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  • Research Article2021-08-31

    Effects of Novel Vibro-Acupuncture on Healthy Subjects and Those with Experimental and Clinical Pain as Assessed by Quantitative Sensory Testing

    Kelun Wang1,*, Dennis Boye Larsen1,2, Silvia Ambite-Quesada3, Yuan Zhang4, Huilin Liu5, César Fernández-de-las-Peñas3, Lars Arendt-Nielsen1,2
    J Acupunct Meridian Stud 2021; 14(4): 157-166 https://doi.org/10.51507/j.jams.2021.14.4.157

    Abstract : Background: To investigate the analgesic effects of vibro-acupuncture (VA), a novel acuvibrator was developed. Objectives: To compare the analgesic effects of VA with those of manual acupuncture (MA) and placebo acupuncture (PA) on subjects with normal sensory perception (Study I), experimentally induced acute pain (Study II), and clinical chronic pain (Study III). Methods: Thirty healthy volunteers (21 males, age: 20-30 years) participated in Study I. Fourteen healthy volunteers (8 males, age: 20-32 years) participated in Study II in which experimental pain was induced by injection of hypertonic saline. Fourteen patients suffering from unilateral epicondylalgia (9 males, age: 30-61 years) participated in Study III. All participants received VA, MA, and PA at LI4 and LI10 points in a randomized, crossover, and double-blinded manner. Quantitative sensory testing (QST) was performed on the ipsilateral forearm before and after each treatment. Data were analyzed using repeated-measures (RM) ANOVA. Results: A significantly higher vibration detection threshold (VDT) was observed after treatment of VA than after MA and PA (p < 0.001). No significant treatment effect on experimental pain intensity was detected (p > 0.086). Significantly lower pain intensity (p = 0.005) and a smaller drawing area (p = 0.011) of unilateral epicondylalgia were found after VA treatment than after PA. Conclusion: A specific effect on the VDT beyond that of MA and PA was evoked by VA. Patients with epicondylitis showed significantly lower pain intensity during VA than during PA. This study indicated that VA may be beneficial in individuals with clinical chronic musculoskeletal pain; however, further studies are needed.

    Abstract
  • Perspective Article2021-06-30
    JAMS

    Abstract : Fu’s subcutaneous needling (FSN) is a novel acupuncture approach. Although it has been popularized and widely used by acupuncture practitioners, theoretical research on its mechanism of action remains lacking. This study establishes an immunological hypothesis for the efficacy of FSN basis existing knowledge in biomedical science, histology and physiology, and traditional acupuncture mechanisms. The theoretical inference indicates that FSN treatment may affect the body's immune system through subcutaneous connective tissue, similar to triggering a cobweb-like system. This article also proposes possible clinical implications of this theory, which require further studies to validate.

    Abstract
  • Research Article2022-02-28

    Primo Vascular Node in the Bone Marrow and Longevity

    Vitaly Vodyanoy1,2,*, Oleg Pustovyy1, Ludmila Globa1
    J Acupunct Meridian Stud 2022; 15(1): 12-24 https://doi.org/10.51507/j.jams.2022.15.1.12

    Abstract : Background: Intra-organic bone marrow node is predicted to be a part of the primo vascular system that plays a critical role in hematopoiesis and generation and regeneration of other cells. Two models of cell regeneration were suggested, one involving DNA synthesis and the other pertaining to DNA recycling. Objectives: The aim of this work is to extract a primo node from bone marrow, characterize its structure, understand its biochemistry and cell composition, and suggest a cell regeneration mechanism. Methods: Primo nodes were sampled from segmented halves of the rat femur. We used immunohistochemistry and high-resolution fluorescent microscopy to analyze 1200 samples obtained from 42 rats and 190 primo nodes. Results: Primo nodes in the bone marrow have an oval or round structure of about one millimeter in diameter, which is encompassed by a fine capsule, having incoming and outgoing vessels filled with the extracellular matrix and hematopoietic, mesenchymal, endothelial stem cells, as well as cells of the megakaryocyte family found in other primo nodes. Conclusion: Our findings imply that bone marrow nodes are intra-organic primo vascular nodes, and they provide ways and approaches for further investigation. Bone marrow nodes are simple to examine ex vivo in a variety of environments to assess cell regeneration mechanisms, wound healing, and organism rejuvenation and lifespan. Further research into these and other intra-organic nodes in animals and humans could lead to new regenerative medicine and longevity strategies that have yet to be discovered.

    Abstract
  • Research Article2021-08-31

    Age Differences in Naloxone Reversibility of Electroacupuncture on the Jaw Opening Reflex in Rats

    Hiromi Yamashita1, Jorge Luis Lopes Zeredo2, Kazuo Toda3,*
    J Acupunct Meridian Stud 2021; 14(4): 167-172 https://doi.org/10.51507/j.jams.2021.14.4.167

    Abstract : Background: Electroacupuncture is one of the most popular physical treatments for clinical pain, but the potential influence of a patient’s age on the effectiveness of electroacupuncture treatment has not been clearly established. Objectives: The present study aimed to detect a potential difference in electroacupuncture- induced analgesia between juvenile and adult rats. Methods: In this study, we investigated the effects of electroacupuncture treatment on the nociceptive jaw-opening reflex evoked by tooth-pulp stimulation in juvenile and adult rats. Results: Our results showed there were age differences in electroacupuncture-induced analgesic effects in rats, especially with naloxone antagonization. The ratio of naloxonereversibility against electroacupuncture analgesia was greater in adult rats than in juvenile rats. Conclusion: These results suggest that electroacupuncture analgesia is produced mainly by the non-opioid system in juvenile rats and by the opioid system in adult rats.

    Abstract
  • Research Article2021-06-30

    Identification of Cleaved Haptoglobin in the Serum of Bee Venom-Hypersensitive Patients

    Jae-Min Ryu1, Han-Heom Na1, Jin-Sung Park2, Byung-Soo Ahn2,3, Keun-Cheol Kim1,*
    J Acupunct Meridian Stud 2021; 14(3): 102-109 https://doi.org/10.51507/j.jams.2021.14.3.102

    Abstract : Background: Bee venom has been used as a therapeutic compound for various human diseases in oriental medicine; however, it can induce anaphylaxis in hypersensitive patients during treatment. Anaphylaxis is an acute allergic reaction that occurs after allergen exposure. IgE is released from immune-related cells such as mast cells and basophils during anaphylaxis. Various inflammatory mediators are also released into the bloodstream during the acute response. Objectives: We aimed to identify specific proteins from bee venom-hypersensitive patients. Methods: We analyzed the blood serum of control and bee venom-hypersensitive patients using two-dimensional (2D) electrophoresis. Results: An interesting protein spot with a molecular size of 10 kDa was identified at an isoelectric point (p.I.) of 5.5. Spots detected both before and after sweet bee venom therapy were not proteins induced by sweet bee venom. The 10 kDa protein was identified as the cleaved form of haptoglobin through liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Statistical analysis indicated that the presence of the spot was highly significant in the bee venom-hypersensitive group. Conclusion: The findings suggest that cleaved haptoglobin may be a significant diagnostic protein for anaphylaxis. In addition, a high incidence of bee venom hypersensitivity may be associated with the haptoglobin genotype.

    Abstract
  • Case Report2022-06-30

    Warm Cupping of the Posterior Thorax in Combination with Standard Conventional Therapy for ARDS in COVID-19 Patients in ICU: a Case Series

    Mehrdad Karimi1, Amir Hooman Kazemi1,2, Asma Asadi3, Azadeh Zarei1, Arman Zargaran4, Seyed Ali Al-hadi Moravej5, Seyede Ferdos Jazayeri5, Omid Nabavian6, Seyedeh Aida Ahmadi6, Reihane Alipour1,*
    J Acupunct Meridian Stud 2022; 15(3): 194-200 https://doi.org/10.51507/j.jams.2022.15.3.194

    Abstract : Acute respiratory distress syndrome (ARDS) is commonly found in critically ill patients with coronavirus disease 2019 (COVID-19). As a non-pharmacological treatment of complementary and alternative medicine (CAM), cupping has been clinically used for respiratory symptoms. We sequentially identified a series of patients with COVID-19 with ARDS who were admitted to the intensive care unit (ICU). Warm cupping of the posterior thorax was performed for seven days. We collected longitudinal severity scores on cough, breathlessness, chest tightness, type of oxygen therapy, and oxygen saturation (SpO2). We hereby report the changes in the severity scores in a series of eight patients who received 21 sessions of cupping in addition to conventional treatments. All patients reported improvement in symptom scores that was matched by an increase in SpO2 by as much as 3.16%. All patients were discharged and did not require the use of a mechanical ventilator. The results suggest that combining cupping with conventional treatment may provide a good prognosis for patients with COVID-19 with ARDS.

    Abstract
  • Research Article2022-06-30

    Postoperative Acupuncture is as Effective as Preoperative Acupuncture or Meloxicam in Dogs Undergoing Ovariohysterectomy: a Blind Randomized Study

    Ana Carla Zago Basilio Ferro1, Caroline Cannolas2, Juliana Cristianini Reginato2, Stelio Pacca Loureiro Luna1,*
    J Acupunct Meridian Stud 2022; 15(3): 181-188 https://doi.org/10.51507/j.jams.2022.15.3.181

    Abstract : Background: Acupuncture has the same analgesic effect as non-steroidal antiinflammatory drugs and opioids. It is challenging to perform preoperative acupuncture in unmanageable animals, while the residual postoperative anesthetic effect facilitates the performance of acupuncture postoperatively.Objectives: To compare preoperative acupuncture or meloxicam versus postoperative acupuncture for postoperative analgesia after ovariohysterectomy.Methods: This is a horizontal prospective positive control blind randomized experimental study. Thirty-six dogs were randomly divided into three groups: GA (preemptive acupuncture), GPA (postoperative acupuncture), and GM (meloxicam 0.2 mg/kg IV preoperatively). After sedation with acepromazine (0.05 mg/kg IM), anesthesia was induced with propofol (5.3 ± 0.3 mg/kg) and maintained with isoflurane/O2. Fentanyl (2 μg/kg, IV) was administered immediately before surgery. Bilateral acupuncture was performed at acupoints Large intestine 4, Spleen 6, and Stomach 36 for 20 minutes, before (GA) or immediately after surgery (GPA). Pain was evaluated by an observer blind to the treatment using the Glasgow scale before and for 24 hours after ovariohysterectomy. Dogs with a score ≥ 6 received rescue analgesia with morphine (0.5 mg/kg IM). Nonparametric data were analyzed by the Kruskal–Wallis test, followed by Dunn’s test and parametric data by ANOVA followed by Tukey’s test.Results: Two GA and one GPA dogs received rescue analgesia once. Two GM dogs received rescue analgesia and one of those was treated again twice. There were no differences in the number of dogs receiving rescue analgesia between groups (p = 0.80).Conclusion: Postoperative acupuncture was as effective as preoperative acupuncture or meloxicam in female dogs undergoing ovariohysterectomy.

    Abstract
  • Research Article2022-06-30

    Temperature Characteristics of Traditional Indirect Moxibustion and Electronic Moxibustion

    Dong-Joo Kim1, Hyo-Rim Jo2, Hansol Jang3, Seong-Kyeong Choi2, Chan-Yung Jung4, Won-Suk Sung2, Seung-Deok Lee5, Byung-Wook Lee6, Eun-Jung Kim2,*
    J Acupunct Meridian Stud 2022; 15(3): 174-180 https://doi.org/10.51507/j.jams.2022.15.3.174

    Abstract : Background: Electronic moxibustion (EM) was developed to minimize the side effects of traditional moxibustion, such as burns, and to overcome therapeutic compliances such as smoke or smell.Objectives: To investigate distributions and thermal stimulation of EM at various depths using silicon phantom and to compare this methodology to traditional indirect moxibustion (TIM).Methods: A silicon phantom composed of polydimethylsiloxane was heated and immersed in a hot plate containing warm water to set the phantom’s temperature to that of biological tissue. K-type thermocouples were inserted into the phantom at depths of 0, 2, 5, 7, and 10 mm to measure temperature changes with thermal stimulation of EM or TIM placed on top of the phantom.Results: At the surface of the phantom, the peak temperature after applying TIM (55.04 ± 0.92℃ [Δ23.79 ± 0.96℃]) was significantly higher than after EM (43.25 ± 1.95℃ [Δ13.00 ± 2.23℃]), with both interventions reaching the highest temperature after 2 minutes. The temperature increase for TIM was also statistically significant compared to EM when measured at a depth of 2 mm. For the experimental setting with TIM, after reaching peak surface temperature, a rapid decrease was observed at the surface and 2 mm while EM showed a much more gradual decline. There was no significant difference in temperature change between the groups at depths of 5, 7, and 10 mm.Conclusion: TIM resulted in a higher temperature rise compared to EM at the surface and at a 2 mm depth reaching over 50℃, which creates risk of burns. Thermal stimulation with EM had a lower risk of burns with temperature increment not being statistically different from TIM below the depth of 5 mm.

    Abstract
  • Abstract : Background: The primo vascular system can be viewed as a circulatory system that plays a therapeutic function in regenerating the body tissue. The anti-CD3 monoclonal antibody was used as an immunotherapeutic agent to treat the novel coronavirus infection (COVID-19). Objectives: In this study, we observed the effect of injecting lymph nodes with Foralumab, an anti- human CD3 epsilon therapeutic monoclonal antibody, on primo vessels. Methods: The structure and atomic stoichiometry of the antibody were determined by transmission electron microscopy and energy dispersive spectroscopy. Alcian blue dying solution was injected into the lymph nodes of the abdominal vena cava of rabbits, and the solution further flowed into the lymph vessels. Results: A primo vessel with primo nodes stained with Alcian blue was clearly visible in the lymph vessel. By injecting Foralumab into lymph nodes of rabbits with lipopolysaccharide-induced inflammation, the floating primo vessel in the lymph vessel appeared thicker and was distinctly visible. Conclusion: The observation of the primo vessel post-treated with Foralumab in the inflamed lymphatic system suggests the possibility of a functional role of the primo vascular circulatory system in pathophysiological conditions.

    Abstract
  • Research Article2022-08-31

    Effects of Acupuncture in the Treatment of Dogs with Neurological Sequels of Distemper Virus

    Bianca P. C. R. Santos1, Jean G. F. Joaquim2, Renata Navarro Cassu3,*, José C. F. Pantoja1, Stelio Pacca Loureiro Luna1
    J Acupunct Meridian Stud 2022; 15(4): 238-246 https://doi.org/10.51507/j.jams.2022.15.4.238

    Abstract : Background: Acupuncture (AP) has been empirically used to relieve post-canine distemper virus (CDV) infection neurological signs in veterinary clinics.Objectives: This clinical study aimed to investigate the effects of AP combined with electroacupuncture (EA) on neurological function in dogs infected by CDV.Methods: Twenty-four CDV-infected dogs with neurological sequelae were recruited to receive weekly AP/EA sections for 24 weeks. Neurological improvements were assessed before each AP/EA session using a modified scoring system. Data were analyzed using the McNemar test, Friedman test, Fisher's exact test, and Kaplan-Meier curves (p < 0.05).Results: Neurological scores improved from seven to 24 weeks after AP/EA treatment compared with pretreatment scores (p < 0.001). Significant improvements were recorded over time for functional limb recovery, cranial nerve deficits, mental status (p = 0.025 – 0.014), and urinary function (p < 0.001). Myoclonus was improved and entirely reversed in 75% and 25% of the dogs, respectively. At the end of treatment, the proportion of dogs with normal proprioception, posture, hopping (p < 0.001), and superficial pain sensation responses (p = 0.004) was greater than pretreatment values.Conclusion: AP/EA therapy promoted significant neurological recovery in CDV-infected dogs and may be considered within the chronic phase of the disease to improve motor and sensory rehabilitation. However, these results are preliminary and must be confirmed by further investigations.

    Abstract

Journal Info

JOURNAL OF MICROBIOLOGY AND BIOTECHNOLOGY
December, 2022
Vol.15 No.6

pISSN 2005-2901
eISSN 2093-8152

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  • Clinical Study Protocol2021-12-31

    Effects of Dry Needling on Connectivity of Corticospinal Tract, Spasticity, and Function of Upper Extremity in People with Stroke: Study Protocol for a Randomized Controlled Trial

    Masoome Ebrahimzadeh1, Noureddin Nakhostin Ansari2,3, Iraj Abdollahi1,*, Behnam Akhbari1, Saeideh Monjezi4
    J Acupunct Meridian Stud 2021; 14(6): 238-243 https://doi.org/10.51507/j.jams.2021.14.6.238

    Abstract : Background: Spasticity is a common motor disorder in adult stroke patients. Injury to the corticospinal tract (CST) is associated with spasticity. Dry needling (DN) has positive impacts on spasticity reduction and improvement in the range of motion (ROM) in stroke patients. This study aims to investigate the effectiveness of DN on the connectivity of the CST and the level of spasticity in adult stroke patients. Methods: This double-blind randomized controlled trial will enroll and randomly assign stroke patients to either the experimental group, for receiving three sessions of DN for the spastic wrist flexors, or the control group, for sham needling. The primary outcome measures will be diffusion tensor imaging and the Modified Modified Ashworth Scale score to assess CST connectivity and wrist flexor spasticity, respectively. The Box and Block Test and standard goniometry are the secondary outcome measures to assess hand dexterity and active and passive wrist ROM, respectively. Measurements will be taken both before and after the intervention. Discussion: The results of this study will provide important evidence of the effects of DN on CST connectivity, spasticity, and arm function in adult stroke patients. Trial registration: This trial is registered in the Iranian Registry of Clinical Trials (IRCT) (https://www.irct.ir; IRCT20191208045649N1).

    Abstract
  • Research Article2021-10-31

    Comparison of the Effects of Electroacupuncture and Melatonin on Nerve Regeneration in Experimentally Nerve-Damaged Rats

    Yasemin Özkan1,*, Mehmet Turgut2, Yasemin Turan1, Mehmet Dinçer Bilgin3, Sinem Sari4, Mustafa Yilmaz3, Yiğit Uyanikgil5, Mahmut Alp Kiliç3, Derya Tanriöver5, Zehra Seznur Kasar1
    J Acupunct Meridian Stud 2021; 14(5): 176-182 https://doi.org/10.51507/j.jams.2021.14.5.176

    Abstract : Background: Development of methods to accelerate nerve regeneration in peripheral nerve damage is important. Electroacupuncture is a new therapeutic method that combines traditional acupuncture with modern electrotherapy. Melatonin has been shown to reduce nerve damage. Objectives: In this study, we aimed to determine and compare the therapeutic effects of electroacupuncture and melatonin on rat sciatic nerve injury. Methods: A total of 56 adult male Wistar Albino rats were divided into four study groups with 14 animals in each group: intact control (group I), subcutaneous saline (group II), subcutaneous melatonin (group III), and electroacupuncture (group IV). Surgical procedure including unilateral (right) sciatic nerve injury was applied to groups II, III, and IV. Saline and melatonin started immediately after surgery for six weeks, while electroacupuncture was given two weeks after surgery for 3 weeks. Functional and histological assessments were used as outcome measurements. Results: Sciatic nerve damage caused a significant decrease in nerve conduction velocity. Both electroacupuncture treatment and melatonin treatment significantly increased the nerve conduction velocity. Both sciatic functional recovery and histological regeneration were faster in these treatment groups compared to the saline. However, no significant difference was observed between the two treatment groups. Conclusion: Electroacupuncture and melatonin are promising alternative treatment strategies for peripheral nerve damage and can be examined in detail in future studies.

    Abstract
  • Perspective Article2022-08-31

    Correlation Between the Sinew Channels with the Myofascial System, Pathology, and Treatment

    Pablo Nava Jaimes*, Alejandro Martínez Reyes, Daniel García Lara, Abel Cristian Patiño Coyuca
    J Acupunct Meridian Stud 2022; 15(4): 201-213 https://doi.org/10.51507/j.jams.2022.15.4.201

    Abstract : The sinew channels are a tendon and muscle network, and their description is based on the observation presented on the Huangdi Neijing Ling Shu. However, the myofascial system is an uninterrupted series of connective tissue that is comprised of layers that run in different directions. The similarities on these pathways are compared, such as a brief description on the myofascial pain syndrome and its similitude with the Impediment disorder from the Traditional Chinese Medicine (TCM). Furthermore, we discuss the treatment of these conditions from a Traditional Chinese Medicine perspective.

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  • Review Article2022-02-28

    The Cellular Architecture of the Primo Vascular System

    Fatma El-Zahraa A. Mustafa*
    J Acupunct Meridian Stud 2022; 15(1): 4-11 https://doi.org/10.51507/j.jams.2022.15.1.4

    Abstract : The primo vascular system (PVS) is of great interest to scientists in the last few years. The PVS plays a role in stem cell migration, immune function, erythropoiesis, tissue regeneration, and cancer metastasis. Discovered by Bong Han Kim in 1960, the PVS was described as a new, independent system that is distributed in the body of different animals. Since then, several cells have been discovered as important constituents of the PVS. Endothelial cells are hallmarks for the identification of the PVS, as they line the sinuses of the primo vessels and are characterized by their arrangement of rod-shaped nuclei in a parallel, broken-line fashion along the primo vessels. Immune cells as mast cells, eosinophils, neutrophils, and lymphocytes are also hallmarks for the identification of the PVS. One of the most interesting cells in the PVS are p-microcells. Primo nodes are a stem cell niche due to their p-microcells content, which express stem cell biomarkers CD133 and Oct 4. Mature erythrocytes and hematopoietic stem cells have also been observed in the PVS. Hematopoietic stem cells were observed in the PVS. Hematopoietic Stem Cells are the source of the cellular component of blood. Additionally, adrenaline and noradrenaline-producing cells, mesothelial cells, and smooth-muscle-like cells have also been described in the PVS.

    Abstract
  • Research Article2021-10-31

    Abstract : Background: Despite the adherence to medications, the control of the modifiable key risk factor—intraocular pressure (IOP)—for the progression of primary open-angle glaucoma (POAG) in diabetics is usually difficult; hence, many glaucoma patients try other alternative therapeutic options. Objectives: This randomized controlled study investigated the short-term IOP response to the combined effects of transcutaneous electrical nerve stimulation over acupoint (Acu-TENS) and yoga ocular exercise in type 2 diabetics with POAG. Methods: Eighty diabetics with bilateral POAG, ages ≥ 50 years, IOP > 21 mmHg in both eyes, and a body mass index below 30 kg/m2 were included in this trial. The patients were randomly assigned to group A (n = 40; this group received 20 minutes of yoga ocular exercise followed by 20 minutes of active Acu-TENS over bilateral BL 61 and BL 62 acupoints) and group B (n = 40; this group received the same protocol as group A but with a placebo Acu-TENS). The repeated measurement of IOP were recorded before, immediately after, 30 minutes, and 60 minutes after the sessions. Results: The repeated measures analysis of variance revealed a greater significant decline of IOP in group A than group B in both eyes at the consecutive intervals of time measurements. Conclusion: According to this short-term observation, the addition of Acu-TENS to yoga ocular exercise could reduce the high IOP in diabetic patients with POAG, but further longterm trials are needed.

    Abstract
  • Research Article2021-12-31

    Effects of Joint Mobilization Versus Acupuncture on Pain and Functional Ability in People with Chronic Neck Pain: A Randomized Controlled Trial of Comparative Effectiveness

    Petros Voulgarakis, Paris Iakovidis, Dimitrios Lytras*, Ioanna P. Chatziprodromidou, Anastasios Kottaras, Thomas Apostolou
    J Acupunct Meridian Stud 2021; 14(6): 231-237 https://doi.org/10.51507/j.jams.2021.14.6.231

    Abstract : Background: Chronic Neck Pain (CNP) is one of the main contributing factors to disability in people of working age.Objectives: The aim of this randomized clinical trial was to compare the efficacy between acupuncture and joint mobilization on pain and disability in patients with CNP. Methods: The study involved 45 men and women with CNP, divided into three groups of 15 each. The first group followed a manual therapy protocol with joint mobilization for eight weeks three times per week. The second group followed an acupuncture protocol of equal duration and frequency, while the third group did not follow any treatment. Pain with the Visual Analog Scale (VAS) for pain and functional limitations with the Neck Disability Index (NDI) questionnaire were assessed before and after an 8-week intervention. Analysis of variance was applied while post-hoc comparisons were made to determine the differences among the groups at each time of measurement. Results: Both intervention groups showed statistically significant differences compared to the control group after the end of the intervention in both the VAS and the NDI scores (p< .001). Furthermore, the acupuncture group showed a statistically significant improvement compared to the joint mobilization team after the end of the intervention in the VAS score (p< .001) and the NDI score (p< .05). Conclusion: Both joint mobilization and acupuncture appear to be effective interventions in reducing pain and improving functional ability in people with CNP. However, acupuncture appears to have a greater analgesic effect than joint mobilization.

    Abstract
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