{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T17:01:34Z","timestamp":1781629294391,"version":"3.54.5"},"reference-count":39,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T00:00:00Z","timestamp":1767830400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T00:00:00Z","timestamp":1772409600000},"content-version":"vor","delay-in-days":53,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J Transl Med"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Chronic fatigue syndrome (CFS) is a complex and disabling disorder characterized by persistent fatigue and functional impairment, with limited safe and effective nonpharmacologic treatment options. Tuina, a traditional manual therapy in Chinese medicine, has been increasingly applied for fatigue-related conditions, yet high-quality clinical evidence remains scarce. This study aimed to evaluate the efficacy and safety of Tuina combined with usual care (UC) in adults with CFS.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n This assessor-blinded, single-center randomized clinical trial was conducted from April 10, 2024, to January 10, 2025, at Shuguang Hospital, Shanghai University of Traditional Chinese Medicine. A total of 110 participants meeting the 1994 US Centers for Disease Control and Prevention diagnostic criteria for CFS were randomly assigned (1:1) to receive Tuina plus UC or UC alone. The Tuina group received three 20-minute sessions per week for 4\u2009weeks (12 sessions in total) in addition to UC, which included health education, lifestyle guidance, and individualized symptom-targeted treatments but excluded Tuina therapy. The primary outcome was fatigue severity at 4\u2009weeks measured by the 11-item Chalder Fatigue Questionnaire (CFQ-11). Secondary outcomes included anxiety and depression (Hospital Anxiety and Depression Scale), sleep quality (Pittsburgh Sleep Quality Index), and physical functioning and bodily pain (Short Form-36 subscales). Data were analyzed using analysis of covariance with baseline scores as covariates.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Baseline characteristics were comparable between groups. At week 4, compared with UC alone, Tuina plus UC led to greater improvement in fatigue (CFQ total score: adjusted mean difference \u22122.90 [95% CI \u22124.69 to \u22121.12];\n p<\/jats:italic>\n \u2009=\u20090.002; effect size 0.62), and more participants achieved the minimal clinically important difference in CFQ total score (89.1% vs 69.1%;\n p<\/jats:italic>\n \u2009<\u20090.01). Benefits also favoured Tuina for physical fatigue (\u22122.21 [95% CI \u22123.40 to \u22121.02];\n p<\/jats:italic>\n \u2009<\u20090.001; effect size 0.70), whereas the effect on mental fatigue was smaller (\u22120.79 [95% CI \u22121.52 to \u22120.06];\n p<\/jats:italic>\n \u2009=\u20090.03; effect size 0.41). Tuina further reduced anxiety (\u22121.79 [95% CI \u22122.92 to \u22120.65];\n p<\/jats:italic>\n \u2009=\u20090.002) and improved overall sleep quality (PSQI total score: \u22121.62 [95% CI \u22122.60 to \u22120.65];\n p<\/jats:italic>\n \u2009=\u20090.0013); among PSQI subscales, only sleep duration remained statistically significant after Bonferroni correction. Other secondary outcomes did not differ significantly between groups, and no serious adverse events occurred.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Tuina combined with UC produced clinically meaningful improvements in overall fatigue and significant improvements in physical fatigue compared with UC alone, with additional benefits in anxiety and overall sleep quality, and was safe and well tolerated. These findings suggest that Tuina may be a promising adjunctive therapy for CFS and warrant confirmation in larger multicenter trials with longer-term follow-up.<\/jats:p>\n <\/jats:sec>\n \n Trial registration<\/jats:title>\n \n International Traditional Medicine Clinical Trial Registry, ITMCTR2025000002. Registered 1 January 2025 \u2013 Retrospectively registered,\n https:\/\/itmctr.ccebtcm.org.cn\/mgt\/project\/view\/-5709466987144715200<\/jats:ext-link>\n .\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1186\/s12967-025-07624-7","type":"journal-article","created":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T14:49:54Z","timestamp":1767883794000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Tuina therapy for patients with chronic fatigue syndrome: a randomized controlled trial"],"prefix":"10.1186","volume":"24","author":[{"given":"Shoujian","family":"Wang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun","family":"Ren","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xin","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sitong","family":"Fang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tianxiang","family":"He","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhiwei","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shanda","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6854-4202","authenticated-orcid":false,"given":"Lingjun","family":"Kong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min","family":"Fang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,8]]},"reference":[{"issue":"12","key":"7624_CR1","doi-asserted-by":"publisher","first-page":"953","DOI":"10.7326\/0003-4819-121-12-199412150-00009","volume":"121","author":"K Fukuda","year":"1994","unstructured":"Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International chronic fatigue syndrome study group. Ann Intern Med. 1994;121(12):953\u201359.","journal-title":"Ann Intern Med"},{"key":"7624_CR2","doi-asserted-by":"publisher","first-page":"103198","DOI":"10.1016\/j.autneu.2024.103198","volume":"255","author":"T Liu","year":"2024","unstructured":"Liu T, Sun W, Guo S, Chen T, Zhu M, Yuan Z, et al. Research progress on pathogenesis of chronic fatigue syndrome and treatment of traditional Chinese and Western medicine. Auton Neurosci. 2024;255:103198.","journal-title":"Auton Neurosci"},{"issue":"1","key":"7624_CR3","doi-asserted-by":"publisher","first-page":"100","DOI":"10.1186\/s12967-020-02269-0","volume":"18","author":"EJ Lim","year":"2020","unstructured":"Lim EJ, Ahn YC, Jang ES, Lee SW, Lee SH, Son CG. Systematic review and meta-analysis of the prevalence of chronic fatigue syndrome\/myalgic encephalomyelitis (CFS\/ME). J Transl Med. 2020;18(1):100.","journal-title":"J Transl Med"},{"key":"7624_CR4","doi-asserted-by":"publisher","first-page":"985","DOI":"10.1007\/978-3-030-57231-0_32","volume-title":"PET and SPECT in psychiatry","author":"Y Watanabe","year":"2021","unstructured":"Watanabe Y. PET\/SPECT\/MRI\/fMRI studies in myalgic encephalomyelitis\/chronic fatigue syndrome. In: Dierckx RAJO, Otte A, de Vries EFJ, van Waarde A, Sommer IE, editors. PET and SPECT in psychiatry. Cham: Springer International Publishing; 2021. p. 985\u20131001."},{"key":"7624_CR5","unstructured":"Centers for Disease Control and Prevention. Myalgic Encephalomyelitis\/Chronic fatigue syndrome: monitoring the use of medicines and supplements. https:\/\/www.cdc.gov\/me-cfs\/hcp\/clinical-care\/monitoring-the-use-of-medicines-and-supplements.html. accessed Sep 10, 2024."},{"key":"7624_CR6","volume-title":"Nice evidence reviews collection. Pharmacological interventions: myalgic encephalomyelitis (or encephalopathy)\/chronic fatigue syndrome: diagnosis and management: evidence review F","author":"C National Guideline","year":"2021","unstructured":"National Guideline C. Nice evidence reviews collection. Pharmacological interventions: myalgic encephalomyelitis (or encephalopathy)\/chronic fatigue syndrome: diagnosis and management: evidence review F. London: National Institute for Health and Care Excellence (NICE); 2021."},{"key":"7624_CR7","unstructured":"Jason LA, Evans M, Porter N, Brown M, Brown A, Hunnell J, et al. The Development of a revised Canadian Myalgic encephalomyelitis chronic fatigue syndrome Case definition. Am J Biochem Biotechnol. 2010;6(2)."},{"issue":"2","key":"7624_CR8","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1177\/014107689108400224","volume":"84","author":"MC Sharpe","year":"1991","unstructured":"Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW, David A, et al. A report-chronic fatigue syndrome: guidelines for research. J R Soc Med. 1991;84(2):118\u201321.","journal-title":"J R Soc Med"},{"issue":"4","key":"7624_CR9","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1111\/j.1365-2796.2011.02428.x","volume":"270","author":"BM Carruthers","year":"2011","unstructured":"Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, et al. Myalgic encephalomyelitis: international consensus criteria. J Intern Med. 2011;270(4):327\u201338.","journal-title":"J Intern Med"},{"issue":"4","key":"7624_CR10","doi-asserted-by":"publisher","first-page":"397","DOI":"10.1017\/S135246581500017X","volume":"44","author":"BA Fernie","year":"2016","unstructured":"Fernie BA, Murphy G, Wells A, Nik\u010devi\u0107 AV, Spada MM. Treatment outcome and Metacognitive change in CBT and GET for chronic fatigue syndrome. Behav Cogn Psychother. 2016;44(4):397\u2013409.","journal-title":"Behav Cogn Psychother"},{"key":"7624_CR11","doi-asserted-by":"publisher","first-page":"400","DOI":"10.1016\/j.psychres.2017.08.035","volume":"257","author":"RL McBride","year":"2017","unstructured":"McBride RL, Horsfield S, Sandler CX, Cassar J, Casson S, Cvejic E, et al. Cognitive remediation training improves performance in patients with chronic fatigue syndrome. Psychiatry Res. 2017;257:400\u201305.","journal-title":"Psychiatry Res"},{"key":"7624_CR12","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1016\/j.smrv.2016.05.001","volume":"33","author":"C Russell","year":"2017","unstructured":"Russell C, Kyle SD, Wearden AJ. Do evidence based interventions for chronic fatigue syndrome improve sleep? A systematic review and narrative synthesis. Sleep Med Rev. 2017;33:101\u201310.","journal-title":"Sleep Med Rev"},{"issue":"10325","key":"7624_CR13","doi-asserted-by":"publisher","first-page":"611","DOI":"10.1016\/S0140-6736(22)00183-0","volume":"399","author":"SA Flottorp","year":"2022","unstructured":"Flottorp SA, Brurberg KG, Fink P, Knoop H, Wyller VBB. New NICE guideline on chronic fatigue syndrome: more ideology than science? Lancet. 2022;399(10325):611\u201313.","journal-title":"Lancet"},{"key":"7624_CR14","doi-asserted-by":"crossref","unstructured":"Vink M, Vink-Niese A. The updated NICE guidance exposed the serious flaws in CBT and Graded exercise therapy trials for ME\/CFS. Healthcare (basel). 2022;10(5).","DOI":"10.3390\/healthcare10050898"},{"issue":"12","key":"7624_CR15","doi-asserted-by":"publisher","first-page":"e2246538","DOI":"10.1001\/jamanetworkopen.2022.46538","volume":"5","author":"ZJ Cheng","year":"2022","unstructured":"Cheng ZJ, Zhang SP, Gu YJ, Chen ZY, Xie FF, Guan C, et al. Effectiveness of Tuina therapy combined with yijinjing exercise in the treatment of nonspecific chronic neck pain: a randomized clinical trial. JAMA Netw Open. 2022;5(12):e2246538.","journal-title":"JAMA Netw Open"},{"issue":"3","key":"7624_CR16","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1007\/s11606-018-4763-5","volume":"34","author":"A Perlman","year":"2019","unstructured":"Perlman A, Fogerite SG, Glass O, Bechard E, Ali A, Njike VY, et al. Efficacy and safety of massage for osteoarthritis of the knee: a randomized clinical trial. J Gen Intern Med. 2019;34(3):379\u201386.","journal-title":"J Gen Intern Med"},{"issue":"6","key":"7624_CR17","first-page":"491","volume":"42","author":"YX Xu","year":"2018","unstructured":"Xu YX. Tuina therapy combining back-shu and head acupoints for the treatment of chronic fatigue syndrome. J Zhejiang Univ Chin Med. 2018;42(6):491\u201393.","journal-title":"J Zhejiang Univ Chin Med"},{"issue":"2","key":"7624_CR18","first-page":"1188","volume":"37","author":"Y Lu","year":"2022","unstructured":"Lu Y, Zhang W, Li HN, Tan T, Su ZC, Zhang HJ. Randomized controlled study of modified Sini- san plus sijunzi decoction combined with abdominal Tuina for liver-stagnation and spleen-deficiency type chronic fatigue syndrome. Chin J Tradit Chin Med. 2022;37(2):1188\u201392.","journal-title":"Chin J Tradit Chin Med"},{"issue":"6","key":"7624_CR19","doi-asserted-by":"publisher","first-page":"819","DOI":"10.1016\/S0254-6272(18)30046-3","volume":"37","author":"H Li","year":"2017","unstructured":"Li H, Wang J, Zhang W, Zhao N, Hai X, Sun Q, et al. Chronic fatigue syndrome treated by the traditional Chinese procedure abdominal tuina: a randomized controlled clinical trial. J Tradit Chin Med. 2017;37(6):819\u201326.","journal-title":"J Tradit Chin Med"},{"key":"7624_CR20","first-page":"286","volume":"31","author":"F Liang","year":"2014","unstructured":"Liang F, Mei RJ. Clinical study of Tongdu Tuina therapy for chronic fatigue syndrome. World Latest Med Inf (Electron Ed). 2014;31:286.","journal-title":"World Latest Med Inf (electron Ed)"},{"issue":"1","key":"7624_CR21","first-page":"67","volume":"44","author":"Z Li","year":"2024","unstructured":"Li Z, Ji R, Yan C, Chen Y, Cao Z, Wang J. Acupoint massage at Shenque (CV 8) for chronic fatigue syndrome: a randomized controlled trial. Zhongguo Zhen Jiu. 2024;44(1):67\u201370.","journal-title":"Zhongguo Zhen Jiu"},{"issue":"2","key":"7624_CR22","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1016\/0022-3999(93)90081-P","volume":"37","author":"T Chalder","year":"1993","unstructured":"Chalder T, Berelowitz G, Pawlikowska T, Watts L, Wessely S, Wright D, et al. Development of a fatigue scale. J Psychosom Res. 1993;37(2):147\u201353.","journal-title":"J Psychosom Res"},{"issue":"1","key":"7624_CR23","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1093\/occmed\/kqu168","volume":"65","author":"C Jackson","year":"2015","unstructured":"Jackson C. The Chalder fatigue scale (CFQ 11). Occup Med (Lond). 2015;65(1):86.","journal-title":"Occup Med (lond)"},{"issue":"6","key":"7624_CR24","doi-asserted-by":"publisher","first-page":"361","DOI":"10.1111\/j.1600-0447.1983.tb09716.x","volume":"67","author":"AS Zigmond","year":"1983","unstructured":"Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361\u201370.","journal-title":"Acta Psychiatr Scand"},{"issue":"2","key":"7624_CR25","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1016\/0165-1781(89)90047-4","volume":"28","author":"DJ Buysse","year":"1989","unstructured":"Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193\u2013213.","journal-title":"Psychiatry Res"},{"issue":"3","key":"7624_CR26","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1097\/00005650-199303000-00006","volume":"31","author":"CA McHorney","year":"1993","unstructured":"McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-item Short-Form Health Survey (SF-36): ii. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31(3):247\u201363.","journal-title":"Med Care"},{"key":"7624_CR27","unstructured":"Yan Y WT, editors. Medical statistics. 5th. 2020. p. 523."},{"issue":"10092","key":"7624_CR28","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1016\/S0140-6736(16)32589-2","volume":"390","author":"LV Clark","year":"2017","unstructured":"Clark LV, Pesola F, Thomas JM, Vergara-Williamson M, Beynon M, White PD. Guided graded exercise self-help plus specialist medical care versus specialist medical care alone for chronic fatigue syndrome (GETSET): a pragmatic randomised controlled trial. Lancet. 2017;390(10092):363\u201373.","journal-title":"Lancet"},{"issue":"3\u20134","key":"7624_CR29","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1093\/biomet\/52.3-4.591","volume":"52","author":"SS Shapiro","year":"1965","unstructured":"Shapiro SS, Wilk MB. An analysis of variance test for normality (complete samples)\u2020. Biometrika. 1965;52(3\u20134):591\u2013611.","journal-title":"Biometrika"},{"key":"7624_CR30","doi-asserted-by":"publisher","first-page":"863","DOI":"10.3389\/fpsyg.2013.00863","volume":"4","author":"D Lakens","year":"2013","unstructured":"Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863.","journal-title":"Front Psychol"},{"key":"7624_CR31","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1186\/s12874-016-0167-6","volume":"16","author":"\u00c5 Nordin","year":"2016","unstructured":"Nordin \u00c5, Taft C, Lundgren-Nilsson \u00c5, Dencker A. Minimal important differences for fatigue patient reported outcome measures-a systematic review. BMC Med Res Methodol. 2016;16:62.","journal-title":"BMC Med Res Methodol"},{"key":"7624_CR32","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1186\/1471-2288-14-75","volume":"14","author":"TP Morris","year":"2014","unstructured":"Morris TP, White IR, Royston P. Tuning multiple imputation by predictive mean matching and local residual draws. BMC Med Res Methodol. 2014;14:75.","journal-title":"BMC Med Res Methodol"},{"issue":"11","key":"7624_CR33","doi-asserted-by":"publisher","first-page":"2172","DOI":"10.1177\/09622802231198795","volume":"32","author":"PC Austin","year":"2023","unstructured":"Austin PC, van Buuren S. Logistic regression vs. predictive mean matching for imputing binary covariates. Stat Methods Med Res. 2023;32(11):2172\u201383.","journal-title":"Stat Methods Med Res"},{"issue":"3","key":"7624_CR34","first-page":"1","volume":"45","author":"van Buuren S","year":"2011","unstructured":"van Buuren S, Groothuis-Oudshoorn K. Mice: multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1\u201367.","journal-title":"J Stat Softw"},{"issue":"5","key":"7624_CR35","doi-asserted-by":"publisher","first-page":"433","DOI":"10.1001\/jama.2021.2825","volume":"326","author":"VA Smith","year":"2021","unstructured":"Smith VA, Coffman CJ, Hudgens MG. Interpreting the results of intention-to-treat, per-protocol, and As-treated analyses of clinical trials. Jama. 2021;326(5):433\u201334.","journal-title":"Jama"},{"key":"7624_CR36","doi-asserted-by":"publisher","first-page":"111457","DOI":"10.1016\/j.jclinepi.2024.111457","volume":"173","author":"J Molero-Calafell","year":"2024","unstructured":"Molero-Calafell J, Bur\u00f3n A, Castells X, Porta M. Intention to treat and per protocol analyses: differences and similarities. J Clin Epidemiol. 2024;173:111457.","journal-title":"J Clin Epidemiol"},{"key":"7624_CR37","unstructured":"Lei W. Effects of spinal pinching and cupping therapy on clinical efficacy and plasma tryptophan levels in patients with chronic fatigue syndrome. 2011 [master\u2019s thesis]. Changsha (China): Hunan Univ Chin Med."},{"key":"7624_CR38","first-page":"483","volume":"4","author":"ZD Liu","year":"2008","unstructured":"Liu ZD, Wang DX, Zhang N, et al. Determination of plasma tryptophan levels in patients with chronic fatigue syndrome. J Cap Med Univ. 2008;4:483\u201386.","journal-title":"J Cap Med Univ"},{"key":"7624_CR39","first-page":"42","volume":"6","author":"LP Shi","year":"2006","unstructured":"Shi LP, Wang F, Ma ZY, He S, Bi HJ. Effects of Yanggan Roujin Formula on brain 5-hydroxytryptamine in rats with exercise-induced central fatigue. Gansu J Tradit Chin Med. 2006;6:42\u201344.","journal-title":"Gansu J Tradit Chin Med"}],"container-title":["Journal of Translational Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12967-025-07624-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12967-025-07624-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12967-025-07624-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T16:19:38Z","timestamp":1781626778000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12967-025-07624-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,8]]},"references-count":39,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["7624"],"URL":"https:\/\/doi.org\/10.1186\/s12967-025-07624-7","relation":{},"ISSN":["1479-5876"],"issn-type":[{"value":"1479-5876","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,8]]},"assertion":[{"value":"13 October 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"8 January 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was conducted in accordance with the Declaration of Helsinki. Ethics approval was obtained from the Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (approval No. 2024\u20131497\u2013080-01). Written informed consent was obtained from all participants.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"All authors declare no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest disclosures"}},{"value":"All authors approved the final manuscript and the submission to this journal.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"301"}}