Comparative Effectiveness of Ear and Body Acupressure for Postoperative Pain in Elderly Women Following Knee Arthroplasty: A Randomized Trial

Abstract

Background:

Knee arthroplasty or knee joint replacement is a common treatment method used to relieve pain caused by knee arthritis among the elderly. Postoperative pain control is a challenge in knee arthroplasty. Despite existing evidence supporting the effectiveness of acupressure for pain management, limited research has directly compared the efficacy of body and auricular acupressure in reducing pain following knee arthroplasty. To address this knowledge gap, the present study aims to compare the effectiveness of these two acupressure techniques in alleviating pain severity among elderly individuals undergoing knee replacement surgery.

Methods:

This three-group randomized clinical trial study was conducted on 141 elderly women undergoing knee arthroplasty surgery at Shafa Yahiaeian Hospital in Tehran in 2023. Patients were randomly assigned to three groups of 47. The patients of the body acupressure and auricular acupressure groups received intervention for 15 min, thrice a day at an interval of 4 h, for 3 days. Control group patients received only routine interventions. Visual analog scale (VAS) and McGill’s Abbreviated Mental Test Scale were completed before the first intervention on the first day and immediately after the last intervention on the first, second, and third days.

Results:

The results revealed that the pain severity assessed using VAS and McGill’s Abbreviated Mental Test Scale during all 3 days in the body and auricular acupressure groups had a more decreasing trend compared with the control group. Moreover, auricular acupressure was more effective than body acupressure in pain control.

Conclusion:

Body acupressure and auricular acupressure as complementary interventions have significant potential in reducing pain after knee arthroplasty in the elderly female population. These methods offer an interesting treatment option by reducing the need for analgesics and thus reducing the side effects of these drugs. However, auricular acupressure may have faster relief effects compared with body acupressure.

Keywords

elderly acupressure pain knee replacement arthroplasty

Introduction

Pain is considered one of the most common manifestations of patients after total knee arthroplasty (TKA). Based on the predictions, its rate will increase by 700% by 2030. Based on the reports, 16%–33% of patients report pain after TKA.^1,2 The elderly, as a group with a higher vulnerability, include a major part of patients undergoing knee arthroplasty surgery.³ The presence of several chronic diseases simultaneously in this age group and the physiologic changes related to aging make them prone to postoperative complications. Thus, it is essential to provide specialized and comprehensive nursing care for these patients.⁴ Most elderly also report a feeling of disability and helplessness in controlling pain after TKA.⁵

The International Council of Nurses considers pain relief to be one of the nursing responsibilities. It can cause a faster disease recovery and quality of life after surgery.⁶ Using complementary therapeutic methods along with common drug treatments in the elderly after knee arthroplasty can be effective as a multifaceted approach in controlling pain and improving the quality of life of these patients. They can improve the patient’s tolerance to treatment and increase his satisfaction by reducing dependence on analgesics and their side effects.⁷

Acupressure is one of the oldest complementary medicine treatments. It regulates the flow of vital energy and improves the body’s physiologic functions by applying pressure to specific points on the body called acupressure points. Based on Traditional Chinese Medicine principles, this noninvasive treatment method is used to alleviate pain and improve various physical and mental conditions without the need for drugs or medication. Several clinical trials in recent years have focused on investigating the efficacy of acupressure in pain control in different populations, including patients undergoing coronary angiography, laparoscopic cholecystectomy, and extracorporeal shock wave lithotripsy.^8–11

Moreover, several systematic review studies and meta-analyses have been conducted to comprehensively investigate the impacts of acupressure on pain control in a wide group of patients.^12–14 Despite the growing evidence on the efficacy of acupressure in pain control in different populations, no study has specifically evaluated the impact of this method on pain control in elderly patients undergoing TKA. This knowledge gap highlights the need for more studies in this area.

Auricular acupressure applies pressure on specific areas of the ear and causes rehabilitation and energy return to the body. It improves the body’s overall condition. Auricular acupressure is effective not only in pain control but also in balancing the level of hormones and neurotransmitters in the body and brain.¹⁵ This action reduces pain and affects the body’s homeostasis by stimulating the release of endorphins in the bloodstream. It also causes changes in the functioning of the human body and all organs by stimulating certain points of each ear.^16,17 Auricular acupressure is based on the Chi concept and balance in the body’s vital system. Paul Nogier (1956) reported the theory of auricular acupressure representing an inverted embryo in the ear and explained that certain points in the ear can be used to treat the body’s dysfunction.^18,19

A systematic review and meta-analysis by Lee et al. (2024) on six clinical trials provided valid evidence on the efficacy of auricular acupressure in reducing pain severity and improving function in people with chronic musculoskeletal pain.²⁰ Several studies have examined the impact of auricular acupressure in controlling the pain of different patients.^21–23 Gao et al. (2024) investigated 61 patients undergoing one-stage radical surgery. They reported that auricular acupressure significantly reduced the pain severity after surgery.²⁴ In addition, the results of systematic reviews over the last years and meta-analyses emphasize the efficacy of auricular acupressure in reducing various types of pain, including pain caused by surgery and musculoskeletal pain.^20,25–29 Despite the high potential of auricular acupressure in pain control, the lack of sufficient studies, especially on the pain caused by knee arthroplasty, indicates a significant gap in their knowledge in this area.³⁰

Given what was stated, several studies have examined the analgesic effects of auricular acupressure and body acupressure and have obtained promising results in this regard. However, there are limited studies in the TKA area. In addition, given the proven effectiveness of both auricular and body acupressure, this study compares the efficacy of auricular acupressure with body acupressure in reducing pain after TKA in elderly women. The results of this study can help to find a better approach for these patients and provide more scientific evidence in this area.

Materials and Methods

Design and setting

This randomized clinical trial was conducted on elderly women undergoing TKA from August 2023 to January 2024 at Shafa Yahyaeian Hospital in Tehran. Figure 1 shows that the study process is presented based on the CONSORT flowchart (Fig. 1).

FIG. 1.

The study process according to the Consolidated Standards of Reporting.

Sampling

Considering a Type I error of 1% and a Type II error of 10%, with SDs of pain scores of 0.84 in the acupressure group and 0.77 in the control group, and expecting a minimum mean difference of 0.7, the required sample size was calculated to be 40 participants. Taking into account potential attrition, the final sample size was set at 47 participants.³¹

n = \frac{{(Z_{1 - α / 2} + Z_{1 - β})}_{}^{2} (s_{1}^{2} + {s_{2}^{2}}^{})}{d^{2}} = \frac{{(2.58 + 1.28)}^{2} ({0.84}^{2} + {0.77}^{2})}{{0.7}^{2}}

The patients were randomly selected and assigned to three groups (auricular acupressure, body acupressure, and control) using a purposeful sampling method. Accordingly, cards labeled A and B were assigned to the two intervention groups, and card C was assigned to the control group. For each participant, one card was drawn at random from a set of identical, nontransparent envelopes containing the three cards. This process was carried out by a researcher not involved in the data collection. The use of identical envelopes ensured allocation concealment, minimizing selection bias. There was no blinding due to the nature of the interventions in this study. In this study, 141 eligible patients were examined, and they did not meet the exclusion criteria for the study.

Eligibility criteria

The participants were elderly women undergoing knee arthroplasty. The inclusion criteria of this study included (1) having an age over 60 years, (2) absence of cognitive disorders based on the Abbreviated Mental Test Scale or AMTS (score ≥8), (3) having the first experience of knee arthroplasty surgery, (4) receiving spinal anesthesia, (5) not suffering from malignancy and inflammatory and vascular disease, and (6) absence of active bleeding, sensory disorders, infectious wound, and skin diseases at the intervention point. The exclusion criteria also included (1) the patient or physician’s unwillingness to continue participation and 2) returning to the operating room.

Measures

The data collection instruments used in this study included a Demographic Information Questionnaire, the Visual Analog Scale (VAS), and the McGill Pain Questionnaire. The primary outcome of the study was pain, which was assessed using two validated tools: the VAS, to measure pain intensity, and the McGill Pain Questionnaire, to assess the qualitative aspects of pain. These instruments were administered before the first intervention on day 1 and immediately after the final intervention on each of the first, second, and third days.

Demographic information form

It included personal characteristics and clinical records of the patient. It is completed by interviewing and examining the patient’s medical records (age, marital status, smoking, and underlying disease, including diabetes or hypertension).

Abbreviated mental test

AMT scale was used to identify any changes in cognitive function to identify elderly female patients suffering from cognitive problems. Each true answer is given a score of 1. The scores of 0 to 3 indicate severe dysfunction, the scores of 4 to 7 indicate moderate dysfunction, and the scores of eight or higher indicate normal cognitive function.³² Cronbach’s alpha for the AMT scale was reported at 0.76, indicating its satisfactory reliability.³³ The AMT was used solely at the beginning of the study as a screening tool to assess cognitive eligibility. Participants who did not meet the minimum required score were excluded from the study. The AMT was not used as an outcome measure.

Visual Analog Scale

This scale is scored between zero and 10. A score of zero on the scale indicates lack of pain, a score of 1–3 indicates mild pain, a score of 4–6 indicates moderate pain, a score of 7–9 indicates severe pain, and a score of 10 indicates the most severe pain.^34,35 In the study by Najafi Dolatabad, its reliability coefficient was reported from 0.77 to 0.84, so the scientific reliability of this scale was confirmed.³⁶

McGill’s abbreviated mental test scale

This self-report pain scale was published by Melzak (1975) to investigate the pain status. The abbreviated form of this scale was designed for ease of answering. It includes 15 items in two areas of sensory pain (11 items) and emotional area (4 items).

Each item is answered as “not at all, mild, moderate, and severe.” The severe option gets a score of 3, the moderate option gets a score of 2, the mild option gets a score of 1, and the “not at all” option gets a score of zero. The range of sensory pain range is 0–33, and the range of emotional range is 0–12. Adel Manesh et al. (2011) reported Cronbach’s alpha of 0.84, a reliability of 0.91 for all areas, and confirmed its validity.³⁷

Intervention

In this study, all enrolled patients received the same analgesic protocol (paracetamol (acetaminophen), celecoxib, gabapentin, pethidine) for postoperative pain management, as they were admitted to and treated under the care of the same specialist in a single clinical service. This standardized approach ensured homogeneity in baseline pain control measures across all study participants.

Body acupressure

In this study, acupressure was performed on points, including 1-Hegu LI4 (LargIntestine4) and 2-LI10 (Shousanli), on both sides of the body, first on the right side and then on the left side. The Yintang acupoint, a singular midline point located at the glabellar region (mid-forehead), was selected for its demonstrated anxiolytic properties and endorphin-mediated analgesic effects. This intervention was specifically used to mitigate postoperative pain in elderly patients following TKA, with the dual mechanism of stress reduction and endogenous opioid activation contributing to its therapeutic efficacy. The acupressure was applied by the researcher (F.G.) who had completed the academic course of acupressure. The radial pulse was assessed before and after the intervention to evaluate its effects, followed by the application of direct and rotating pressure to the targeted points. The pressure level was such that 1.3 of the nail bed turned white, and the patient felt tingling or warmth at that point.³⁸ The intervention duration was 15 min. It was repeated thrice a day for 3 days with an interval of 4 h.

Auricular acupressure

Auricular acupressure was performed after disinfecting the ears and placing ear seeds. The radial pulse was assessed before and after the intervention to evaluate its effects. Three minutes of gentle pressure on the following points to a degree that did not cause severe pain in the patient and ensured that the adhesive patches remained intact without displacement or detachment: (1) Shenmen at the junction of the upper and lower crus of the antihelix in both ears, (2) the thalamus at the base of the concha wall in the vertical part behind the antitragus in both ears, and (3) The knee point was applied in the middle area of the antihelix only on the operated side.³⁹ The intervention lasted 15 min and was repeated thrice at 4-h intervals for 3 days, with the priority of the intervention for the right ear and then the left ear. In accordance with the attending physician’s instructions, the seeds were removed after each intervention to prevent any potential skin sensitivity.

Control

The patients of the control group, like all patients in intervention groups, received the same analgesic protocol for postoperative pain management, and the pain level was measured thrice a day for 3 days at the same time intervals as the intervention groups.

Statistical data analysis

The data were analyzed in SPSS-16 software using descriptive statistics (frequency, percentage, mean, and standard deviation [SD]) and inferential statistics (Chi-square, Analysis of Variance (ANOVA), Analysis of Covariance (ANCOVA), Repeated Measure ANOVA, eta square, and least significant difference [LSD] test). The normal distribution of the data was examined using the Kolmogorov–Smirnov test.

Results

All 141 participants were randomly assigned to the groups. The mean age of the subjects was 69.02 ± 6.12. It is important to note that no adverse events or side effects were reported or observed among participants throughout the study period. Rigorous safety monitoring protocols were implemented to ensure a thorough evaluation of all potential adverse outcomes, irrespective of their severity or suspected association with the study interventions.

Demographic variables

The results of ANOVA and Chi-square tests did not show statistically significant differences between the groups regarding the variables of age, marital status, smoking, alcohol consumption, and underlying disease (p > 0.05) (Table 1).

Table 1.

Comparison of the Demographic Characteristics of the Participants Between the Groups

Characteristics	Groups			p-value^*
Characteristics	Auricular acupressuremean ± SD	Body acupressuremean ± SD	Controlmean ± SD	p-value^*
Age (years)	70.42 ± 5.90	68.21 ± 6.02	68.43 ± 6.37	F = 1.971 p ≥ 0.05

	Auricular acupressure N (%)	Body acupressure N (%)	Control N (%)	p-value^**
Marital status
Married	33 (70.2)	23 (48.9)	26 (55.3)	$χ^{2} =$ 3.808
Single	1 (2.1)	1 (2.1)	2 (4.3)	p ≥ 0.05
Widow/divorced	13 (27.7)	23 (48.9)	19 (40.4)
Smoking
Yes	7 (14.9)	5 (10.6)	8 (17)	$χ^{2} =$ 0.816
No	40 (85.1)	42 (89.4)	39 (83)	p ≥ 0.05
Alcohol consumption
Yes	1 (2.1)	1 (2.1)	2 (4.3)	$χ^{2}$ = 1.023
No	46 (97.9)	46 (97.9)	45 (95.7)	p ≥ 0.05
Underlying disease (diabetes or hypertension)
Yes	40 (85.1)	42 (89.4)	39 (83)	$χ^{2}$ = 1.184
No	7 (14.9)	5 (10.6)	8 (17)	p ≥ 0.05

p-values calculated using the ANOVA.

p-values calculated using the $χ^{2}$ test.

SD, standard deviation.

Primary outcome: Pain

McGill’s AMTS and VAS were used to assess the pain of the subjects. ANOVA test was used to compare the studied groups regarding the pain variable before the intervention. The results showed no statistically significant difference between the three groups in pain scores (p < 0.05). ANCOVA test showed a statistically significant difference between the study groups regarding the pain level on the first, second, and third days, considering the possible differences before the intervention (p < 0.001). The Repeated Measure ANOVA test showed that the trend of changes has a significant difference in different time intervals of the interventions. This trend was reported as a decrease in the groups (p-time <0.001). The trend of changes was significant based on the type of intervention, and the decreasing trend of changes among different groups did not have the same pattern. Examining the means of the study groups indicated that auricular acupressure had a higher impact in reducing pain severity (p-intervention <0.001).

Examining the interaction effect of time and intervention also revealed that the pain reduction in the auricular acupressure group over time was different from that of the body acupressure group (p-interaction <0.001). Eta square showed that the difference in the pain reduction was significant (η2 > 0.14). LSD post hoc test was used to compare two groups at the end of the first, second, and third days. The results of this test revealed a statistically significant difference between the three groups (intervention and control groups) (p < 0.001). According to the means, the mean pain in the auricular acupressure group was lower, and this intervention was more effective (Tables 2 and 3).

Table 2.

Comparison of the Pain Between the Groups with Visual Analog Scale

Group	Mean ± SD				Repeated measure ANOVA
Group	Before	End of first day	End of the second day	End of the third day	Time effect (Eta square)	Intervention effect(Eta square)	Interaction effect (Eta square)
Auricular Acupressure	6.59 (0.82)	5.72 (0.65)	5.04 (0.62)	4.32 (0.47)	p < 0.001 (0.595)	p < 0.001 (0.572)	p < 0.001 (0.154)
Body Acupressure	6.76 (0.78)	6.04 (0.62)	5.47 (0.65)	4.80 (0.53)	p < 0.001 (0.827)
Control	6.79 (0.72)	6.32 (0.66)	6.04 (0.69)	5.64 (0.67)	p < 0.001 (0.848)
P (Eta square)	^*0.428 (0.012)	p < 0.001^** (0.198)	p < 0.001^** (0.390)	p < 0.001^** (0.545)

p-values calculated using the ANOVA.

p-values calculated using the ANCOVA.

SD, standard deviation.

Table 3.

Comparison of the Pain Between the Groups with McGill

Group	Mean ± SD				Repeated measure ANOVA
Group	Before	End of the first day	End of the second day	End of the third day	Time effect (Eta square)	Intervention effect (Eta square)	Interaction effect (Eta square)
Auricular Acupressure	27.42 (0.58)	23.25 (0.49)	18.25 (0.57)	14.42 (0.49)	p < 0.001 (0.883)	p < 0.001 (0.978)	p < 0.001 (0.845)
Body Acupressure	27.59 (0.77)	23.15 (0.78)	20.27 (0.54)	17.62 (0.60)	p < 0.001 (0.975)
Control	27.89 (0.67)	26.79 (0.75)	25.36 (0.87)	24.63 (0.57)	p < 0.001 (0.991)
P (Eta square)	^*0.145 (0.707)	p < 0.001^** (0.852)	p < 0.001^** (0.950)	p < 0.001^** (0.982)

p-values calculated using the ANOVA.

p-values calculated using the ANCOVA.

SD, standard deviation.

Discussion

The results demonstrated that both auricular and body acupressure were more effective in reducing pain compared with the control group. However, auricular acupressure was found to be more effective than body acupressure in pain reduction. Alimoradi et al. (2020) conducted a similar study comparing the effects of these interventions on labor pain and reported similar findings: both types of acupressure reduced labor pain, but auricular acupressure was more effective.⁴⁰ In a clinical trial, Khalu Baghari et al. (2022) compared the effects of acupressure at Hugo’s point with auricular acupressure on pain after elective cesarean section. They showed that both methods of auricular acupressure and Hugo acupressure were effective in reducing pain after cesarean section. However, the continuation of pain reduction in the auricular acupressure was more than in the Hugo acupressure.⁴¹ Several studies have examined the impact of acupressure on pain reduction in different populations.^11,36

Yeung et al. (2024) examined the effect of acupressure on presumptive knee osteoarthritis in middle-aged and older adults during a randomized clinical trial in Hong Kong. They reported that using acupressure was effective and affordable in relieving knee pain and improving mobility in middle-aged and older adults with presumptive knee osteoarthritis.⁴² Lang et al. (2007) conducted a study titled “Acupressure on the Baihui and Hegu points to relieve the pain of patients with radial bone fracture before reaching the hospital.” The results indicated a significant difference in pain severity between the acupressure group and the control group.⁴³ Sharifi Rizi et al. (2018) examined the impact of acupressure on the pain of cancer patients undergoing bone marrow biopsy during a clinical trial. They reported that the mean pain score of the intervention group decreased significantly compared with the other groups.³¹

Reviewing the results of various studies does not provide a clear picture of the efficacy of acupressure in controlling pain in different clinical conditions. However, some studies have reported a significant improvement in the pain control of patients with renal colic using acupressure. Other studies such as Bolvardi et al. (2019) and Lao et al. (1999) did not report significant effects of this treatment method. Kilinç T et al. (2024) also obtained similar results in a study on patients after laparoscopic cholecystectomy.^44–46

The difference in results may be attributed to several factors. Some of them are the differences in the target population, the acupressure points used, the follow-up duration, the initial pain severity, and the type and dose of the drugs. Furthermore, variations in pain control methods and data analysis techniques may influence the outcomes of these studies. Due to the conflicting results of existing research, it is currently inconclusive whether acupressure is definitively effective in pain management. To establish more reliable findings, future studies should use rigorous designs and larger sample sizes. In addition, a more detailed examination of the mechanism of the action of acupressure in pain control and the identification of predictive factors of response to this treatment can be useful in improving its efficacy.

Various studies have indicated that auricular acupressure can be an effective intervention in pain control, especially postoperative pain. For example, in a study on patients undergoing knee arthroplasty, Romuli et al. (2014) observed a significant reduction in pain severity and an improvement in physical function after receiving auricular acupressure.⁴⁷ A meta-analysis by Pin Lee et al. (2023) also indicated that the combination of auricular acupressure with conventional treatments is much more effective in reducing postoperative pain in hip fracture patients than conventional treatment alone.²⁶ Hoffman et al. (2024) also proved the efficacy of auricular acupressure in reducing pain after knee and hip replacement surgery in their clinical trial.⁴⁸

The exact mechanism of the action of auricular acupressure on reducing pain has not yet been clarified. However, studies indicate that this method can work through several neurologic and physiologic mechanisms.¹¹ One of these mechanisms is the activation of the body’s endorphin system and the release of endorphins as natural pain relievers. Auricular acupressure can also help reduce the transmission of pain signals to the brain by modulating the activity of neurotransmitters in the central nervous system and stimulating the sensory receptors of the skin and muscles.

Some studies have also indicated that auricular acupressure can help improve mood and reduce anxiety by reducing cortisol (stress hormone) levels and increasing serotonin levels. The gate control theory of pain can also be proposed as one of the possible mechanisms of the auricular acupressure effect. Based on this theory, stimulating sensory receptors of the skin and muscles during acupressure sends stronger nerve signals to the spinal cord. They can block pain signals and prevent their transmission to the brain.^12,49

The results of the present study are inconsistent with those of some previous studies, such as Chang et al. (2012) and Yeh et al. (2010), who examined the impact of auricular acupressure on reducing postoperative pain.^50,51 These studies revealed that auricular acupressure was not significantly effective in reducing the patients’ pain after knee arthroplasty surgery and back surgery. The difference in the results of these studies can be attributed to several factors, such as the differences in the acupressure points used, the intervention duration, the surgery type, the initial pain severity, and the characteristics of the study population. For example, selected acupressure points might not have been effective enough to reduce pain in the study by Chang et al. In addition, the short duration of the intervention in the study by Yeh et al. might not have been enough to cause permanent changes in pain severity. Moreover, the difference in the pain points can affect the efficacy of auricular acupressure.

The pain caused by different surgeries may have different neural mechanisms and, thus, respond differently to different treatments. Generally, the conflicting results of existing studies on the impact of auricular acupressure on pain reduction highlight the complexity of this issue and the need for more studies with a more accurate design and better control of intervening variables. These studies should investigate the factors affecting the efficacy of auricular acupressure, such as acupressure points, intervention duration, initial pain severity, and the surgery type. Future studies should also investigate the neural mechanisms underlying the effect of auricular acupressure to gain a better understanding of how this method affects pain reduction.

Limitations

The lack of including male elderly and long-term follow-up of the participants limits the generalizability of the results. Future studies with a stronger design and more comprehensive sampling can eliminate these limitations and provide a more complete picture of the efficacy of the intervention. These studies can investigate the efficacy of auricular acupressure in other age groups, types of surgeries, and in combination with other therapeutic interventions. Conducting a study on the neurologic and physiologic mechanisms underlying the effect of auricular acupressure can also help to develop and improve this therapeutic method.

Conclusion

The results suggest that auricular acupressure can be used as an effective complementary intervention in pain control after knee arthroplasty in elderly women. This therapeutic method was effective in reducing pain severity. In addition, it can be considered a safe and accessible treatment option for patients due to its cost-efficacy and noninterference with pharmaceutical treatment methods. The results emphasize the significance of multidimensional approaches in postoperative pain control. Combining pharmaceutical and complementary techniques such as acupressure can help improve treatment outcomes and increase patient satisfaction.

Confirmation Statement

The authors F.G., T.B., N.R., H.Y., and K.S. declare that they have not been employed by the government of Iran; moreover, the performed research has been conducted in personal capacity (not as an official representative in the mentioned country) and personal finance. The authors F.G., T.B., N.R., H.Y., and K.S. cooperated with Shahed University as an academic institution where research or education is the primary function of the entity; this cooperation is needed for case study availability and ethical issues approval, which is done by the Ethics Committee of Shahed University. All listed authors declare that figures must be printed in black and white. No color figures existed. The authors F.G., T.B., N.R., H.Y., and K.S. confirm all the above statements.

Authors’ Contributions

Conceptualization: F.G., T.B., and N.R.; data curation: H.Y.; formal analysis: F.G.; investigation: F.G. and K.S.; methodology: F.G., T.B., and N.R.; supervision: N.R.; writing—original draft: F.G. and T.B.; and writing—review and editing: F.G., T.B., N.R., H.Y., and K.S.

Footnotes

Acknowledgments

This research is an extension of a thesis Ghanbari, F. (2024). Comparing the effect of Auricular Acupressure and Body Acupressure on Pain and Anxiety in female older adults undergoing Knee Replacement Arthroplasty (Bachelor’s thesis, Shahed University, Tehran, Iran). Bachelor of Science in Geriatric Nursing, defended on June 15, 2024.⁵² The authors want to express their sincere gratitude to the university administration, the management of Shafa Yahiaeian, and all the participants who generously contributed their time and expertise to this study.

Author Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

This article received no external funding.

Ethics Approval and Consent to Participate

Ethical permission was obtained from the Ethics Committee of Shahid University with a code of IR.SHAHED.REC.1402.024. The trial with an ID of IRCT20110912007529N28 was registered in the list of clinical trials in Iran. This study was conducted based on the ethical standards included in the Declaration of Helsinki and based on the guidelines of the Ministry of Health, Medicine, and Medical Education of Iran. The participants completed the informed consent form after being informed about the purpose and method of the study. To protect the privacy and identity of the subjects, the code numbers were used instead of their names. Also, no penalty was considered for patients who wanted to leave the trial.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article.

Supplemental Material

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