key: cord-0819535-68wuvbfc authors: Yang, Juan; Do, Alex; Mallory, Molly J; Wahner-Roedler, Dietlind L; Chon, Tony Y; Bauer, Brent A title: Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic date: 2021-12-12 journal: Glob Adv Health Med DOI: 10.1177/21649561211058076 sha: 1cb669f4c0d709ed849645880d9875d617a178a9 doc_id: 819535 cord_uid: 68wuvbfc Anxiety is highly reported during the COVID-19 pandemic. The use of acupressure for anxiety is a common practice in integrative medicine, and previous literature has shown that acupressure can be an effective and feasible alternative treatment for decreasing anxiety. Given the social distancing requirements during the COVID-19 pandemic, it appears reasonable to assume that acupressure may be especially suited to treat anxiety under these circumstances. However, there has been relatively little reported use of acupressure for anxiety during the pandemic. This viewpoint aims to highlight the possible role of acupressure as a self-administered therapeutic approach for anxiety amidst the COVID-19 pandemic and to outline key areas for future research. general population during the COVID-19 pandemic reached 15.15%. 2 Front line medical health care providers have been reported to have high anxiety with prevalence rates of 11.4% among physicians and 27.9% among nurses. 3 Given the fact that anxious reactions might trigger social behavioral responses to viral outbreaks-both mitigating as well as facilitating the spread of infection, the mental health of people during the COVID-19 outbreak has received widespread attention. It is critical that health officials and health care providers understand that heightened levels of anxiety call for optimal self-care and accessible mental health services. Given that little empirical attention has been devoted to this issue, it is not surprising that there has been no optimal guideline developed specific to the treatment of anxiety during COVID-19. Treatments need to be based on our knowledge of how to manage anxiety in medically ill, as well as physically healthy, individuals while taking into consideration the effects of social distancing, travel restriction, quarantine, case isolation, and uncertainty of the magnitude, duration, and speed of the pandemic. The optimal anti-anxiety interventions should be implemented mainly as a home-based practice to augment the patient's own resiliency in coping with the COVID-19 pandemic. At present, there are multiple pharmacologic agents that may be used for treating acute anxiety in the out-patient setting as well as in hospitalized patients with COVID-19 infection including alprazolam, lorazepam, gabapentin, hydroxyzine, olanzapine, quetiapine, and haloperidol. Due to limitations such as overuse, side-effects, adverse events, tolerance, and substance addiction, the discovery of non- pharmacological methods that decrease anxiety effectively is clinically significant. The use of integrative medicine in this setting is now emphasized. Expert recommendations include anti-anxiety lifestyle strategies such as breathing exercises, relaxation techniques, self-compassion, remaining physically active, finding sources of joy and inspiration, and connecting with others. Self-interventions such as self-administered acupressure, Yoga, Qigong et al are also often recommended by health care providers for use at home. Acupressure is a form of Tuina, also known as "Chinese massage"-which is a branch of Traditional Chinese Medicine. It is a technique of pressing or/ and rubbing acupoints with a finger or noninvasive tool. It has been proven to be effective in many medical and psychological disorders. In recent years, acupressure has been receiving more attention for anxiety management, and many randomized controlled trials 4-13 and reviews [14] [15] [16] have shown promising evidence for anxiety relief (Table 1 ). According to the Oxford grading of evidence, all reported studies strongly support the favorable effect. Based on the theory of Traditional Chinese Medicine, meridians are a network of a person's energy, also known as Qi, connected to different areas, specific organs, or body systems, while acupoints on the meridians reflect the physiological and pathological conditions of their corresponding body part. Manipulations performed on specific acupoints can stimulate the meridians Qi, resulting in the regulating of the channels and balancing of energy, thus restoring the body to normal health. Previous publications indicate that acupressure can effectively regulate the autonomic nervous system, increase parasympathetic activity, and reduce plasma cortisol levels without significantly decreasing normal heart rate and blood pressure among healthy populations. 5, 7, 12 The COVID-19 pandemic has had a detrimental impact on global healthcare systems with a remarkable ripple effect on every aspect of life as we know it, resulting in a series of subsequent social-economic consequences including social distancing, travel restriction, self-isolation, shortage of medical resources, lack of personal protective equipment, economic crisis, and recession. Convenient, secure, and cost-effective medical care services for millions of people are needed. Acupressure, if effective, is a safe, economic, and easily accessible technique that could provide anxious people with a tool to help control and manage their emotional and mental health concerns during this epidemic as well as in the future. Due to its simplicity and accessibility, acupressure can be selfadministered without physical contact with practitioners or healthcare providers. Successful self-treatment administrated by the participants indicates that this approach is useful in reducing anxiety without seeking help from others. Therefore, we hypothesize that acupressure can be of benefit in decreasing the anxiety among people in the shadow of COVID-19 in addition to other related symptoms and signs such as stress, pain, fatigue, insomnia, vomiting, and nausea. Acupoints of Yin Tang (EX-HN3), Shenmen (HT7), Neiguan (P6), Hegu (LI4), Taichong (LV3), Jianjing (GB21), Zu San Li (ST36), Sanyinjiao (SP6), Neiting (ST44), Auricular Shenmen acupoint (inferior lateral wall of the triangular fossa), and Relaxation point (superior lateral wall of the triangular fossa) are the most frequently used points to treat anxiety. Intermittent pressure can be used on the selected acupoint for 3-10 minutes per point, 2-3 points per session, twice daily. "Intermittent acupressure" here means pressure moderate pressure resulting in mild distention of De Qi on a point every .5 seconds. "Deqi" refers to a traditional Chinese medicine term indicating the achievement of satisfactory therapeutic effects of acupoint stimulation of suan (aching or soreness), ma (numbness or tingling), zhang (fullness, distention, or pressure), and zhong (heaviness) felt by the patients. (Figure 1 ) Acupressure could open an attainable avenue of medical care for patients to directly reduce their anxiety in a safe, comfortable, and cost-effective manner. Developing this intervention may aid healthcare professionals, researchers, and policymakers to gain more feasible information on how to deal with anxiety related to the COVID-19 crisis. When interpreting our recommendation, several limitations must be considered. Future research into acupressure intervention should be focused on the following 3 main areas. First and foremost, while there are a few studies examining acupressure for anxiety thus far, we are not aware of any trials specifically evaluating acupressure on patients with anxiety under the pandemic conditions of COVID-19. Second, the most frequently used acupoints recorded in literature are predominantly distributed on different superficial parts of the head, trunk, hand, and foot of the human body, whereas their detailed effects and mutual interactions are not known yet. Finally, except for sparse reports, the actual underlying mechanisms of acupressure therapy are still not fully known, and there is a clear need for more laboratory and clinical research to confirm the magnitude of the effect of acupressure on anxiety during COVID-19 pandemic. In conclusion, preliminary data regarding the use of acupressure for anxiety supports our hypothesis that acupressure can effectively reduce anxiety during the COVID-19 pandemic. We therefore recommend that health care providers consider applying this noninvasive method to address anxiety. While further studies regarding this practice are needed, the existing evidence suggests that acupressure may be safe and effective in the interim. WHO coronavirus (COVID-19) dashboard Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: A systematic review and meta-analysis Prevalence and Influencing Factors of Anxiety and Depression Symptoms in the First-Line Medical Staff Fighting Against COVID-19 in Gansu The effect of acupressure at third liver point on the anxiety level in patients with primary dysmenorrhea Auricular acupressure relieves anxiety and fatigue, and reduces cortisol levels in postcaesarean section women: A single-blind, randomised controlled study The Effect of Acupressure at GB-21 and SP-6 Acupoints on Anxiety Level and Maternal-Fetal Attachment in Primiparous Women: a Randomized Controlled Clinical Trial. Nursing and midwifery studies The effect of acupressure on pain, anxiety, and the physiological indexes of patients with cancer undergoing bone marrow biopsy The effect of acupressure application on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer Effect of acupressure on preoperative cesarean section anxiety Auricular acupressure as a treatment for anxiety before extracorporeal shock wave lithotripsy in the elderly Effectiveness of acupressure on dental anxiety in children Comparison of the effects of hand reflexology versus acupressure on anxiety and vital signs in female patients with coronary artery diseases The effects of acupressure on physiological indicators of pain in children undergoing tonsillectomy: A randomized, single-blind, placebo-controlled trial study Acupuncture or Acupressure on Yintang (EX-HN 3) for Anxiety: A Preliminary Review Effects of acupressure on anxiety: A systematic review and meta-analysis The effect of acupressure on the anxiety of patients undergoing hemodialysis-a review We gratefully acknowledge the valuable support of The HEAD Foundation, Singapore for this work. BB contributed to the conception and design of the work. JY collected the data and prepared the first draft of the manuscript. BB and DW revised the manuscript critically for important intellectual content. AD, MM and TC revised the last version of the manuscript. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.