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Clinical Study Protocol

J Acupunct Meridian Stud 2024; 17(5): 178-186

Published online October 31, 2024 https://doi.org/10.51507/j.jams.2024.17.5.178

Copyright © Medical Association of Pharmacopuncture Institute.

Electroacupuncture Protocol for Sensory and Motor Function Recovery After Orthognathic Surgery: a Randomized Clinical Trial

Itana Lisane Spinato1 , Taisi da Cunha Antunes2 , Fabiano Politti2 , Ruth Ellen Nogueira Izidio3 , Daniela Aparecida Biasotto-Gonzalez2 , Delane Viana Gondim1,*

1Postgraduate Program in Morphofunctional Sciences, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
2Postgraduate Program in Rehabilitation Sciences, Ninth of July University, São Paulo, São Paulo, Brazil
3Undergraduate Student, Physiotherapy Course, Estácio University Center, Fortaleza, Ceará, Brazil

Correspondence to:Delane Viana Gondim
Postgraduate Program in Morphofunctional Sciences, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
E-mail delane@ufc.br

Received: March 27, 2024; Revised: June 6, 2024; Accepted: October 2, 2024

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Importance: Orthognathic surgery is utilized to rectify facial deformities, but it can lead to neurosensory alterations. Electroacupuncture has been shown to enhance sensitivity and motor functions in patients post-surgery. However, its application in traumatic facial injuries remains inadequately researched.
Objective: To investigate the effects of electroacupuncture on sensitivity and orofacial function in patients undergoing orthognathic surgery.
Design, Setting, and Population: A randomized clinical trial involving patients undergoing bimaxillary orthognathic surgery and genioplasty who are randomly allocated to either a physiotherapy (PT) or physiotherapy plus electroacupuncture group (PTEA).
Exposures: Participants will be allocated to their respective therapies for a duration of six weeks. The PT group will receive a 50-minute physical therapy session along with 30 minutes of simulated procedure. The PTEA group will receive 50 minutes of physical therapy followed by 30 minutes of electroacupuncture.
Main Outcomes and Measures: Before treatment, sensitivity will be assessed using the SMILE Sensitivity Test-BAURU kit, edema will be evaluated using the MD Anderson Cancer Center Head and Neck Lymphedema protocol, range of motion will be measured using a digital caliper, and muscle pain and fatigue will be gauged using numerical scales. The chewing function will be evaluated using the Chewing Quality Assessment Questionnaire.
Results: All assessments will be repeated at three and six months following the initiation of treatment.
Conclusions and Relevance: This study may provide reliable and high-quality clinical evidence regarding the impact of electroacupuncture on restoring altered sensation and motor function in patients undergoing orthognathic surgery.

Keywords: Clinical protocol, Electroacupuncture, Motor function, Orthognathic surgery, Paresthesia

INTRODUCTION

Orthognathic surgery is commonly employed to correct facial deformities and craniofacial disorders [1-3]. The main objective of these procedures is to enhance facial esthetics, restore chewing function, and align dentofacial structures [4,5]. However, postoperative recovery is influenced by factors such as surgery time, complications (undesirable fractures and bleeding), and immediate postoperative care, presenting challenges for patients. Complications are often associated with changes in sensitivity in the orofacial region, such as numbness, tingling, and hypersensitivity [6-8].

Despite advancements in orthognathic surgery, fundamental issues and gaps in knowledge persist regarding patient recovery post-surgery, particularly concerning changes in sensitivity [9-11]. Changes in sensitivity caused by inferior alveolar nerve injury are common complaints among patients who have undergone similar surgical procedures, and therapeutic resources for recovering sensitivity in such cases remain scarce [12-14].

Electroacupuncture is a traditional Chinese medicine treatment that utilizes electrical stimulation at specific acupuncture points. This stimulation aims to improve tissue response beyond what is achieved with manual needling [7]. The goal is to substantially improve neurological and motor functions in patients experiencing altered sensitivity. However, limited research exists on its application in treating traumatic facial injuries [15-18].

This study hypothesizes that electroacupuncture positively impacts the recovery of facial sensitivity and motor function, leading to improvements in quality of life and orofacial function in patients who have undergone bimaxillary orthognathic surgery with genioplasty. This paper describes the protocol for a clinical trial to investigate the effect of electroacupuncture on orofacial sensitivity and motor function in patients undergoing bimaxillary orthognathic surgery with concomitant genioplasty to correct orofacial deformities.

METHODS

1. Study design

A randomized clinical trial will be conducted in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT statement, 2013) guidelines to investigate the effect of electroacupuncture on the recovery of facial sensitivity and orofacial function in patients undergoing bimaxillary orthognathic surgery and genioplasty.

2. Ethical aspects and informed consent

The Research Ethics Committee of the Federal University of Ceará approved this study protocol (protocol number: 30725720.7.0000.5054; approval number: 4.505.894). Additionally, the clinical study protocol was registered on ClinicalTrials.gov under the protocol number: NCT05310019. Before data collection, all volunteers who agreed to participate in the study will be required to provide written informed consent (Supplementary Material 1). The participants may withdraw from the study at any time without providing justification and without facing penalties. All participants will obtain detailed descriptions of the assessments and treatment.

3. Study population

The population will include young adults in the postoperative phase following bimaxillary orthognathic surgery and genioplasty intended to correct dentofacial deformities, provided they meet the eligibility criteria.

4. Eligibility criteria

Individuals aged 18 to 50, both male and female, undergoing bimaxillary orthognathic surgery with genioplasty and experiencing postoperative paresthesia within the first to fourth week post-surgery, will be eligible for inclusion upon providing informed consent. Additionally, participants must have at least 24 teeth in the oral cavity, exhibit class II or III skeletal malocclusion diagnosed using cephalometric radiographs, and have undergone surgery within one to four weeks prior to the commencement of physiotherapy care. Individuals with the following conditions will be excluded from the study: cleft lip or palate, prior orthopedic or rheumatological diseases affecting the face (e.g., fractures, facial paralysis, systemic lupus erythematosus), neurological alteration resulting from facial or trigeminal nerve injury or compression, chronic lymphedema, current or past oncological treatment, vascular abnormalities in the facial region, past surgeries of the face (e.g., bichectomy and surgery of the temporomandibular joint, excluding tooth extraction without associated nerve impairment), or if they are undergoing or have undergone other surgeries along with orthognathic surgery. Additionally, patients receiving botulinum toxin for temporomandibular disorder treatment or esthetic reasons and those experiencing postoperative complications, such as infection, will also be excluded.

5. Procedures

The study will be conducted at the Teaching Clinic of Estácio University Center. Patient recruitment will occur at the Oral and Maxillofacial Surgery and Traumatology service of Walter Cantídio University Hospital at the Federal University of Ceará.

Eligible participants will receive both oral and written explanations about the study. A stratified randomization process will be conducted before the therapeutic intervention to allocate participants to either the physiotherapy (PT) group, serving as the control group, or the physiotherapy plus electroacupuncture (PTEA) group, serving as the intervention group. Participants will be directed to refrain from any additional treatments during the interventions.

Access to the trial dataset will be restricted until the study’s conclusion. Study information will be securely stored, with participant data kept in closed files in restricted-access areas. Data will be entered into a password-protected computer in numerical sequence. Data entry will be conducted twice to ensure accuracy and identify any potential inconsistencies or omissions.

For clarity and organization, the study schedule will adhere to the SPIRIT (Fig. 1) and STRICTA guidelines [19], with principles outlined according to the Consolidated Standards of Reporting Trials (CONSORT) (Fig. 2) [20].

Figure 1. SPIRIT schematic diagram of study schedule. SPIRIT, standard protocol itens: recommendations for interventional trial: –t1 = pre-study, screening/consent; t0 = pre-study, baseline/randomization; t1–t6 = study, intervention period; t7 = tree-months follow-up; t8 = six-months follow-up.
Figure 2. Flowchart of study (CONSORT). SA = sensitivity assessment; MMO = maximum mouth opening; AFS = assessment of facial swelling; NPRS = numeric pain-rating scale; FA = fatigue assessment; ACQ = assessment of chewing quality.

6. Randomization

A stratified block randomization process will be conducted before the therapeutic intervention to assign treatments, taking into account the post-surgical period (participants can arrive between the first and fourth week after surgery) and gender. Randomization will be performed using Microsoft Excel 2010 by a research team member not involved in recruitment or assessment (DABG). Blocked randomization is necessary, with each block representing the time elapsed since surgery (one to four weeks before treatment) and gender, and containing a predetermined number of participants. For example, each block will have an equal number of participants allocated to intervention (A) and control (B) groups, with treatment order randomly permuted within each block. Random permutation ensures equitable allocation of participants across each block [21].

Randomization will take into account the start of the study protocol, which occurs between one and four weeks postoperatively, along with the participants’ gender. Participants will be assessed by a second researcher (FP). Participants will not be informed of the particulars of the specific treatment to which they are allocated. To minimize potential biases, the researcher responsible for outcome assessment will be blinded to the allocation of participants to the different groups. Similarly, the statistician conducting the analyses will be blinded to the participant allocation, ensuring a bias-free objective analysis.

7. Sample size

A previous survey determined that during 2018 and 2019, each year 94 patients underwent orthognathic surgery at the Oral and Maxillofacial Surgery and Traumatology Service of the university hospital. Using the criterion of the annual average of patients undergoing orthognathic surgery (finite sample = 184 patients, confidence interval = 95%, population proportion = 50%, and error = 5%), the required sample size was determined to be 60 patients per group (total sample: 120 patients).

Following the CONSORT checklist, the researcher must specify the number of participants in the study to satisfactorily achieve the objectives. In cases of withdrawal, non-compliance, or missing data, intention-to-treat analysis will be conducted.

8. Intervention

After completing the assessment chart using socio-epidemiological data, the participant will undergo the facial assessment. This evaluation will include measurement of edema, sensitivity, mandibular range of motion, and the patient’s subjective perception of pain intensity, stiffness of the face, and muscle fatigue. These measurements will be repeated at the beginning of each session. Both groups will receive six physiotherapy sessions, regardless of their admission period to the study, between the first and fourth postoperative weeks or their postoperative condition. The sessions will occur once a week for six weeks.

In the control group, physiotherapy sessions will last 50 minutes. In the intervention group, each physiotherapy session will also last 50 minutes, supplemented by 30 minutes for electroacupuncture treatment. This approach will assess whether the inclusion of electroacupuncture treatment enhances sensory and motor recovery in patients compared to those undergoing only physiotherapy.

After completing the six sessions, chewing function will be assessed. All measurements will be repeated at three- and six-month intervals post-treatment. The study protocols will be administered by a physiotherapist or acupuncturist with substantial clinical experience, and no variations will be permitted.

9. Physiotherapy protocol (control group)

The physiotherapy protocol will be divided into six sessions:

1st session (for participants in the first week of the postoperative period):

Initial assessment. Warm compress with thermal facial cloth (5 min); mobility training of respiratory muscles and relaxation of neck muscles (5 min); facial lymphatic drainage (25 min); myolymphokinetic exercises for orbicular muscles of the mouth, zygomaticus major and minor muscles, the elevator of the upper lip, and the ala of the nose, buccinator, and platysma (15 min).

2nd session (for participants in the second week of the postoperative period):

Initial assessment. Warm compress with thermal facial cloth (5 min); mobility training of respiratory muscles and relaxation of neck muscles (5 min); facial lymphatic drainage (15 min); myolymphokinetic exercises for orbicular muscles of the mouth, zygomaticus major and minor muscles, the elevator of the upper lip, and the ala of the nose, buccinator, and platysma (15 min); and vacuum therapy at 60 mmHg (5 min).

3rd session (for participants in the third week of the postoperative period):

Initial assessment. Warm compress with thermal facial cloth (5 min); intraoral inspection and release of adherences (10 min); free active exercises of mandibular movements to the left and right sides, mandibular protrusion, and mouth opening (15 min); myolymphokinetic exercises for orbicular muscles of the mouth, zygomaticus major and minor muscles, the elevator of the upper lip, and the ala of the nose, buccinator, and platysma (10 min); and vacuum therapy at 60 mmHg (10 min).

4th session (for participants in the fourth week of the postoperative period):

Initial assessment. Warm compress with thermal facial cloth (5 min), intraoral inspection and release of adherences (5 min); free active exercises of mandibular movements to the left and right sides, mandibular protrusion, and mouth opening (10 min); maintenance of mouth opening with wooden tongue depressors (20 min); myolymphokinetic exercises for orbicular muscles of the mouth, zygomaticus major and minor muscles, the elevator of the upper lip, and the ala of the nose, buccinator, and platysma (15 min); and vacuum therapy at 60 mmHg (5 min).

5th and 6th sessions (for participants in the fifth and sixth weeks of the postoperative period):

Initial assessment. Warm compress with a thermal facial cloth (5 min); intraoral inspection and release of adherences (5 min); free active exercises of mandibular movements to the left and right sides, mandibular protrusion, and mouth opening (10 min); maintenance of mouth opening with wooden tongue depressors (20 min); myolymphokinetic exercises for orbicular muscles of the mouth, zygomaticus major and minor muscles, the elevator of the upper lip, and the ala of the nose, buccinator, and platysma (10 min). Reassessment of all parameters.

Patients who begin physiotherapy four weeks after surgery will follow the same protocol described for the fifth and sixth sessions throughout all six sessions, starting from the fifth week onward.

10. Electroacupuncture protocol (intervention group)

Participants in this group will undergo the same 50-minute physiotherapy protocol as those in the control group, followed by 30 minutes of electroacupuncture using an eight-channel electrostimulator (model EL-608 V2; brand: NKL). This device generates low-intensity pulsed electrical stimuli to sensitize transcutaneous acupuncture points using the following parameters: electrostimulation time: 30 min; repetition time: 1 seg; (F1 = 10 Hz, F2 = 45 Hz; 10 mA). Stimulation will first be tested on the right forearm, where the participant will have a normal, sensitive response to ensure that the intensity does not exceed the patient’s tolerance. After disinfecting the skin with 70% alcohol, disposable stainless-steel acupuncture needles with a size adapted to the face [caliber: 0.25 mm; length: 15 mm (DBC, Dong Bang Acupuncture, Korea)] will be used. The needles will be inserted completely (15 mm) without aiming to obtain qi or muscular contraction.

This procedure has been approved by the National Health Surveillance Agency (ANVISA). Needles will be inserted into the acupoints as indicated in Fig. 3. Nine needles will be used, with eight connected to electrodes. Electrical stimulation will be bilaterally applied to five traditional Chinese medicine facial acupoints per session: ST4 (stomach 4), jiachengjiang (extra acupoint – HN19), ST5 (stomach 5), and ST6 (stomach 6). The CV24 (conception vessel 24) acupoint will only receive needling without electrical stimulation. All patients will undergo an identical protocol for electroacupuncture, and the selected points will remain the same.

Figure 3. Acupuncture points that received electrical stimulation with needles. Parameters: F1 = 10 Hz, F2 = 45 Hz; repetition time = 1 sec.; 10 mA; 30 min. Acupoints: ST4 (stomach 4), jiachengjiang (extra point), ST5 (stomach 5), ST6 (stomach 6). The CV24 (conception vessel 24) acupoint received only needling (0.25 × 15 mm). Source of the figure: artificial intelligence CANVA.

11. Outcome measures

The primary outcomes will include sensitivity, edema, mandibular range of motion, pain, fatigue during speech, and chewing quality. Assessments will occur at the start of each session and at three and six months following the conclusion of treatment.

1) Sensitivity assessment

The SMILE Sensitivity Test-BAURU kit will be used for sensitivity assessment, employing Semmes–Weinstein monofilaments [22-24]. This method comprises six filaments of varying colors and progressively increasing thicknesses. Each filament exerts uniform pressure on the application site. When the calibrated pressure is reached, the filament bends, indicating that no further stimulus is applied in the area under investigation. Thicker filaments exert greater pressure. Participants are more likely to detect thinner filaments in cases of milder nerve injury. During the test, participants will be blindfolded and instructed to raise a hand upon perceiving the touch of the filament. The assessor will begin with filaments of smaller diameter and replace them with progressively thicker filaments if the participant fails to feel the touch.

The facial region analyzed corresponds to areas innervated by the branches of the trigeminal nerve—maxillary nerve and mandibular nerve. Fig. 4 shows the points for sensitivity assessment. The distance between points will be 2 cm, originating from the midline of the face and extending distally along three lines that are parallel to the floor in the cephalocaudal direction: (1) Line 1 extends from the ala of the nose to the tragus, marking points 1P1, 1P2, and 1P3; (2) Line 2 extends from the labial commissure to the earlobe, marking points 2P1, 2P2, and 2P3; (3) Line 3 extends from the central region of the chin to the angle of the mandible, marking points 3P1, 3P2, 3P3, 3P4, and 3P5; (4) Regarding the lips, points will commence at the center of the upper lip (L1) and proceed around the mouth toward the patient’s left at a distance of 1 cm between points. Point L2 is located on the left portion of the upper lip, L3 on the left portion of the lower lip, L4 at the center of the lower lip, L5 on the right portion of the lower lip, and L6 on the right portion of the upper lip.

Figure 4. Points for assessing sensitivity. Points located between ala of nose and tragus (1P1, 1P2, 1P3), between lip commissure and earlobe (2P1, 2P2, 2P3), between central region of chin and angle of mandible (PM, 3P1, 3P2, 3P3, 3P4 and 3P5) and points on upper and lower lips (L1, L2, L3, L4, L5 and L6) to investigate sensitivity (Semmes-Weinstein monofilament; SMILE Sensitivity Test- BAURU). Source of the figure: artificial intelligence CANVA.

2) Assessment of functioning

The assessment of the face will take into account the presence of edema, mandibular range of motion (mouth opening and lateral excursions), the patient’s perceptions of pain intensity, muscle stiffness, and fatigue during speech, along with an analysis of chewing function.

Edema will be measured using a flexible metric tape following the facial composition of the MD Anderson Cancer Center Head and Neck Lymphedema protocol [25,26], which has been validated in the Portuguese language [27]. Measurements will be taken during the initial assessment and repeated before each session by an assessor who has undergone training and calibration exercises. The measurement unit will be centimeters (cm). The following measurements will be taken (Fig. 5):

Figure 5. Swelling assessment. Face measurements were taken using a measuring tape in centimeters following the facial composition of the MD Anderson Cancer Center Head and Neck Lymphedema protocol (MDACC HNL). L1 = Tragus to mental protuberance. L2 = Tragus to labial commissure. L3 = angle from the mandible to the nasal ala. L4 = angle from the jaw to the inner corner of the eye. L5 = angle from the jaw to the outer corner of the eye. L6 = mental protuberance at the inner corner of the eye. Source of the figure: artificial intelligence CANVA.

(1) Tragus to mentum

(2) Tragus to the labial commissure

(3) Angle of the mandible to the ala of the nose

(4) Angle of the mandible to the inner corner of the eye

(5) Angle of the mandible to the outer corner of the eye

(6) Mentum to the inner corner of the eye

(7) Angle of the mandible to mentum

3) Assessment of mandibular range of motion

Mandibular movements will be measured using digital calipers (WESTERN – ref DC 6). Mouth opening will be determined by the distance between the right maxillary and mandibular incisors. Lateral excursions to the right and left sides will also be measured [28,29].

4) Assessment of pain intensity and fatigue when speaking

The patient’s perception of pain intensity and fatigue when speaking will be assessed using numerical scales from zero to ten, with zero indicating the absence of pain or fatigue and ten indicating the maximum intensity of these sensations [30,31].

5) Assessment of chewing function

The chewing function will be evaluated using the Chewing Quality Assessment Questionnaire, which has been validated in Portuguese [32-34]. The questionnaire comprises 26 objective questions designed to assess food choices based on chewing capacity over the previous two weeks. It is divided into the following domains: eating-chewing; habits; meats; fruits and vegetables.

12. Data collection and analysis

The database will be created in EpiData 3.0 and analyzed using the STATA 14.0 statistical package. The data will be analyzed descriptively and organized into tables. The Kolmogorov–Smirnov test will be employed to assess the distribution (normal or non-normal) of continuous variables. Parametric tests, including the paired t-test, independent t-test, ANOVA, and Pearson’s correlation test, will be utilized for variables exhibiting a normal distribution. Nonparametric tests, including the Wilcoxon matched-pairs signed-rank test, Mann–Whitney U test, Kruskal–Wallis test, and Spearman’s correlation test, will be used for variables exhibiting a non-normal distribution. A significance level of 5% will be adopted for all analyses.

RESULTS

After completing the protocols, patients will be reassessed at three and six months, and the following parameters will be considered: sensitivity, edema, mandibular range of motion, pain, fatigue during speech, and chewing.

DISCUSSION

The proposed randomized clinical trial represents the first endeavor toward incorporating electroacupuncture into a physiotherapeutic protocol aimed at restoring sensitivity and motor function. The outcomes may propose an innovative alternative therapy for patients encountering paresthesia and motor alterations after bimaxillary orthognathic surgery and genioplasty.

The primary objective of the proposed study is to ascertain whether electroacupuncture considerably influences the recovery of sensitivity in patients who have undergone bimaxillary orthognathic surgery and genioplasty, compared to those in the control group. The secondary objective is to investigate whether this considerable impact extends to edema, mandibular range of motion, pain intensity, and fatigue when speaking. Additionally, we will evaluate the quality of chewing function at the conclusion of treatment and at the three- and six-month follow-up assessments. Notably, no previous study has examined the effect of electroacupuncture on all these variables simultaneously.

Patients undergoing orthognathic surgery frequently experience reduced sensitivity, and available treatment options for this condition are limited. Whether temporary or permanent, secondary paresthesia can considerably impact the quality of life by disrupting basic activities such as eating and drinking, potentially resulting in unintentional biting of the lower lip due to diminished sensitivity [9,35]. Another proposed approach for treating paresthesia is low-level laser therapy, which can expedite the healing process of damaged tissues by promoting neovascularization, a crucial factor for neural regeneration. The spontaneous recovery from paresthesia within a period of three to six months varies considerably. Some authors recommend prescribing a vitamin B complex to facilitate the development of the myelin sheath surrounding nerves [8,36,37].

Additionally, some patients also report symptoms of neuropathic pain; however, only a portion of these patients experience spontaneous recovery [10]. Most nerve injuries involve a combination of neurapraxia and axonotmesis, with predominant therapeutic interventions adopting a conservative, noninvasive strategy, which is more acceptable to the patients [38,39]. This rationale justifies the testing of a protocol involving electroacupuncture with the activation of facial acupoints to enhance sensitivity and motor function in patients who have undergone bimaxillary orthognathic surgery and genioplasty.

SUPPLEMENTARY MATERIAL

Supplementary data to this article can be found online at https://doi.org/10.51507/j.jams.2024.17.5.178.

ACKNOWLEDGEMENTS

The authors acknowledge the Teaching Clinic of Estácio University Center and the Oral and Maxillofacial Surgery and Traumatology service of the Walter Cantídio University Hospital at the Federal University of Ceará.

AUTHORS’ CONTRIBUTIONS

ILS, DVG, and DABG participated in the conception of the study and wrote the first draft of the manuscript. FP, RENI, and TCA contributed to the design and operation of the study. DVG, ILS, and DABG edited the final manuscript. All authors revised the final version of the protocol and approved the final manuscript.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Fig 1.

Figure 1.SPIRIT schematic diagram of study schedule. SPIRIT, standard protocol itens: recommendations for interventional trial: –t1 = pre-study, screening/consent; t0 = pre-study, baseline/randomization; t1–t6 = study, intervention period; t7 = tree-months follow-up; t8 = six-months follow-up.
Journal of Acupuncture and Meridian Studies 2024; 17: 178-186https://doi.org/10.51507/j.jams.2024.17.5.178

Fig 2.

Figure 2.Flowchart of study (CONSORT). SA = sensitivity assessment; MMO = maximum mouth opening; AFS = assessment of facial swelling; NPRS = numeric pain-rating scale; FA = fatigue assessment; ACQ = assessment of chewing quality.
Journal of Acupuncture and Meridian Studies 2024; 17: 178-186https://doi.org/10.51507/j.jams.2024.17.5.178

Fig 3.

Figure 3.Acupuncture points that received electrical stimulation with needles. Parameters: F1 = 10 Hz, F2 = 45 Hz; repetition time = 1 sec.; 10 mA; 30 min. Acupoints: ST4 (stomach 4), jiachengjiang (extra point), ST5 (stomach 5), ST6 (stomach 6). The CV24 (conception vessel 24) acupoint received only needling (0.25 × 15 mm). Source of the figure: artificial intelligence CANVA.
Journal of Acupuncture and Meridian Studies 2024; 17: 178-186https://doi.org/10.51507/j.jams.2024.17.5.178

Fig 4.

Figure 4.Points for assessing sensitivity. Points located between ala of nose and tragus (1P1, 1P2, 1P3), between lip commissure and earlobe (2P1, 2P2, 2P3), between central region of chin and angle of mandible (PM, 3P1, 3P2, 3P3, 3P4 and 3P5) and points on upper and lower lips (L1, L2, L3, L4, L5 and L6) to investigate sensitivity (Semmes-Weinstein monofilament; SMILE Sensitivity Test- BAURU). Source of the figure: artificial intelligence CANVA.
Journal of Acupuncture and Meridian Studies 2024; 17: 178-186https://doi.org/10.51507/j.jams.2024.17.5.178

Fig 5.

Figure 5.Swelling assessment. Face measurements were taken using a measuring tape in centimeters following the facial composition of the MD Anderson Cancer Center Head and Neck Lymphedema protocol (MDACC HNL). L1 = Tragus to mental protuberance. L2 = Tragus to labial commissure. L3 = angle from the mandible to the nasal ala. L4 = angle from the jaw to the inner corner of the eye. L5 = angle from the jaw to the outer corner of the eye. L6 = mental protuberance at the inner corner of the eye. Source of the figure: artificial intelligence CANVA.
Journal of Acupuncture and Meridian Studies 2024; 17: 178-186https://doi.org/10.51507/j.jams.2024.17.5.178

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