Jurnal Kesehatan Vol 10 No.

2 Oktober (2022) – P-ISSN : 2338-7823 E-ISSN : 2747-0253

Health Journal “Love That Renewed”

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Halaman Utama Jurnal : https://journal.stikesborromeus.ac.id/index.php/

Sebuah Review Mengenai Efek Akupuntur Terhadap Rehabilitasi Covid-19

Yelini Fan Hardi 1, Willie Japaries2

STIAB Nalanda
Jl. Pulo Gebang No.107, RT.13/RW.4, Pulo Gebang, Kec. Cakung, Kota Jakarta Timur, Daerah Khusus
Ibukota Jakarta

Abstract
In December 2019, Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2), a highly
transmissible and virulent human infecting virus that emerged in Wuhan, China, causing a respiratory
disease called Corona Virus disease 2019 (COVID-19), which has massively impacted global public health
and caused widespread disruption to daily life. After COVID-19, some patients may experience
immobilization syndrome associated with respiratory dysfunction, and up to 20% cases progresses to Post
COVID Syndrome (PCS) followed by headache, attention disorder, hair loss, and dyspnea, with life-
threatening conditions, both of which require rehabilitation interventions. In this study, we selected English
language full texts from PubMed from 2020 until 2022, mainly discussed about acupuncture effects in
COVID-19 rehabilitation including PCS. Although only limited evidence found, acupuncture has certain
beneficial effects in COVID-19 rehabilitation.

Keywords: Acupunture, Rehabilitation, COVID_19.

Abstrak
Sindrom Pernafasan Akut Parah Corona Virus 2 (SARS-CoV-2), virus yang menginfeksi manusia
yang sangat mudah menular dan ganas yang muncul di Wuhan, Cina, pada Desember 2019; menyebabkan
penyakit pernapasan yang disebut penyakit Virus Corona 2019 (COVID-19), yang telah memberikan dampak
besar pada kesehatan masyarakat global dan menyebabkan gangguan luas pada kehidupan sehari-hari.
Setelah COVID-19, beberapa pasien mungkin mengalami sindrom imobilisasi yang terkait dengan disfungsi
pernapasan, dan hampir mencapai 20% kasus berkembang menjadi Post COVID Syndrome (PCS) diikuti
oleh sakit kepala, gangguan perhatian, rambut rontok, dan dispnea, dengan kondisi yang mengancam jiwa,
yang keduanya memerlukan intervensi rehabilitasi. Dalam studi ini, kami memilih teks lengkap bahasa
Inggris dari PubMed dari tahun 2020 hingga 2022, terutama membahas tentang efek akupunktur dalam
rehabilitasi COVID-19 termasuk PCS. Meskipun hanya bukti terbatas yang ditemukan, akupunktur memiliki
efek menguntungkan tertentu dalam rehabilitasi COVID-19.

Kata Kunci: Akupuntur, Rehabilitasi, COVID_19.

I. PENDAHULUAN
In December 2019, COVID-19 emerged in Wuhan, Hubei province, China, and spread rapidly
throughout the world, causing a large global outbreak and becoming a major health concern [1]. The World
Health Organization (WHO) declared COVID-19 Public Health Emergency of International Concern
(PHEIC) on January 2020, and subsequently a global pandemic on March 2020 [2, 3]. Globally, as for
December 2022, there were 646,740,524 confirmed cases, including 6,637,512 deaths, reported to WHO [4].
Patients with COVID-19 presented various symptoms including fever and dry cough as main
manifestations; accompanied with fatigue, headache, loss of smell, sore throat, upper airway congestion,
muscle ache, shortness of breath, and diarrhea. Progression to pneumonia, mainly occurring during the second
or third week of a symptomatic infection, and is associated with decreased oxygen saturation, gas exchange
reduction in arterial blood, extreme increase in inflammatory markers, and lymphocytopenia [5-9]. It may
causes various degrees of illness, with clinical manifestations ranging from asymptomatic cases to
complications which are susceptible to elderly people and patients with underlying comorbidities, those

Received Agustus 30, 2022; Revised September 2, 2022; Accepted Oktober 22, 2022
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including Acute Respiratory Distress Syndrome (ARDS), refractory metabolic acidosis, septic shock, low
blood oxygen and Multiple Organ Dysfunction Syndrome (MODS) [10-13].
After suffered from severe COVID-19, many patients would experience a variety of normal
functioning problems [14], such as undergoing prolonged bed rest, leading to immobilization syndrome
associated with respiratory dysfunction, both of which might require rehabilitation interventions. Prolonged
immobilization which have a strong impact on patients’ general condition, leads to muscle weakness, motor
deconditioning syndrome, balance and postural impairment, joint stiffness, pain and limitation [15,16].
During stay in the Intensive Care Unit (ICU), some patients might undergo various degrees of respiratory,
physical and psychological distress, which mostly persisting beyond ICU or hospital discharge [17,18].
Most people with COVID-19 could fully recover, but current evidence shows that approximately
10% to 20% of people experience various medium and long-term effects after recovering from the initial
illness [19]. These medium and long-term effects are called Post-COVID syndrome (PCS), also known as
Long-COVID Syndrome (LCS). PCS is a complex, multi-system illness, that is diagnosed when symptoms
persist 1–3 months after COVID-19 (20-22). PCS is widespread, with 37% of patients experiencing at least
1 symptom 3 months after COVID-19 [23]. Fatigue, which affecting 58% of patients, is the most common
PCS symptom, usually followed by headache, attention disorder, hair loss, shortness of breath, rarely life-
threatening conditions (e.g., stroke and inflammatory cardiomyopathy) [24]. Multiple organ (i.e. in the lungs,
heart, kidneys, liver, spleen, or pancreas) imaging abnormalities were found in 29% of PCS patients [25]. As
there is no single treatment for PCS, a multidisciplinary approach was recommended by guidelines and expert
panels [22,23,26].
The diagnosis of COVID-19 infection can only be made by Real-Time Polymerase Chain Reaction
(RT-PCR) nucleic acid detection in respiratory tract samples [27]. Currently, there is not any approved
treatment for COVID-19, therefore the treatment management of the disease are symptomatic and supportive,
with the main goal of maintaining hydration, nutrition and controlling fever and respiratory symptoms [28].
The ongoing COVID-19 is also challenging rehabilitation services, placing heavy burden on the
healthcare systems, especially acute care units, and is already impacting the rehabilitation communities
[15,16,29]. Many services were reduced, in aim to free up healthcare staff for emergency services, and to
minimize the risk to patients, many of whom are at higher risk [30].
The complexity and variability of the damage caused by COVID-19, combined with the long term
disabling status that many patients will have. This means that there is no single COVID-19 specific method
for determining the need for rehabilitation [14]. It is therefore important that any rehabilitation intervention
should be tailored to the specific circumstance of each patient, and that it should be acknowledged, as already
observed in Severe Acute Respiratory Syndrome Corona Virus (SARS-CoV) and Middle East Respiratory
Syndrome Corona Virus ( MERS-CoV ). SARS-CoV may also have neurotropic effects causing neurological
involvement, which may be the reason for acute respiratory failure in COVID-19 patients to a certain degree
[31]. There is no specific evidence for COVID-19 rehabilitation, but it is a problem solving process and there
is a lot of evidence supporting for its effectiveness [14]. In a multi-disciplinary and multi-professional setting
which focusing on respiratory and motor functions, rehabilitation plays a vital role in the management of
patients with COVID-19 and PCS . Therefore it is important to set up rehabilitation treatment strategies that
achieve the optimal recovery of these patients.

II. TINJAUAN PUSTAKA

Acupunture
Acupuncture is well-known as one of the external treatment in Traditional Chinese Medicine (TCM)
for thousand years. Acupuncture has been used as a supporting treatment for some modern acute infectious
diseases, such as epidemic hemorrhagic fever, influenza, acute bacterial dysentery and SARS. Acupuncture
also effective in reducing fever, relieving cough and phlegm, alleviating gastrointestinal symptoms,
promoting respiratory function and preventing deterioration of disease [32-36]. A variety of studies have
investigated showed acupuncture were effective in alleviating the symptoms caused by COVID-19 and
played useful role in the prevention, treatment, and rehabilitation of patients with COVID-19 during this
pandemic [37].

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III. METODOLOGI PENELITIAN
In this review, we selected studies from PubMed with publication year from 2020 until 2022.
Inclusion criteria are studies with available full text in English language, with the main topic of acupuncture
(combined with or without other Traditional Chinese treatment, e.g. Chinese medicine, moxibustion, etc)
effects in COVID-19 rehabilitation including PCS. PRISMA Method were used for screening.

IV. HASIL DAN PEMBAHASAN

We found 65 databases from Pubmed related to Acupuncture, Covid-19 and rehabilitation. After
removing duplicate records and non related articles such as non acupuncture therapy, prevention and
treatment topic, we finally found 9 studies of acupuncture for COVID-19 rehabilitation as main topic. (Fig
1)

Records identified from:

Identification

PubMed Records removed before

Databases (n = 65) screening: (n = 2)
Duplicate records removed

Records screened Records excluded (n = 41)

(n = 63) Non acupuncture therapy for
COVID-19
Screening

Reports assessed for eligibility Reports excluded: (n = 13)

(n = 22) Acupuncture for COVID-19
prevention and treatment (n = 9)

Studies included in review

Included

(n = 5)
Reports of included studies
(n = 4)

Fig. 1 Prisma flow diagram for the review process

Related Reviews
Acupuncture can be used as a supportive treatment in low respiratory function and decreased
oxygen saturation cases. It also effective in relaxing respiratory muscles to improve respiratory function and
produce the local and systemic anti inflammatory effect on COVID-19 through the activation of cholinergic
anti-inflammatory pathway. Acupuncture can relieve anxiety and depression, enhance function retention and
improve life quality [38].
Early clinical reports suggest acupuncture can effectively deal with both symptoms and the
fundamental causes of PCS. Latest reports provided preliminary evidence of acupuncture's effectiveness in
managing PCS and may also have disease-modifying benefits. Acupuncture is an applicable supportive health
care method as part of a multidisciplinary approach for symptom control and disease management to improve
quality of life in PCS patients [20].
The result of a scoping review of 131 eligible studies about the effect of acupuncture and
moxibustion in the treatment, prevention and rehabilitation of patients with COVID-19, shows the
rehabilitation topic of the included studies were only 12.2%, frequently using acupoints Zusanli (ST36),
Feishu (BL13), Guanyuan (RN4), Dazhui ( DU14 ) [39].

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A meta-analysis and systematic review clarified the acupuncture safeness and effectiveness on
respiratory rehabilitation for patients during the COVID-19 treatment after weaning from the ventilator,
thereby improving the physiological function and life quality [40]. Acupuncture has a certain rehabilitative
effect on both respiratory disorders caused by COVID-19 and respiratory problems caused by mechanical
ventilation.

Case Reports
A 52-year-old female with PCS had 10 months of stiff fingers and liver contraction according to
ultrasound imaging. Other symptoms were chest oppression and difficulty in breathing, accompanied with
mild fever and body soreness. TCM diagnose was liver blood deficiency and blood stagnation. Acupuncture
treatment acupoints were: GeShu (UB17), GanShu (UB18), PiShu (UB20), ShenShu (UB23), QuQuan
(LR8), ZuSanLi (ST36), SanYinJiao (SP6), GuanYuan (CV4), YinGu (KI10); WaiGuan (TE5), ZuLinQi
(GB41), TianShu (ST25), WaiLing (ST26), DaJu (ST27), YinLingQuan (SP9), FengLong (ST40), XingJian
(LV2). The needles were retained for 40 minutes, with neutral manual manipulation every 10 minutes.
Acupoints selected are mainly related to recover the normal function of liver, replenishing the deficiency in
Qi and blood, regulating the blood circulation. After treatment, she reported considerable relief in breathing,
the fingers stiffness also reduced significantly and became movable. The ultrasound image of the liver
improved significantly. No adverse effects were reported by the patient [41].
Daily acupuncture and Chinese herbal medicine therapy were administered to an 81-year-old
woman, who suffered from a severe case of COVID-19 with repeated symptoms and prolonged illness total
51 days in hospital. Her mainly symptoms were fever, significant shortness of breath and decrease in
peripheral oxygen saturation (SpO2). After 9 days of therapy, the patient’s shortness of breath improved; CT
scan and blood tests showed significant enhancement. Acupuncture significantly decreased the patient’s
difficulty of breathing and heart rate, increased the SpO2, presented an anti inflammatory and calming effect,
improved the patient’s breathing function, while Chinese herbal medicine might make the effect of
acupuncture more stable (42).
A case study of a 46-year-old male with PCS had chest pain, low fever, poor appetite, mild
intermittent nausea, and headache. The TCM diagnostic was Lung Qi and Yin Deficiency, Qi and Blood
Stagnation, and Spleen Qi Deficiency with dampness. Acupuncture for this patient was associated with
reduced symptoms and signs of PCS. Patient stopped the treatment after 12 session due to the disappearance
of the symptoms and health improvement [43].
Another study case of a 50-year-old woman with PCS had 8 months of fatigue, loss of smell, chest pressure,
palpitations, and other symptoms followed by mild assessment-confirmed COVID-19. Previous medical tests
showed multi system-inflammatory involvement such as pericardial effusion, thyroid dysfunction and
elevated D-dimers. Cardiology and Pneumology cleared the patient for exercising to tolerance considering
that no serious pathology occur. The impression according to TCM was Heart, Lung, Spleen, and Kidney Qi
Deficiency. Then, this patient was given 7 sessions multidisciplinary acupuncture treatment of scalp,
auricular and body. After first acupuncture treatment session, her chest pressure and palpitations resolved.
After 6 treatment sessions, extending 9 weeks with PT-led SPTA, she completely recovered and continued
her normal exercise [44].
Discussion
According to TCM Febrile Disease theory, COVID-19 is regarded as the category of heat-
dampness‒toxin pestilence. In this study, patients who need rehabilitation were mostly in critical and post
state, which occur internal blockage, external desertion, Qi blood Yin Yang and internal organs exhaustion.
The rehabilitation goal is to nurture the fundamental deficiency condition in the Lungs and Kidney Qi, tonify
energy, and counter chronic fatigue by improving the digestive function. From the perspective of TCM,
acupuncture treatments were focused on reinforcing the kidney and spleen, and regulating the lung, heart and
liver [43], frequently chosen acupoints were Zusanli (ST36), Feishu (BL13), Guanyuan (RN4), Dazhui
(DU14).
In terms of rehabilitation effects, acupuncture has beneficial effects on improving respiratory
function, producing the local and systemic anti-inflammatory effect, relieving anxiety and depression,
enhancing function retention and improving life quality. We have not found any reports about its adverse and
side effect. Acupuncture is also convenient, simple & low in cost. The role of acupuncture as a part of
integrative therapies, did not replace antibiotics and symptomatic treatment as the standard care, although
specific drugs and therapies for COVID-19 are still lacking.

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We also found that the number of the evidence of acupuncture for COVID-19 rehabilitation is small and
heterogeneity scheme. Most of the included studies types were reviews, case reports, systematic reviews and
meta-analyses. In some countries, acupuncture was under-used, under-evaluated, and under-reported for the
treatment of COVID-19 [39]. Some reasons that acupuncture has not been chosen as a first-line therapy,
especially in the severe stage, were due to its invasive nature and the concern of the disease transmission to
healthcare providers from the patients through prolonged and close contact .

V. KESIMPULAN DAN SARAN

Acupuncture has beneficial effects for COVID-19 rehabilitation, such as improving respiratory
function, producing the local and systemic anti-inflammatory effect, relieving anxiety and depression,
enhancing function retention and improving life quality. Acupuncture also has beneficial effects on
inflammation and immunity for PCS patients. COVID-19 has challenged all healthcare units including
rehabilitation, and will remain in existence for at least a few years. Through analyzing and disseminating
acupuncture during the epidemic, escorting appropriate studies, and further advance evidence-based clinical
practice guidelines, we expect acupuncture can be promoted for greater role in worldwide assays to combat
the epidemic.

Ucapan Terima Kasih

This research was fully supported by Jakarta Nalanda Buddhist and Traditional Healthcare College.

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