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The Clinical Application of Equine Acupuncture

Article in Journal of Equine Veterinary Science October 2009


DOI: 10.1016/j.jevs.2009.08.001

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CLINICAL TECHNIQUES
The Clinical Application of Equine Acupuncture
Justin Shmalberg, DVM, CVA and Huisheng Xie, DVM, PhD

INTRODUCTION the end of a discarded plastic guide tube from an acupunc-


The addition of acupuncture to integrative treatment pro- ture needle is employed. Important diagnostic points
tocols for a variety of equine conditions offers an adjunctive follow to facilitate an integrative lameness examination
approach based on a historical model of experience-based (Table 1).
clinical findings and therapies. Although many clinicians Diagnostic points, when sensitive, may serve as treatment
employing the modality pursue advanced training in the points. However, it is beneficial to treat the suspect area
traditional diagnostic and therapeutic systems of Chinese first with local acupoints and recheck the degree of sensitiv-
medicine, a conventional diagnosis often lends itself to itygenerally one finds that when the correct joint or
the selection of a basic group of points suitable for a partic- muscle groups are treated, the referred sensitivity is no
ular condition. Where available, clinical research and longer appreciable.
revision guides the recommendation of the most appropri- Core points for the treatment of any lameness cover acu-
ate and beneficial acupoints. However, given the infancy of points said to display clinical effects over either skeletal,
scientific studies on equine acupuncture,1 this research- tendon, or muscular pathologic conditions. To cover all
driven approach is supplemented by practitioner experi- three areas, one may select BL-23 and BL-11 for the first,
ence, as has been related in the following descriptions of GB-34 and BL-18 for the second, and BL-20 for the third
common clinical applications. Clinicians starting to use area, respectively. In addition, SI-9, SI-3, and TH-1 for any
the technique generally find that acupuncture needles, lameness of the forelimb and BL-54, BL-67, and ST-45 for
alone or in combination with other techniques including the hindlimb are recommended. A trained acupuncturist
the injection of sterile saline or vitamin B12, elicit worth- makes modifications by accounting for the pattern diag-
while clinical results, as described later. nosis: the collection of physical examination, historical,
environmental, behavioral, and seasonal factors that pro-
duce the observed signs.6 However, knowledge of the
MUSCULOSKELETAL APPLICATIONS
pattern is not necessary to elicit systemic effects mediated
The most common and rewarding aspect of equine acu-
by opioids,7 serotonin,8 or the local effects that may be
puncture remains the diagnosis and treatment of musculo-
influenced by histamine9 or substance P.10 Local points
skeletal pathology, whether acute or chronic. Foundational
in addition to the aforementioned core points are selected
texts for the location of acupoints in horses date as early as
on the basis of either diagnostic sensitivity or confirmatory
1608, in which 189 points are described, many with
conventional diagnostic testing and will vary based on the
emphasis on treating lameness.2 Acupuncture, through
region involved (Table 2).
a combination of proposed mechanisms, is well suited to
For lumbar pain, points along the bladder meridian
addressing the needs of the equine, regardless of athletic
(approximately 9 cm off dorsal midline on both sides)
ability3; as with all of Chinese veterinary medicine, new
can be selected. Results of both retrospective and pro-
concepts have emerged that refine modern clinical practice.
spective equine cases demonstrate a high efficacy in the
One such recent addition is an expansion of diagnostic
treatment of nonspecific thoracolumbar pain.1113 As
points, which are palpated to determine specific anatomic
with most conditions associated with lameness, electroa-
structures that may contribute to an observed lameness.
cupuncture, aquapuncture (saline or B12 injections), and
From a traditional sense, these embody connections along
conventional acupuncture needles are used, often in
meridians, or channels, between points.4 When looking
combination.
through a more scientific lens, myofascial trigger points,
Despite the lack of significant differences in the only
as described elsewhere,5 may explain why sensitivities can
equine study on acupuncture for laminitic or navicular
be appreciated in areas referred from the primary site of
pain,14 this is a common and successful intervention. The
lameness. In practice, practitioners can simply palpate these
most distal points known as jing, or well in English,
points and meridians using their fingers. A 2 mm metal
points are frequently employed. PC-9 is located between
probe is used to check these points, or more commonly,
the heel bulbs of the forelimb, and the remaining five
Reprint requests: Huisheng Xie, Acupuncture Service, College of Veterinary Medicine, equally spaced points are located just above the coronary
University of Florida, Gainesville, FL 32610. band (from caudolateral to caudomedial on the forelimb,
0737-0806/$ - see front matter
2009 Elsevier Inc. All rights reserved. they include: HT-9, SI-1, TH-1, LI-1, and LU-11).
doi:10.1016/j.jevs.2009.07.010 Qian-ti-men, or Thoracic Hoof Gate, at the caudodorsal

Journal of Equine Veterinary Science  Vol 29, No 8 (2009) 645


646 J Shmalberg et al  Vol 29, No 8 (2009)

Table 1. Indication and location of diagnostic points in horses


Acupuncture Points Indication Anatomic Location*
LI-18 Foot (hoof, navicular, coffin) The depression just above the jugular groove
along the line of the ventral mandible with the
head extended
PC-1 Foot (hoof, navicular, coffin) In the depression between the heel bulbs
(forelimb)
LI-16 Fetlock Immediately cranial to the scapula, 1/3 the
distance from the glenohumeral joint to
craniodorsal border of the scapula
TH-15 Front suspensory ligament Depression on the craniodorsal border of the
scapula at the junction of the scapula and
scapular cartilage
Hua-tuo-jia-ji at C4 Carpus Two points located immediately above and
below the fourth cervical vertebra
LI-15 Shoulder Immediately cranial to the point of the shoulder
BL-54 Hip 1/2 the distance on a line connecting the greater
trochanter to the lumbosacral space
Lu-gu Hip 1/3 the distance on a line from the greater
trochanter to the lumbosacral space
SP-11 Stifle In the depression approximately 5 cm
cranioventral from the distal border of the
tuber coxae
ST-31 Stifle In the depression approximately 5 cm
caudoventral from the distal border of the
tuber coxae
GB-27 Hock 1.5 cm craniodorsal to the cranial aspect of the
iliac spine
Bladder points Thoracolumbar 9 cm lateral to the dorsal midline in an adult
horse, at each intercostal space
*Note: Traditional measurement is in cun, a scaled system based on the anatomic location of the point. Generally, in an adult horse, one cun represents 3 cm
(a conversion used in this and following tables). Most acupoints are located in a palpable depression.

border of the heel bulbs, has been used for conditions of GASTROINTESTINAL DISORDERS
the distal limb for hundreds of years. The treatment of equine gastrointestinal disorders using
By supplementing the core points above with local points modern medical acupuncture may rely on stimulation of
and sensitive diagnostic points, the practitioner may achieve somatovisceral connections whereby the somatic input
a recipe for a full acupuncture treatment. In addition to from needle stimulation possesses the ability to alter under-
the regions discussed, points located around each joint, rep- lying organ parameters such as regional blood flow.15 The
resenting both the joint itself and surrounding myofascial neural connectivity between the gastrointestinal (GI) tract
planes, will be necessary for treatment. Recommended and cutaneous fibers has been documented in human pain
examples include PC-6 for the carpus, SI-9 for the shoul- studies.16 Moreover, specific alterations of visceral pain
der, BL-53 for the hip, ST-36 for the stifle, BL-60 for the thresholds through endogenous opioid mediators also
tarsus, and KID-1 or Hou-ti-men (the hindlimb counter- may play a contributory role.17 The equine literature, spe-
part to Qian-ti-men) for the distal hindlimb (Table 3). cifically, suggests a participatory role of acupuncture in
Clinical experience has demonstrated that an average of providing analgesia for experimental colic through this
three treatments are necessary to resolve lameness or mechanism and other potential pain pathways.18 Similar
decreased performance from muscular injury. Orthopedic results are documented in other species.19
and degenerative conditions take longer, and, as expected, In addition to analgesia, effects on motility likely contrib-
clients should be instructed that changes in tendon struc- ute to clinical responses seen in the horse. In both hyper-
ture require a number of treatments to achieve complete motile and hypomotile states, similar points appear
resolution. capable of normalizing GI motility. Specifically, GV-1,
J Shmalberg et al  Vol 29, No 8 (2009) 647

Table 2. Core or foundational points for the treatment of equine lameness


Acupuncture points Anatomic location
BL-23 9 cm from dorsal midline lateral to the L2L3 intervertebral space; may also be found by
following the caudal-most border of the 18th rib dorsally
BL-11 Cranial to the withers, approximately 5 cm lateral to dorsal midline
GB-34 In the interosseous space between the tibia and fibula, immediately cranioventral to the head
of the fibula
BL-18 Two points located at the 13th and 14th intercostal spaces, 9 cm lateral to dorsal midline
BL-20 9 cm lateral to dorsal midline at the 17th intercostal space
SI-9 A large depression at the junction of the long and lateral heads of the triceps with the caudal
border of the deltoid muscle
SI-3 In a depression on the caudolateral aspect of the third metacarpal (cannon) bone, distal to
the end of the lateral splint bone (fourth metacarpal), and over the lateral palmar digital
vein
TH-1 Immediately lateral to cranial midline, proximal to the coronary band of the forelimb
BL-54 1/2 the distance on a line connecting the greater trochanter to the lumbosacral space
BL-67 Immediately proximal to the coronary band on the caudolateral aspect of the hindlimb
ST-45 Immediately proximal to the coronary band on cranial midline of the hindlimb

Table 3. Additional points for lameness treatment by affected area


Acupuncture Points Indication Anatomic Location
PC-9 Distal forelimb In the depression between the heel bulbs (forelimb)
PC-6 Carpus Cranial to the distal border of the chestnut, 9 cm proximal to
the accessory carpal bone, between the flexor carpi radialis
and flexor carpi ulnaris
SI-9 Shoulder A large depression at the junction of the long and lateral heads
of the triceps with the caudal border of the deltoid muscle
BL-53 Hip In the large depression approximately 6 cm caudal to the tuber
coxae
ST-36 Stifle In the cranial tibialis muscle, approximately 9 cm distal from
the patella and 12 cm lateral (long linear point in the muscle
belly)
BL-60 Tarsus Located between the lateral malleolus of the tibia and the tuber
calcanei
KID-1 Distal hindlimb In the depression between the heel bulbs (hindlimb)

used more commonly for diarrhea, may depress motility,20 unnecessary confusion. Such human acupoints traditionally
whereas ST-36 may enhance peristalsis through choliner- associated with improvements in human GI disorders have
gic21 and endocrine pathways.22 emerging scientific data to support their validity.23
The clinical approach adopted in Chinese veterinary med- The commonly used core points for any GI disorder in-
icine for a number of GI conditions may use a core group of clude ST-36, SP-6, Qi-hai-shu, BL-20, and BL-21 (Table 4).
points located on the spleen and stomach meridians. For diarrhea, GV-1 is recommended, especially with
Because of Chinese translations and descriptions of the electroacupuncture, for its aforementioned depressive ef-
chief digestive organ, the spleen was said to be responsible fects on colonic motility. Recent studies further suggest
for the digestion and processing of food. As with other is- that colonic pathologic conditions actually may alter the
sues of terminology, the language can be thought to repre- cutaneous properties of the GV-1 point itself.24
sent a collection of experience-based points bearing Infectious diarrhea associated with fever and leukocyte
a relationship to their perceived common function in nor- elevations may benefit from GV-14, a point shown to
malizing the GI tract. Literal interpretations generate diminish fever in human patients25 and traditionally
648 J Shmalberg et al  Vol 29, No 8 (2009)

Table 4. Acupoints indicated in the treatment of gastrointestinal disorders


Acupuncture points Anatomic location
ST-36 In the cranial tibialis muscle, approximately 9 cm distal from the patella and 12 cm lateral
(long linear point in the muscle belly)
SP-6 9 cm proximal to the medial malleolus, caudal to the tibial border, and just caudal to the
saphenous vein
Qi-hai-shu 9 cm lateral to dorsal midline, between the longissimus dorsi and the iliocostalis muscle,
at the 16th intercostal space
BL-20 9 cm lateral to dorsal midline at the 17th intercostal space
BL-21 9 cm lateral to the dorsal midline, caudal to the last rib
GV-1 In the depression between the ventral aspect of the tail and the anus
GV-14 On dorsal midline in the depression at C7T1
Jiang-ya Alar cartilage within the lateral corner of the nares (see above)
Er-ding In a depression at the cranial aspect of the base of the ear; the needle should be passed
through the auricle
CV-12 Midway between the xiphoid and the umbilicus on ventral midline (approximately 12 cm
cranial to the umbilicus)

associated with heat-clearing properties. There is some Chinese and conventional approaches.30 The only proto-
suggestion that needles alone may be more beneficial col-specific research done in this country has focused on
than electroacupuncture, which fits with the sentiment administration of prostaglandin into an acupuncture point,
that electroacupunture is contraindicated in cases of Bai-Hui, versus a non-acupuncture point, with conflicting
heat such as acute inflammation or pyrexia.26 results.31 Given the lack of protocol-specific data, the prac-
For the treatment of colic, historic and anecdotal evi- titioner must rely on the classic Chinese differentiations of
dence support the use of the classical Jiang-ya acupoint, specific patterns for point recommendations.
located within the alar cartilage of the lateral aspect of Core points for reproduction include Bai-hui,-Yan-chi,
the inside of the nares. The point exerts what appears to Shen-Shu, and BL-23. Ovulatory dysfunction, regardless
be a strong analgesic response and may help distinguish of cause, is viewed as one of a number of possible deficiency
between medical and surgical colic when combined with patterns, which implies that there is an aspect of the body
other clinical parameters. A 1.5-inch 21-gauge needle is that must be strengthened to achieve clinical results. Addi-
indicated at a perpendicular insertion. Er-ding is another tive points for a variety of conditions, ranging from anovu-
point traditionally used for equine colic. CV-12, the latory follicles, irregular estrous cycles, and repeat failures
alarm point for the stomach, may mediate a visceral of breeding (artificially or naturally), include LIV-3 and
analgesic effect.27 In general, electroacupuncture is useful, KID-6. CV-4 particularly is among a group of points found
when available, in the treatment of colic, given its pro- to possess endocrine effects pertinent to reproduction, spe-
nounced, and well-documented, roles in activating opioid cifically ovulation; however, access in the horse is diffi-
receptors. cult.32,33 For inflammatory, or excess, conditions, the
most prominent of which are vaginitis or metritis, specific
acupoints applied include GV-14, LI-4, and CV-1. Unfor-
REPRODUCTION tunately, the spectrum of reproductive diseases does not at
The treatment of reproductive disorders and the promotion this time have evidence-based protocols corresponding to
of fertility represent cornerstones of many equine-related each condition. As a result, similar points are thought to
industries. Recent attempts have sought to define the exert normalizing influences on a variety of seemingly differ-
appropriate integration of acupuncture into reproductive ent pathophysiologic influences (a feature integral to much
practice although there is some degree of difficulty predict- of Chinese medicine). An integrative approach is therefore
ing the exact hormonal and temporal response of equids to recommended for the most promising results (Table 5).
the modality.28 However, standardized approaches in
China have proved successful in treatment of anovulatory
follicles and the induction of estrus.29 Similarly, promising NEUROLOGIC DISORDERS
human studies, although varying widely in experimental The neurologic basis and application of acupuncture is
approach, have prompted calls for mergers between widely accepted. Recent reviews have highlighted the
J Shmalberg et al  Vol 29, No 8 (2009) 649

Table 5. Acupoints for reproductive dysfunction


Bai-hui On dorsal midline at the lumbosacral space
Shen-Shu 6 cm lateral to the lumbosacral space (Bai hui acupoint)
BL-23 9 cm from dorsal midline lateral to the L2L3 intervertebral space; may also be found by
following the caudal-most border of the 18th rib proximally
Yan-chi Located 1/2 the distance between the proximal aspect of the tuber coxae and the acupoint
Sheng-peng (6 cm from dorsal midline above the tuber coxae)
LIV-3 Approximately 1/3 the distance between the tarsus and fetlock on the craniomedial aspect of
the third metatarsal (cannon) bone
KID-6 In the depression between the tuber calcanei and the talus
GV-14 On dorsal midline in the depression at C7T1
LI-4 In the depression between the second and third metacarpal bones at the distal aspect of the
second metacarpal bone (splint bone)
CV-1 On ventral midline, halfway between the anus and the scrotum or vulva

Table 6. Acupoints indicated in the treatment of laryngeal hemiplegia


GB-21 Immediately cranial to the cranial scapular border, 1/2 the distance from the glenohumeral
joint to the craniodorsal border of the scapula
LI-18 The depression just above the jugular groove along the line of the ventral mandible with the
head is extended
LI-17 6 cm from the cranial border of the scapula, 1/3 the distance from the glenohumeral joint to
the craniodorsal border of the scapula
Hou-shu Immediately adjacent to the lateral aspect of the third tracheal ring (approach from the
ventral neckthe trachea can be pushed to the side for needle placement)
Hou-bi 1/2 the distance between SI-17 (see below) and ST-9 (see below), on the caudal border
of the mandible
ST-9 In the depression caudal to the angle of the mandible
SI-17 Immediately caudal to the mandible at the level of intervertebral space between C2C3,
approximately 1/2 the distance along the ramus
LI-15 Immediately cranial to the point of the shoulder

neural foundation for many of the physiologic responses Traumatic nerve injuries, such as suprascapular paralysis,
witnessed by practitioners.34 Acupoints frequently coin- respond equally well, with complete resolution possible. Ex-
cide with neurovascular structures,35 and attempts are perimental injuries of major nerves have produced convincing
ongoing to use this knowledge to correctly transfer the results with treatment via electroacupuncture.40 In general,
human point system to each veterinary species (so-called acupoints are chosen that run along the nerve itself or in the
transpositional points).36 In addition to the analgesic effect innervated muscle groups. For suprascapular paralysis, repre-
produced from electroacupuncture, mediated by endoge- sentative points include GB-21, Bo-lan, SI-13, and Fei-pan.
nous opioids such as beta-endorphin,37 the technique is Aggressive treatment schedules may be required to maintain
clinically employed for cases of nerve dysfunction or injury. stimulation and neuromuscular input. If managed in the acute
Laryngeal hemiplegia, a problem relatively common phase, every-other-day therapy can be elected. Concurrent
among Thoroughbred horses, arises from dysfunction of rehabilitation programs are encouraged for maximal results.
myelinated fibers, most commonly within the left recurrent Cases of paresis or paralysis, by extension, often benefit
laryngeal nerve.38 Electroacupuncture at a combination from acupuncture therapy. Proximal to distal leads may
of frequencies (10 minutes at 20 Hz, 10 minutes at 80 prove helpful. Examples include SI-9 to PC-9 for the fore-
120 Hz) was found to reduce or resolve the severity of dys- limb and BL-54 to KID-1 for the hindlimb. Aggressive treat-
function through endoscopic grading.39 The approach was ment (daily) can be undertaken in acute cases (Tables 68).
standardized: CV-23 connected to left GB-21, left LI-18 to
left LI-17, Hou-shu to Hou-shu, bilateral ST-9 to Hou-bi, ANHIDROSIS
and bilateral SI-17 to ipsilateral LI-15. Six treatments (gen- The mechanism by which acupuncture anecdotally appears
erally weekly) are often necessary to achieve clinical effect. to benefit some cases of anhidrosis remains unclear. Recent
650 J Shmalberg et al  Vol 29, No 8 (2009)

Table 7. Suprascapular paralysis (Sweeney)sample acupoints


GB-21 Immediately cranial to the cranial scapular border, 1/2 the distance from the glenohumeral
joint to the craniodorsal border of the scapula
Bo-lan Immediately caudal to the caudal border of the scapula at the level of the junction of the
scapula and scapular cartilage
SI-13 Immediately caudal to the scapular spine, 12 cm below the dorsal border of the scapula
Fei-pan On the caudal border of the scapula, 1/3 ventral to the caudodorsal border of the scapula

Table 8. Useful acupoints for the treatment of paresis or paralysis


SI-9 A large depression at the junction of the long and lateral heads of the triceps with the caudal
border of the deltoid muscle
PC-9 In the depression between the heel bulbs (forelimb)
BL-54 1/2 the distance on a line connecting the greater trochanter to the lumbosacral space
KID-1 In the depression between the heel bulbs (hindlimb)

Table 9. Acupuncture points for equine anhidrosis


Er-jian The tip of the ear; can be needled to release blood or the needle may be inserted for the
treatment duration (20-30 minutes)
Wei-jian The tip of the tail; can be needled to release blood or the needle may be inserted for the
treatment duration
GV-14 On dorsal midline in the depression at C7T1
HT-7 On the caudolateral aspect of the radius, in the depression caudal to the lateral ulnar muscle
at the level of the accessory carpal bone
Fei-shu Located in the 9th intercostal space, found by connecting a line between the glenohumeral
and coxofemoral joints

research highlights the role of climatic factors in the down- acupuncture protocols. The only English-language study
regulation of proteins requisite for the secretory function of the efficacy of acupuncture in RAO produced no signif-
of the gland cells in response to chronic adrenaline input; it icant differences; however, only one treatment was used,45
appears that as the condition progresses, function of the and in general, experience dictates that multiple treatments
gland cells themselves may be lost because of irreparable prove necessary to elicit clinical response. Notwithstanding
changes.41 Acupuncture-based intervention uses points differences in pathophysiology, repeat treatments in hu-
said to exert control over a generalized sweat response in man cases of chronic obstructive pulmonary disease
all species. In addition, an herb known as Xiang Ru (Elsholt- achieved a substantial difference in dyspnea scores in a pro-
zia species) may be employed by some practitioners, given its spective study.46 Acupuncture in human asthma may func-
historical usage for inducing sweating in humans despite any tion through a decrease in levels of substance P in the
concrete evidence for this effect.42 Advances in intradermal dorsal horn of the spinal cord.47 Attention has been paid
testing offer the potential for evaluating response to acu- to the role of neural control of equine RAO,48 and acu-
puncture and herbal medications,43 although the molecular puncture may exert influences here as well. Given the com-
mechanism will likely require further elucidation before the plex cause, likely involving T-cellmediated responses and
precise activity of any treatments, including acupuncture, is environmental factors,49 additional research proves neces-
realized.44 In the interim, practitioners may apply treatments sary before precise guidelines can be established for the
to affected horses, along with other environmental changes, suitability of acupuncture and for the recommended num-
and judge clinical response and suitability (Table 9). ber of treatments. In the interim, however, several points,
stimulated with acupuncture needles, electroacupuncture
(preferred), or aquapuncture (B12), are warranted given
RECURRENT AIRWAY OBSTRUCTION the minimal side effect profile. Ding-chuan, CV-22, and
The long-term management of recurrent airway obstruc- GV-14 have been used, both historically and in modern sci-
tion (RAO) is frequently enhanced by the addition of entific study,50 for the treatment of respiratory disorders.
J Shmalberg et al  Vol 29, No 8 (2009) 651

Table 10. Acupoints indicated in equine recurrent airway obstruction


BL-13 9 cm lateral to dorsal midline, at the caudal edge of the scapular cartilage (ICS 8)
LU-7 On the craniomedial aspect of the radius, cranial to the cephalic vein at the level of the distal
border of the chestnut (approximately 4.5 cm proximal to the transverse carpal crease)
CV-17 On ventral midline at the level of the caudal border of the elbow or at the level of the fourth
intercostal space
Ding-chuan 1.5 cm to ventral midline at the level of T1
CV-22 On ventral midline in the depression immediately cranial to the sternum
Fei-men 1/3 the distance of the cranial aspect of the scapula ventrally, immediately cranial to the
scapular border

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principles. Response usually dictates treatment duration, ture channel imbalance in the equine sport horse purchase examina-
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corticosteroids and bronchodilators (Table 10). activity of myofascial trigger points in control sites in equine
cleido-brachialis muscle: an observational study. Acupuncture in
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However, research consistently highlights a promising role namic and respiratory effects, and B-endorphin concentration in spinal
in the integrative application of the modality because of sys- fluid and plasma of horses after acupuncture and electroacupuncture.
temic effects based on wide-ranging neural pathways51 and AJVR 2002;63:14351442.
because of regional influences via local mediators.52 En- 8. Takagi J, Yonehara N. Serotonin receptor subtypes involved in mod-
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promise of further influencing and guiding the fluid and 514.
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terim, the practitioner provides the frontline for continued ture on the mast cells in the acupoints of the stomach meridian. Zhen
experience-based evaluation. The time required and mini- Ci Yan Jiu 1996;21:6870 [Chinese].
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