Telemedicine Resources for Acupuncturistsm, Part III: A Focus on Breath

September 21, 2021   |   Evidence in Integrative Healthcare

Part three in a series of blog post, this installment explores the importance of the breath and treatment options that acupuncture providers can offer with the use of telemedicine.

As referenced in part I of this series, many providers and patients may not have considered telemedicine as an option for chronic pain management. Yet, think of what acupuncturists “do” in a typical in-person treatment – pain management requires more than just needles. Providers often focus on the foundations of Traditional East Asian Medicine (TEAM): rest, diet, exercise, mental health, and if needed other modalities such as self-acupressure and breath work. This post will explore the importance of assessing breathing patterns for patients with chronic pain (cPain).

Note: When working with patients who experience chronic pain, providers should assess general well-being and ask about current mental health on a regular basis. Research suggests this population has a higher prevalence of anxiety, depression, catastrophizing and suicidal ideation and may be more susceptible to COVID-19.1Shanthanna H, et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia. 2020;75(7):935-44.

A recent article from an international panel of experts highlights recommendations for the management of chronic pain during the COVID-19 Pandemic.2Shanthanna H, et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia. 2020;75(7):935-44. This panel calls for multidisciplinary therapies and online programs for exercise, sleep hygiene, pacing and healthy lifestyle. As practitioners of TEAM, acupuncture providers often focus on similar foundations. Namely, TEAM-related breathing exercises that enhance the active involvement of patients in their recovery. See below for examples of how to support your patients with Telemedicine:

  • The Need
    • The diaphragm performs both postural and breathing functions; disruption in one function can negatively affect the other3Hodges PW, et al. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71.
    •  Poor diaphragm function is linked to chronic Low Back Pain (cLBP)4Kolar P, et al. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-62.
      • cLBP is #1 cause of cPain5Gaskin DJ, et al. The economic costs of pain in the United States. J Pain. 2012;13(8):715-24.
    • Thoracic Dominant Breathing or Paradoxical Breathing is a common breathing pattern disorder (BPD); abdomen draws in during inhalation, out on exhalation
      • Equates to limited diaphragmatic involvement
      • Often associated with stress or an emotional response to a traumatic event
    • Are you observing the breath of your patients? Evaluation and treatment of BPDs may be a missing component in the treatment of cPain.
  • Some Data
    • BPDs are an independent risk factor for cLBP6Smith MD, et al. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother. 2006;52(1):11-6. (N.B. cLBP is #1 cause of cPain7Gaskin DJ, et al. The economic costs of pain in the United States. J Pain. 2012;13(8):715-24.)
    • Patients with cPain have increased incidence of anxiety, depression, catastrophizing and suicidal ideation8Shanthanna H, et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia. 2020;75(7):935-44.
    • During the COVID-19 Pandemic, there are increased levels of anxiety and social isolation.9Smith BJ, et al. How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Res Pract. 2020;30(2)
    • All of the primary acupuncture meridians pass through the diaphragm; regulate breath = regulate the meridians
      • The Zhunag Zi speaks of, “The Authentic being breathes from the heels, the Commoner from their throat.”
  • Select Treatment Options
    • Are your patients breathing from the abdomen? If needed, have them place a hand on their chest & abdomen to evaluate while you observe.
    • Exercise (online or outdoors)
      • Simple 6 step technique (standing, seated or supine):
        • 1.      Grounding: Observe your heels
        • 2.      Belly: Breath from the belly
        • 3.      No tension: Make it more comfortable
        • 4.      Track: 4 phases of breath
        • 5.      Pause: Pause in the space/stillness after the exhale
        • 6.      Repeat…
    • Tai Chi & Qi Gong
      • Two meta-analyses suggest they may improve symptoms in patients with chronic low back pain.10Zhang Y, et al. The Beneficial Effects of Traditional Chinese Exercises for Adults with Low Back Pain: A Meta-Analysis of Randomized Controlled Trials. Medicina (Kaunas). 2019;55(5) 11Qin J, et al. Effect of Tai Chi alone or as additional therapy on low back pain: Systematic review and meta-analysis of randomized controlled trials. Medicine. 2019;98(37):e17099.
    • Acupressure (Self-administered)
      • Research suggests it may reduce cLBP12Murphy SL, et al. Self-Administered Acupressure for Chronic Low Back Pain: A Randomized Controlled Pilot Trial. Pain Med. 2019;20(12):2588-97, enhance sleep and reduce anxiety13Monson E, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-21.
      • Consider adding additional key acupoints to release the diaphragm; guide the patient through location and technique
        • Diaphragm (Ge) primary acupoints: BL-17 (Ge Shu) & BL-46 (Ge Guan); use a ball on the wall to apply direct pressure
        • Diaphragm attachment points: LR-13, GB-25, CV-14
        • Associated muscles:
          • Illio-psoas: GB-28
          • QL: BL-23/52
          • Transverse abdominus: GB-26
          • Obliques: GB-26, SP-21

General Reminders for Telemedicine Visits

  • The patient & acupuncturist must be located in same state
  • The acupuncturist must maintain an Active status license (in same state as patient)
  • Telemedicine must meet the standard of care for the particular patient and condition being treated
  • Chart documentation is same as in-person services; note that consent was obtained
  • Verbal consent OK, so long as costs are discussed