alternative for treating constipation. This study observed that its application was restricted to patients undergoing postoperative orthopedic surgery for lower extremity fractures (the femur, pelvis, tibia, fibula, ankle, and pedis). The study was elegantly ... Continue reading READ ALL The authors present an enjoyable alternative for treating constipation. This study observed that its application was restricted to patients undergoing postoperative orthopedic surgery for lower extremity fractures (the femur, pelvis, tibia, fibula, ankle, and pedis). The study was elegantly designed and executed with great skill and accomplishment. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Conclusions. Adequate e also concerning further studies. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pediatric Gastroenterology, Hepatology and Nutrition. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Machado NC. Reviewer Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357292 ) The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357292 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 11 Sep 2025 Enny Selawaty Boangmanalu , Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia 11 Sep 2025 Author Response Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is ... Continue reading Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Response: Thank you for your insightful feedback. I will revise the article accordingly and consider using a more appropriate term. I will also update the title to reflect the specific focus on postoperative orthopedic surgery. 2. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Response: Thank you for your suggestion. We will ensure that the relevant keywords are incorporated into the abstract, title, and conclusions to enhance the study’s visibility. 3. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Response: Thank you for your comment. We will revise the manuscript to avoid redundancy between the text and tables, and we will replace "Gender" with "Sex" as recommended. 4. Conclusions. Adequate e also concerning further studies. Response: Thank you for the comment. We will revise the conclusion to better address this, emphasizing the importance of further research in this area. Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Response: Thank you for your insightful feedback. I will revise the article accordingly and consider using a more appropriate term. I will also update the title to reflect the specific focus on postoperative orthopedic surgery. 2. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Response: Thank you for your suggestion. We will ensure that the relevant keywords are incorporated into the abstract, title, and conclusions to enhance the study’s visibility. 3. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Response: Thank you for your comment. We will revise the manuscript to avoid redundancy between the text and tables, and we will replace "Gender" with "Sex" as recommended. 4. Conclusions. Adequate e also concerning further studies. Response: Thank you for the comment. We will revise the conclusion to better address this, emphasizing the importance of further research in this area. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 11 Sep 2025 Enny Selawaty Boangmanalu , Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia 11 Sep 2025 Author Response Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is ... Continue reading Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Response: Thank you for your insightful feedback. I will revise the article accordingly and consider using a more appropriate term. I will also update the title to reflect the specific focus on postoperative orthopedic surgery. 2. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Response: Thank you for your suggestion. We will ensure that the relevant keywords are incorporated into the abstract, title, and conclusions to enhance the study’s visibility. 3. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Response: Thank you for your comment. We will revise the manuscript to avoid redundancy between the text and tables, and we will replace "Gender" with "Sex" as recommended. 4. Conclusions. Adequate e also concerning further studies. Response: Thank you for the comment. We will revise the conclusion to better address this, emphasizing the importance of further research in this area. Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Response: Thank you for your insightful feedback. I will revise the article accordingly and consider using a more appropriate term. I will also update the title to reflect the specific focus on postoperative orthopedic surgery. 2. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Response: Thank you for your suggestion. We will ensure that the relevant keywords are incorporated into the abstract, title, and conclusions to enhance the study’s visibility. 3. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Response: Thank you for your comment. We will revise the manuscript to avoid redundancy between the text and tables, and we will replace "Gender" with "Sex" as recommended. 4. Conclusions. Adequate e also concerning further studies. Response: Thank you for the comment. We will revise the conclusion to better address this, emphasizing the importance of further research in this area. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (1) Version 3 VERSION 3 PUBLISHED 03 Oct 2025 Revised Reviewer Response 13 Oct 2025 nilton machado , São Paulo State University, São Paulo, Brazil 13 Oct 2025 Reviewer Response Approved version 3. Competing Interests: No competing interests were disclosed. Approved version 3. Approved version 3. Competing Interests: No competing interests were disclosed. Close Report a concern Comment ADD YOUR COMMENT keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 Version 3 (revision) 03 Oct 25 Version 2 (revision) 23 Jun 25 read read read Version 1 18 Dec 24 read read Nilton Carlos Machado , São Paulo State University, São Paulo, Brazil Robin S Miccio , Rutgers University, Newark, UK Emil Huriani , Universitas Andalas, Padang, Indonesia Jie Hao , University of Nebraska Medical Center, Omaha, USA Comments on this article All Comments (1) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hao J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Aug 2025 | for Version 2 Jie Hao , University of Nebraska Medical Center, Omaha, USA 0 Views copyright © 2025 Hao J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The manuscript entitled "Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study" has been reviewed. The manuscript explores a relevant and practical nursing intervention—Swedish abdominal massage versus warm water therapy—for managing postoperative constipation in patients with lower extremity fractures. The topic is of clinical interest, particularly given the high incidence of postoperative constipation and the need for non-pharmacological, nurse-led interventions. The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. The conclusion that "Swedish abdominal massage was noticeably more successful" may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. Reviewer Expertise Physical therapy, rehabilitation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 03 Oct 2025 Sri Nining, Faculty of Nursing, Universitas Kristen Krida Wacana, West Jakarta, 12120, Indonesia Comment 1 The baseline constipation scores between the two intervention groups differ notably (10.13 vs. 8.40), raising concerns about the comparability of groups. While the authors mention no significant differences in demographics (p>0.05), the baseline CAS differences affect the internal validity of between-group comparisons. Response: Thank you for pointing this out. We have revised the Discussion section to highlight this limitation. We now explicitly state that the baseline imbalance may have influenced the results, and that the observed superiority of Swedish abdominal massage should be interpreted cautiously. In addition, within-group pre-post analyses were added to the Results section to provide a clearer picture of intervention effectiveness. We also recommend the use of ANCOVA or stratified randomization in future studies to minimize baseline variability. Comment 2 The conclusion that “Swedish abdominal massage was noticeably more successful” may be overstated given this imbalance. A within-group pre-post comparison would be more appropriate, or statistical adjustment could help account for baseline differences. Response: We agree with this comment. The statement in the Discussion and Conclusion sections has been revised to a more cautious interpretation. We now emphasize that both interventions were effective, with Swedish abdominal massage showing greater within-group reduction, but superiority cannot be firmly concluded due to baseline differences and the small sample size. Comment 3 The study includes only 15 participants per group, which limits the power to detect meaningful differences and generalize the findings. No power analysis is provided to justify the sample size, and effect sizes are not reported. Response: We have acknowledged the small sample size as a key limitation in the Discussion section and clarified that it reduces statistical power and generalizability. To strengthen the findings, we have now reported effect sizes (Cohen’s d ) and 95% confidence intervals in the Results section and revised Table 2 accordingly. These additions provide greater clarity regarding the clinical significance of the results. Comment 4 The results report p-values but not confidence intervals or effect sizes, which are essential for interpreting clinical significance. Response: This has been addressed in the revised Results section and Table 2, where we now include 95% confidence intervals and effect sizes for both interventions. The narrative has also been updated to interpret these findings more appropriately. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Hao J. Peer Review Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395120) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395120 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Huriani E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Aug 2025 | for Version 2 Emil Huriani , Faculty of Nursing, Universitas Andalas, Padang, West Sumatra, Indonesia 0 Views copyright © 2025 Huriani E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review this manuscript. Overall, this is a well-conducted study. There are several extents need to be executed to make the conclusion of the study is readable and acceptable. Background Background does not explain well the magnitude of the problem, the urgency of the research, and the state of the art based on the available literature. The researcher does not reveal the novelty of the research. The application of abdominal massage to overcome constipation has been widely documented in references. The author has not explained the advancement revealed through this research. I'm a little confused because in the background of the study, the researchers stated that an intervention involving "teaching patients about high-fiber foods like vegetables and papaya" could relieve constipation. In contrast, the researchers tested the effect of using warm water therapy to relieve constipation. Another confusing statement is "Constipation will speed up the defecation process by using warm water to soften the stool.". What do you mean with this statement? The authors need to explain why they chose to compare abdominal massage and warm water therapy in this study. Methods Participants Regarding randomization, researchers do not need to explain the lottery process in detail. Were there any exclusion criteria for selecting respondents? Please provide these. Was there any control over the type of anesthesia used, whether spinal or general? Instruments What is the validity and reliability of the CAS score after being translated into a bahasa? In intervention section, it is stated “Over the course of three days, the second group, which was given a Swedish abdominal massage, ‘had their abdominal muscles massaged for fifteen to twenty minutes.” Then, what was done during the first three days. Researchers recorded the first time the respondent was able to defecate to calculate the defecation time. I couldn't find this data in the results table. Data Analysis There is a repetition of sentences at the end of this section. Ethical approval It's important to explain the ethics protocol and how researchers meet the ethical aspects of health research. Has the research protocol received ethical approval from the appropriate agency? Results Researchers need to provide data on laxative use because laxative use is often used to treat constipation and the Barthel index score because this score describes the level of dependency and the level of ability to carry out activities. Before continuing to statistical test on differences of CAS score after the intervention between the two respondents’ groups, authors must go first with homogeneity test of CAS score before the intervention between the two respondents’ groups as well as homogeneity tests for respondent characteristics (age and gender). When the CAS scores before the intervention in both groups were found to be homogeneous, then the statistical test can be continued by comparing the CAS scores after the intervention. Otherwise, if the data at the baseline were not homogeneous, the researcher should go with a statistical test that was appropriate for non-homogeneous data. The research results are not in sync with the SPSS output in the Extended data related to participants’ characteristics such as age and gender. The extended data provided shows repetitions on analysis of research data and the results are different between the initial analysis and the subsequent analysis. In Table 2 dan its narration, it is confusing when you are presenting the difference constipation score, but still there are constipation scores both pre-test and post-test of both groups of respondents. Discussion. The first sentence in the discussion is not supported by adequate statistical analysis. Furthermore, the authors need to elaborate on the main effects observed in this study before discussing other benefits of the intervention being tested. Conclusion I also emphasize the research conclusions. The conclusion does not explicitly convey the final results of the research that has been conducted. The statement "The protocol of drinking warm water and Swedish abdominal massage immediately after waking up effectively reduces constipation scores on postoperative lower extremity fracture patients and can be used to adjuvant therapy" has not answered the aim of comparing the effectiveness of drinking warm water and Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. Moreover, the recommendations given do not correspond to the research conclusions. Perhaps, the authors can improve this manuscript so that it can present clear research results and contain elements of novelty, described well and clearly, so that it can be acceptable and readable. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Cardiovascular Nursing I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Huriani E. Peer Review Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r395119) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-395119 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Machado N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 Aug 2025 | for Version 2 Nilton Carlos Machado , São Paulo State University, São Paulo, Brazil 0 Views copyright © 2025 Machado N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors accepted and did the correction solicited. Competing Interests No competing interests were disclosed. Reviewer Expertise Pediatric Gastroenterology, Hepatology and Nutrition. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Machado NC. Peer Review Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.183692.r394054) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1531/v2#referee-response-394054 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Miccio R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Feb 2025 | for Version 1 Robin S Miccio , Rutgers University, Newark, UK 0 Views copyright © 2025 Miccio R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Overall, this is a wonderful study. My biggest concern is with the strong statement in the conclusion: “The results showed that Swedish abdominal massage was noticeably more successful than warm water drinking therapy in reducing the constipation score.” The heterogeneity between groups at baseline makes this statement not entirely true. The authors note that “the statistical test found significant differences between the two intervention groups’ respondent characteristics (gender, age, and type of analgesic; p>0.05).” If the groups were significantly different at baseline, we are not comparing apples to apples. I’m a bit confused with p>0.05 – if p is greater than 0.05 that usually means that there is NO significant difference between groups? Would statisticians consider Levine’s Test to determine whether the assumption of homogeneity of variance is met? If there truly are differences at baseline, is another statistical test more appropriate to compare groups (like mixed-effects models)? If this is not possible, I think you can only compare pre and post data within groups (not between). It would also be good to note the limitations of a small sample size and report the effect size. Please note I am not a statistician, but thinking these areas need to be addressed. More information should be included about the groups. Such as: was the control group able to drink hot beverages during the intervention (i.e. tea or coffee), what about water consumption at baseline and throughout? Did the patients use laxatives at all? What other pain meds were used during the intervention (even non-opiate pain meds can cause constipation). From a massage therapist perspective, would be helpful to report details on the massage intervention – how was massage applied: over clothes/on skin, what techniques, what position was the patient in, who performed the massage and what was their training? Lastly, the way the aim is worded is confusing. I think the word “versus” or “against” may help clarify. It is also in the end of the Intro. Example correction: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Massage therapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 10 Sep 2025 Enny Selawaty Boangmanalu, Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. Respon: The respondent characteristics (gender, age, and type of analgesic; p>0.05) indicate that there was no significant difference between the two intervention groups—those receiving warm water therapy and those receiving Swedish abdominal massage. This conclusion is supported by the statistical tests (p-value > 0.05; α ≥ 0.05), which demonstrate no significant variance between the groups. The homogeneity of variance was tested using the chi-square test and Levene’s test, confirming that the groups were comparable at baseline. 2. Respon: The homogeneity of respondent characteristics was tested using the chi-square test and Levine’s test. These tests confirmed that the assumption of homogeneity of variance was met, allowing for valid comparisons between the intervention groups. We acknowledge that alternative statistical methods, such as mixed-effects models, may provide further insight, particularly if baseline differences were present. Additionally, we recognize the importance of discussing the limitations of our sample size and reporting the effect size for a more comprehensive analysis. 3. Respon: In the warm water therapy group, participants consumed 500 ml of warm water (temperature: approximately 31°C) each morning before breakfast. No other hot beverages (such as tea or coffee) were permitted during the intervention. Participants were allowed to eat breakfast 30-45 minutes after consuming the warm water. To minimize confounding factors, only non-opioid analgesics were used during the study, and no participants were given laxatives. The Swedish abdominal massage was performed directly on the skin, involving specific abdominal muscle movements. Each massage session lasted 15-20 minutes and was conducted daily for three consecutive days immediately after waking up. Patients remained in a supine position during the massage and were instructed to delay breakfast for 30-45 minutes post-intervention. The massages were administered by trained nurses, in accordance with their professional scope of practice under national nursing regulations. 4. Respon: The objective of this study is to compare the effectiveness of drinking warm water versus Swedish abdominal massage on constipation scores on post-operative lower extremity fractures. We accept your advice, we have revised our article View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Miccio RS. Peer Review Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357284) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357284 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Machado N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Jan 2025 | for Version 1 Nilton Carlos Machado , São Paulo State University, São Paulo, Brazil 0 Views copyright © 2025 Machado N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors present an enjoyable alternative for treating constipation. This study observed that its application was restricted to patients undergoing postoperative orthopedic surgery for lower extremity fractures (the femur, pelvis, tibia, fibula, ankle, and pedis). The study was elegantly designed and executed with great skill and accomplishment. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Conclusions. Adequate e also concerning further studies. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Pediatric Gastroenterology, Hepatology and Nutrition. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 11 Sep 2025 Enny Selawaty Boangmanalu, Faculty of Nursing, Universitas Indonesia, Depok, 16424, Indonesia Thank you for your feedback. We have reviewed and implemented your suggestions. All feedback has been addressed through revisions to the article. 1. The small number of patients is noteworthy. The term "Closed Fracture Reduction" does not fit well with the study. Perhaps a more fitting term could be suggested. Title. Please insert "postoperative orthopedic surgery" since the sample is restricted to this type of surgery. Response: Thank you for your insightful feedback. I will revise the article accordingly and consider using a more appropriate term. I will also update the title to reflect the specific focus on postoperative orthopedic surgery. 2. Please include the keywords in the abstract, title, and conclusions to increase the study's visibility. Response: Thank you for your suggestion. We will ensure that the relevant keywords are incorporated into the abstract, title, and conclusions to enhance the study’s visibility. 3. Results. Avoid repeating information in the text and Tables. In this manuscript, I think the variable "Gender" can be replaced by "Sex." Response: Thank you for your comment. We will revise the manuscript to avoid redundancy between the text and tables, and we will replace "Gender" with "Sex" as recommended. 4. Conclusions. Adequate e also concerning further studies. Response: Thank you for the comment. We will revise the conclusion to better address this, emphasizing the importance of further research in this area. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Machado NC. Peer Review Report For: Swedish abdominal massage against warm water therapy on postoperative orthopaedic surgery constipation: a comparison quasi-experimental study [version 3; peer review: 1 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :1531 ( https://doi.org/10.5256/f1000research.174914.r357292) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1531/v1#referee-response-357292 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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