Role of acupuncture in the treatment of insomnia: A comprehensive review

Acupuncture for primary insomnia: Effectiveness, safety, mechanisms and recommendations for clinical practice

Primary insomnia (PI) is an increasing concern in modern society. Cognitive-behavioral therapy for insomnia is the first-line recommendation, yet limited availability and cost impede its widespread use. While hypnotics are frequently used, balancing their benefits against the risk of adverse events poses challenges. This review summarizes the clinical and preclinical evidence of acupuncture as a treatment for PI, discussing its potential mechanisms and role in reliving insomnia. Clinical trials show that acupuncture improves subjective sleep quality, fatigue, cognitive impairments, and emotional symptoms with minimal adverse events. It also positively impacts objective sleep processes, including prolonging total sleep time, improving sleep efficiency, reducing sleep onset latency and wake after sleep onset, and enhancing sleep architecture/structure, including increasing N3% and REM%, and decreasing N1%. However, methodological shortcomings in some trials diminish the overall quality of evidence. Animal studies suggest that acupuncture restores circadian rhythms in sleep-deprived rodents and improves their performance in behavioral tests, possibly mediated by various clinical variables and pathways. These may involve neurotransmitters, brain-derived neurotrophic factors, inflammatory cytokines, the hypothalamic-pituitary-adrenal axis, gut microbiota, and other cellular events. While the existing findings support acupuncture as a promising therapeutic strategy for PI, additional high-quality trials are required to validate its benefits.

Alterations in Gut Microbiota and Upregulations of VPAC2 and Intestinal Tight Junctions Correlate with Anti-Inflammatory Effects of Electroacupuncture in Colitis Mice with Sleep Fragmentation

Simple Summary

Along with the modernization of society and people getting older, sleep disturbances and gut health have been identified as two key factors influencing aging, with dramatic effects on immunity and metabolism. Sleep is closely related to the gut, reflects the degree of chronic inflammation, and is associated with many degenerative diseases, hence the term “inflammaging”. This article addresses how sleep fragmentation affects the inflammatory state of the gut and elucidates the effects of restorative sleep and acupuncture on inflammatory gut remodeling and gut microbial recovery. In summary, fragmented sleep disrupted intestinal repair in mice with colitis, while electroacupuncture demonstrated likely results in alleviating colon inflammation, including maintaining colon length and daily body weight changes. In addition, the structure of the microbiota changed with decreasing gut inflammatory status. The intestinal tight junction proteins may be the key mechanism of electroacupuncture in treating sleep-fragmented ulcerative colitis mice. Electroacupuncture affects VIP through VPAC2 and further regulates intestinal mucosal immunity. This experiment demonstrates how physical stimulation stabilizes the intestinal epithelium and exerts an important anti-inflammatory effect.

Abstract

The relationship between inflammatory bowel disease and sleep disturbances is complicated and of increasing interest. We investigated the inflammatory and immunological consequences of EA in sleep-deprived colitis and found that dextran sulfate sodium (DSS)-induced colitis in sleep-fragmented (SF) mice was more severe than that in mice with normal sleep. This increase in the severity of colitis was accompanied by reduced body weight, shortened colon length, and deteriorated disease activity index. DSS with SF mice presented obvious diminished intestinal tight junction proteins (claudin-1 and occludin), elevated proinflammatory cytokines (CRP, IFN-γ, IL-6), lowered melatonin and adiponectin levels, downregulated vasoactive intestinal peptide (VIP) type 1 and 2 receptor (VPAC1, VPAC2) expression, and decreased diversity of gut bacteria. EA ameliorated colitis severity and preserved the performance of the epithelial tight junction proteins and VIP receptors, especially VPAC2. Meanwhile, the innate lymphoid cells-derived cytokines in both group 2 (IL-4, IL5, IL-9, IL-13) and group 3 (IL-22, GM-CSF) were elevated in mice colon tissue. Furthermore, dysbiosis was confirmed in the DSS group with and without SF, and EA could maintain the species diversity. Firmicutes could be restored, such as Lachnospiraceae, and Proteobacteria become rebalanced, mainly Enterobacteriaceae, after EA intervention. On the other hand, SF plays different roles in physiological and pathological conditions. In normal mice, interrupted sleep did not affect the expression of claudin-1 and occludin. But VPAC1, VPAC2, and gut microbiota diversity, including Burkholderiaceae and Rhodococcus, were opposite to mice in an inflamed state.

The Role and Clinical Observation of Traditional Chinese Medicine in Relieving Senile Insomnia: A Systematic Review and Meta-Analysis

Objective

To assess the role and clinical observation of traditional Chinese medicine (TCM) in relieving senile insomnia and conduct a systematic evaluation and meta-analysis.

Methods

We searched Chinese literatures from some database, including the China Knowledge Network database, Chongqing CQVIP Chinese database, Wanfang database, and Chinese Biomedical Literature database. In addition, English literature retrieval database PubMed and the Cochrane Library were included in this meta-analysis. The randomized controlled trial (RCT) of cognitive behavioral therapy was found in the treatment of chronic insomnia. All articles were current up to December 1, 2021, and references in the literature were hand searched.

Results

About 16 studies were included, involving 1260 elderly patients with insomnia. Meta-analysis results showed that compared with the control group, the sleep latency of the experimental group MD = -8.02, 95% CI (10.95, 5.01), the number of awakenings of the experimental group MD = -0.41, 95% CI (0.68, 0.14), the total sleep time of the experimental group MD = 39.41, 95% CI (27.05, 51.71), the sleep efficiency of the experimental group MD = 7.82, 95% CI (1.87, 13.75) the Pittsburgh sleep quality index of the experimental group MD = 2.41, 95% CI (3.12, 1.46), the effective rate of the experimental group: OR = 3.12, 95% CI (1.76, 5.48), and the insomnia severity index of the experimental group MD = 1.05, 95% CI (2.04, 0.52).

Conclusion

Our current study has indicated that TCM may play a central role in relieving senile insomnia and may be effective when treating insomnia. However, due to the low quality of trial methodology and publication bias, it cannot be fully confirmed. Further high-quality trials are needed to be investigated in the future.

Can acupuncture improve objective sleep indices in patients with primary insomnia? A systematic review and meta-analysis

BACKGROUND

The efficacy of acupuncture for treating primary insomnia (PI) has been explored in several meta-analyses where the outcomes measures were based on subjective self-reported sleep rating scales. Sleep state misperception is common in PI and self-reports underestimate sleep duration and quality. No systematic reviews or meta-analyses have investigated the efficacy of acupuncture in improving objective sleep measures in PI.

OBJECTIVE

To perform a systematic review to determine whether objective sleep parameters are improved by acupuncture in patients with PI.

METHODS

Randomized controlled trials treating PI via verum-acupuncture versus sham-/placebo-acupuncture or waitlist control were searched for in English [MEDLINE (via PubMed), Sciverse ScienceDirect, Cochrane Central Register of Controlled Trials (CENTRAL), AMED, Springer, EMBASE (Elsevier), Ebsco Medline, and PsycINFO (ProQuest)] and Chinese (SinoMed, CNKI, Wanfang and CQVIP) databases, from the dates of the databases' inception to January 2020. The parameters of polysomnography (PSG), actigraphy, or micromovement sensitive mattress/pillow sleep monitoring systems were considered as the primary outcome measures. Revman 5.3 and Stata 16.0 software were used to conduct the meta-analysis. Heterogeneity was examined by using I² statistics and publication bias was assessed via Egger's test.

RESULTS

Eleven studies involving 775 patients met the inclusion criteria. The results of meta-analysis suggested that acupuncture can increase total sleep time [MD = 55.29, 95%CI (29.16, 81.42), p < 0.01], increase sleep efficiency [MD = 8.96, 95%CI (3.97, 13.95), p < 0.01], decrease wake after sleep onset [MD = -49.54, 95%CI (-82.98, -16.09), p < 0.01], and reduce number of awakening times [MD = -6.29, 95%CI (-10.75, -1.82), p < 0.01] compared with either sham-/placebo-acupuncture or waitlist control. Subsequent analysis indicated a superior effect for verum-acupuncture in comparison with sham-/placebo-acupuncture or waitlist-control when the recommended lowest threshold dosage (12 sessions) was met. Despite positive outcomes, most studies reviewed were heterogeneous and at risk of bias due to methodological issues.

CONCLUSIONS

Despite limited evidence, acupuncture was significantly associated with improvements in several objective sleep parameters (increases in total sleep time and sleep efficiency, and reductions in wake after sleep onset and number of awakening times) as well as subjective sleep quantity and quality in patients with PI. A minimum therapeutic threshold dosage (≥12 sessions) is recommended. Well-designed RCTs using PSG are required to clarify the influence of acupuncture on sleep architecture/structure and to promote better application of acupuncture as a treatment for PI.

Research trends of acupuncture therapy on insomnia in two decades (from 1999 to 2018):a bibliometric analysis

Objectives

We aimed to evaluate the global scientific output of research of acupuncture on insomnia and explore the hotspots and frontiers from 1999 to 2018, by using bibliometric methods.

Methods

Articles about acupuncture therapy on insomnia were retrieved from the Web of Science Core Collection (WoSCC). We used Citespace V to analyze publication years, journals, countries, institutions, authors and cited authors. We plotted the reference co-citation network and key words to analyze the research hotspots and trends.

Results

Until August 31, 2018 31, 2018, a total of 292 records in acupuncture therapy on insomnia research were identified from 1999 to 2018. The number and rate of the annual publication gradually increased. Respectively, SLEEP and J NEUROPSYCH CLIN N (journal of neuropsychiatry and clinical neurosciences) ranked the first in the frequency and centality of cited joural. Among countries, China ranked highest in the number of publications and the top 3 institutes were in Hong Kong. Chung KF and Yeung WF were the most productive authors and YEUNG WF ranked the first in the cited authors. In the ranking of frequency and in cited reference, the first was the article published in by CAO HJ and KALAVAPALLI R. ‘Randomized controlled trial’ had a high frequncy and centrality in keyword.

Conclusions

A higher degree of acceptance acupuncture was obtained in the Asian. Recently, systematic reviews and clinic trials most focused on electrocacupuncture and acupressure among the acupuncture therapy.

Acupuncture for Back Pain, Knee Pain and Insomnia in Transverse Myelitis – a Case Report

This case report describes the use of acupuncture for back pain, knee pain and insomnia in a 49 year old woman with a recent diagnosis of transverse myelitis with paraplegia, sensory disturbance, and bladder and bowel dysfunction. She was receiving intensive in-patient multi-disciplinary rehabilitation but was struggling to participate fully due to pain and poor sleep quality. She received a course of acupuncture in addition to standard care and reported substantial benefits including reduction in pain, improved sleep and mood, and reduction in daytime fatigue. Effective symptom control allowed this patient to participate more fully in her rehabilitation programme. Reduction of knee pain and sleep disturbance was maintained until discharge, 15 weeks after the last acupuncture treatment. This case report suggests that acupuncture may be an option to consider for other patients with pain or sleep disturbance that is interfering with their rehabilitation programme.

Instant sedative effect of acupuncture at GV20 on the frequency of electroencephalogram α and β waves in a model of sleep deprivation

Sleep deprivation (SD) adversely affects brain function and is accompanied by frequency-dependent changes in electroencephalograms (EEGs). Recent studies have suggested that acupuncture is an emerging alternative therapy for SD. However, the involvement of the frequency of EEG α and β waves in the protective effect of acupuncture against SD remains unknown. The present study investigated the instant effect of acupuncture at GV20 on insomnia by analyzing the frequency of α and β waves using electroencephalography in a model of sleep deprivation. A total of 16 rats (Wistar; male; weight, 340±10 g) were divided randomly into four groups (4 rats per group) to create a rat model of sleep deprivation using the modified multiple platform method in the GV20 group, the sham acupoint group and the model group. After 72 h of sleep deprivation for these three groups and normal feeding for the blank group, the EEG data of all four groups were documented. Following the initial measurement, the GV20 group was treated by acupuncture at GV20 and the sham acupoint group was treated at the sham acupoint, and their EEGs were recorded during the treatment. The frequency of α and β waves of all EEG data were analyzed. Prior to intervention, the GV20 group, the sham acupoint group and the model group exhibited no significant differences in α and β wave frequencies; however, the α wave frequency of these three groups was significantly decreased compared with the blank group (P<0.05), whereas the β wave frequency of these three groups was significantly increased compared with the blank group (P<0.05). This suggested that sleep deprivation affected the frequency of brain waves and enhanced the excitability of the cerebral cortex. During acupuncture treatment with retained needle conditioning, the GV20 group indicated a significant increase in α wave frequency (P<0.05), as well as a significant decrease in β wave frequency compared with prior to treatment (P<0.05), whereas the sham acupoint group exhibited no significant changes. The present findings from a rat model of sleep deprivation suggested that acupuncture treatment at GV20 may reduce the excitability of the brain cortex. Due to its sedative effect, treatment at GV20 may be considered for the treatment of insomnia and related symptoms.

Sleep patterns in a randomized controlled trial of auricular acupuncture and cognitive behavioral therapy for insomnia

The aim of the study was to objectively examine how sleep patterns were affected in a short- and long-term perspective after auricular acupuncture (AA) and cognitive behavioral therapy for insomnia (CBT-i). Sixty participants with insomnia disorders (men/women 9/51; mean age of 60.5 years, (SD 9.4)), were randomized to group treatment with AA or CBT-i. Actigraphy recordings were made at baseline, post-treatment and 6-month follow-up. The CBT-i group reduced their time in bed, their actual sleeping time, their sleep latency and their actual time awake. The AA group slept longer, increased their time in bed and decreased their sleep latency post-treatment. The between-groups results differed in wake-up time, rising, time in bed, actual sleep time and actual wake time. The differences were not maintained six months later. In accordance with previous findings the results support the notion that the objective sleep time does not necessarily affect the subjective perception of insomnia.

A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury

Background: Headaches are prevalent among Service members with traumatic brain injury (TBI); 80% report chronic or recurrent headache. Evidence for nonpharmacologic treatments, such as acupuncture, are needed. Objective: The aim of this research was to determine if two types of acupuncture (auricular acupuncture [AA] and traditional Chinese acupuncture [TCA]) were feasible and more effective than usual care (UC) alone for TBI-related headache. Materials and Methods:Design: This was a three-armed, parallel, randomized exploratory study. Setting: The research took place at three military treatment facilities in the Washington, DC, metropolitan area. Patients: The subjects were previously deployed Service members (18-69 years old) with mild-to-moderate TBI and headaches. Intervention: The interventions explored were UC alone or with the addition of AA or TCA. Outcome Measures: The primary outcome was the Headache Impact Test (HIT). Secondary outcomes were the Numerical Rating Scale (NRS), Pittsburgh Sleep Quality Index, Post-Traumatic Stress Checklist, Symptom Checklist-90-R, Medical Outcome Study Quality of Life (QoL), Beck Depression Inventory, State-Trait Anxiety Inventory, the Automated Neuropsychological Assessment Metrics, and expectancy of outcome and acupuncture efficacy. Results: Mean HIT scores decreased in the AA and TCA groups but increased slightly in the UC-only group from baseline to week 6 [AA, -10.2% (-6.4 points); TCA, -4.6% (-2.9 points); UC, +0.8% (+0.6 points)]. Both acupuncture groups had sizable decreases in NRS (Pain Best), compared to UC (TCA versus UC: P = 0.0008, d = 1.70; AA versus UC: P = 0.0127, d = 1.6). No statistically significant results were found for any other secondary outcome measures. Conclusions: Both AA and TCA improved headache-related QoL more than UC did in Service members with TBI.

Factors affecting decision-making of patients choosing acupuncture in a public hospital

BACKGROUND

With increasing evidence to support its practice, acupuncture has been integrated within many hospitals around the world. The purpose of this study is to understand the factors affecting decision making of patients as they select acupuncture treatment for their medical conditions and symptoms within a public hospital.

METHODS

A qualitative study consisting of in depth interviews with 14 patients was conducted. All patients attended an acupuncture clinic within a public hospital. Data collected was analysed via thematic analysis.

RESULTS

Four main factor groups affecting decision making of patients were identified- factors affecting the level and value of patient-centric care, the confidence and trust patients place within the acupuncture service, the presence of collaborative efforts between acupuncturists and Western medicine practitioners, and the knowledge, culture and belief society has regarding the role of acupuncture and Western medicine. All participants interviewed had more than one factor group present as enablers toward their eventual selection of acupuncture for ailment management. It was also noted that although the majority of participants had sufficient knowledge regarding acupuncture, there were a select few who had misperceptions or no knowledge regarding certain aspects of acupuncture.

CONCLUSIONS

There may be certain patterns in the way patients choose to utilise acupuncture services in public hospitals. Further studies should also be carried out in other public hospitals to analyse the factor groups identified further.

Effects of electroacupuncture on stress-related symptoms in medical students: a randomised placebo-controlled study

OBJECTIVE

To assess the effects of electroacupuncture (EA) on relieving stress-related symptoms-sleep disorders, anxiety, depression and burnout-in medical students.

METHODS

Eighty-two students were randomised into an EA treatment group (n=30), a sham TENS group (n=18) and an untreated control group (n=34). EA was applied at a continuous frequency of 2 Hz to the limbs, face, ears and scalp for 20 min once a week, over 6-8 weeks. Sham transcutaneous electrical nerve stimulation (TENS) was performed on similar sites for the same number of times in each session and for the same length of time. Outcome measurements included a comparison of the indices obtained by different self-applied questionnaires before and after treatment. The surveys used were the Mini-Sleep Questionnaire (MSQ), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), the Beck Depression and Anxiety Inventories (BDI and BAI) and the Maslach Burnout Inventory-Student Survey (MBI-SS), in addition to the Quality of Life Questionnaire-abbreviated version (WHOQOL-bref).

RESULTS

EA significantly improved scores on the MSQ, PSQI, BDI and the cynicism and academic efficacy (AE) dimensions of the MBI-SS in relation to the control. Sleep quality (MSQ) improved from 36.9 (SD 7.6) to 25.0 (5.7) with EA, 37.6 (6.0) to 32.1 (6.9) with sham TENS, and 36.5 (5.9) to 33.6 (6.7) in the controls (p=0.0000). Compared with the sham TENS group, EA significantly reduced scores on the PSQI. Score improvements in the sham TENS group in relation to control group were significant in the MSQ, BDI and AE. In the EA group, the number of students with better scores after intervention was significantly higher for the MSQ, PSQI, ESS and BAI. This only occurred for the MSQ in the sham TENS group and for the MSQ and ESS in the control group.

CONCLUSIONS

EA significantly reduced stress-related mental symptoms. The improvement obtained by sham TENS compared with the control group confirmed the presence of a placebo effect resulting from the treatment ritual.

Effects of acupuncture on the symptoms of anxiety and depression caused by premenstrual dysphoric disorder

OBJECTIVE

The objective of this investigation was to evaluate the effects of acupuncture and sham acupuncture on the symptoms of anxiety and depression brought on by premenstrual dysphoric disorder (PMDD).

METHODS

In a single-blind randomised clinical trial, 30 volunteers with PMDD were assigned alternately to group 1 (acupuncture) or group 2 (sham acupuncture), and completed an evaluation of symptoms of anxiety and depression using the Hamilton Anxiety (HAM-A) and Hamilton Depression (HAM-D) Rating Scales. The procedure was performed twice a week for two menstrual cycles, for a total of 16 attendances for each participant.

RESULTS

Before the intervention the mean HAM-A and HAM-D scores did not differ between groups. Following the intervention symptoms of anxiety and depression were reduced in both groups; however, the improvement was significant in group 1 compared to group 2, as shown by a mean reduction in HAM-A scores of 58.9% in group 1 and 21.2% in group 2 (p<0.001). The reduction in the mean HAM-D scores was 52.0% in group 1 and 19.6% in group 2, resulting in a significant difference (p=0.012).

CONCLUSIONS

The results suggest that acupuncture could be another treatment option for PMDD patients.

The effect of Benson's relaxation technique on the quality of sleep of Iranian hemodialysis patients: a randomized trial

OBJECTIVE

This study was performed to evaluate the effectiveness of Benson's relaxation technique in the quality of sleep of hemodialysis patients.

DESIGN

It was a randomized controlled trial with a pre-post-test design. A total of 86 hemodialysis patients referring to hemodialysis units were assigned to either the intervention (receiving Benson's relaxation technique) or the control group (routine care) through block randomization.

SETTING

The study was performed in two hemodialysis units affiliated to Shiraz University of Medical Sciences, Shiraz, Iran.

INTERVENTION

The patients in the intervention group listened to the audiotape of Benson's relaxation technique twice a day each time for twenty minutes for eight weeks.

MAIN OUTCOME MEASURES

The global score of Pittsburgh Sleep Quality Index (PSQI) as well as its components was computed in both the intervention and the control group before and at the 8th week of the intervention.

RESULTS

The results of ANCOVA indicated significant differences between the two groups regarding the scores of Pittsburgh Sleep Quality Index subscales, such as sleep disturbance, daytime dysfunction, the use of sleep medication, and subjective sleep quality and as well as its global scores at the 8th week of the intervention (p<0.05).

CONCLUSIONS

This study highlighted the importance of Benson's relaxation technique in improvement of the sleep quality of the patients on hemodialysis. Thus, educational sessions are recommended to be planned on this cost effective and easy to use relaxation technique in order to improve hemodialysis patients' sleep quality. Further studies are needed to assess the effectiveness of this technique in other groups of patients.

Review of systematic reviews about the efficacy of non-pharmacological interventions to improve sleep quality in insomnia

Background  Insomnia is a very common condition in various populations. Non-pharmacological interventions might offer (safe) alternatives for hypnotics. Aim  To evaluate the evidence for efficacy from systematic reviews about non-pharmacological interventions to improve sleep quality in insomnia by a systematic review of systematic reviews and meta-analyses. Search strategy  Search strategies were conducted in the Database of Abstracts of Reviews of Effects (2002-July 2008), The Cochrane Database of Systematic Reviews (2000-July 2008) and PubMed (1950-July 2008). Sleep quality was the outcome measure of interest. Selection criteria  Systematic reviews about the efficacy of one or more non-pharmacological interventions for insomnia, concerning both adult and elderly populations, were included. Reviews that included studies performed among populations suffering with severe neurological or cognitive impairments or with addictive disorders were excluded. Data analysis  Relevant data were extracted. The quality of the reviews found was appraised by using the Overview Quality Assessment Questionnaire. The evidence was appraised and divided into six classes. Results and conclusions  Sixteen reviews about 17 interventions were included. Six reviews were of adequate methodological quality. Of these, only one provided an effect size: a moderate effect was found for music-assisted relaxation. Weak evidence indicating a large effect was found for multicomponent cognitive behavioural therapy, progressive muscle relaxation, stimulus control and 'behavioural only'. Weak evidence indicating a moderate effect was found for paradoxical intention. Finally, weak evidence indicating a moderate to large effect was found for relaxation training. Because of the lack of sufficient methodological quality and the lack of calculated effect sizes, most of the included reviews were not suitable for drawing rigorous conclusions about the effect of non-pharmacological interventions on sleep quality in insomniacs. The non-pharmacological treatment of insomnia would benefit from renewed reviews based on a rigorous methodological approach.

Acupuncture for insomnia

BACKGROUND

Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are widely practised. However, it remains unclear whether current evidence is rigorous enough to support acupuncture for the treatment of insomnia.

OBJECTIVES

To determine the efficacy and safety of acupuncture for insomnia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts International, CINAHL, AMED, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the World Health Organization (WHO) Trials Portal (ICTRP) and relevant specialised registers of the Cochrane Collaboration in October 2011. We screened reference lists of all eligible reports and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised controlled trials evaluating any form of acupuncture for insomnia. They compared acupuncture with/without additional treatment against placebo or sham or no treatment or same additional treatment. We excluded trials that compared different acupuncture methods or acupuncture against other treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We used odds ratio (OR) and mean difference for binary and continuous outcomes respectively. We combined data in meta-analyses where appropriate.

MAIN RESULTS

Thirty-three trials were included. They recruited 2293 participants with insomnia, aged 15 to 98 years, some with medical conditions contributing to insomnia (stroke, end-stage renal disease, perimenopause, pregnancy, psychiatric diseases). They evaluated needle acupuncture, electroacupuncture, acupressure or magnetic acupressure.Compared with no treatment (two studies, 280 participants) or sham/placebo (two studies, 112 participants), acupressure resulted in more people with improvement in sleep quality (compared to no treatment: OR 13.08, 95% confidence interval (CI) 1.79 to 95.59; compared to sham/placebo: OR 6.62, 95% CI 1.78 to 24.55). However, when assuming that dropouts had a worse outcome in sensitivity analysis the beneficial effect of acupuncture was inconclusive. Compared with other treatment alone, acupuncture as an adjunct to other treatment might marginally increase the proportion of people with improved sleep quality (13 studies, 883 participants, OR 3.08, 95% CI 1.93 to 4.90). On subgroup analysis, only needle acupuncture but not electroacupuncture showed benefits. All trials had high risk of bias and were heterogeneous in the definition of insomnia, participant characteristics, acupoints and treatment regimen. The effect sizes were generally small with wide confidence intervals. Publication bias was likely present. Adverse effects were rarely reported and they were minor.

AUTHORS' CONCLUSIONS

Due to poor methodological quality, high levels of heterogeneity and publication bias, the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia. Larger high-quality clinical trials are required.

A comparison between acupuncture versus zolpidem in the treatment of primary insomnia

BACKGROUND

To determine the relative efficacy of acupuncture and zolpidem in the treatment of primary insomnia, we administered a sleep quality scale to thirty-three patients with primary insomnia randomly chosen to receive one of the two therapies at a psychosomatic clinic.

METHODS

A study in the psychosomatic clinic at a teaching hospital in southern Taiwan from November 2007 to November 2008. The 19 patients in acupuncture group underwent one acupuncture session a week. The 14 patients in the control group took zolpidem 1# (10mg) every night. Members of both groups returned to our clinic once a week for four weeks. The main outcome measure was the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Both groups were found to have improved significantly. Using generalized estimating equation analysis to test the variance with group and time as factors, we found both groups improved over time at a similar rate (p=0.79). In regression analysis, setting the fourth total PSQI score to zero, the baseline PSQI score was 4.13 (p<0.001), the second score 1.32 (p=0.005), and the third 1.49 (p=0.03); men had a higher PSQI score 1.56 than women (p=0.02); the increasing age of one year would have lower PSQI score 0.08 (p<0.001) and increasing educational level of one year which would decrease PSQI score 0.25 (p=0.007).

CONCLUSIONS

Acupuncture might be used as an alternative strategy compared to zolpidem for the treatment of primary insomnia.

Effects of electroacupuncture on stress-related symptoms in medical students: a randomised controlled pilot study

OBJECTIVE

To assess the effects of electroacupuncture on stress-related symptoms-sleep disorders, anxiety, depression and burnout-in medical students, and provide data to inform a power analysis to determinate numbers for future trials.

METHODS

Twenty-five students were randomly assigned to an electroacupuncture (n=12) group or control group (n=13) that did not receive treatment. Electroacupuncture was applied at a continuous frequency 2 Hz for 20 min once a week for 8 weeks at sites on the extremities, face, ear and scalp. The outcomes of the students treated with electroacupuncture were compared with those of the control group at the endpoint, controlling the influence of baseline scores. The instruments used were self-administered questionnaires that comprised the validated Portuguese version of the mini-sleep questionnaire (MSQ), the Pittsburgh sleep quality index (PSQI), the Epworth sleepiness scale (ESS), the Beck depression inventory (BDI), the Beck anxiety inventory, the Maslach burnout inventory-student survey (MBI-SS), and World Health Organization quality of life assessment - abbreviated version (WHOQOL-bref).

RESULTS

The medical students treated with electroacupuncture showed a significant decrease compared with the control group for MSQ scores (p=0.04) and PSQI (p=0.006). After treatment, 75% students in the electroacupuncture group presented a good sleep quality, compared with 23.1% of the students in the control group. No significant difference on daytime sleepiness was shown by the ESS. The electroacupuncture group showed significant improvement on depressive symptoms (BDI), the emotional exhaustion and cynicism dimensions of burnout (MBI-SS) and physical health (WHOQOL-bref).

CONCLUSIONS

Electroacupuncture was associated with a significant reduction of stress-related symptoms, but because of the study design the authors cannot say what proportion of the reduction was due to needle stimulation.

Acupuncture for depression and myalgia in patients with hepatitis: an observational study

BACKGROUND

Depressive symptoms and myalgia are commonly seen in patients with chronic hepatitis B and chronic hepatitis C.

OBJECTIVE

To investigate the efficacy of acupuncture treatment on depressive symptoms and myalgia in patients with hepatitis.

METHODS

Of 44 patients with hepatitis screened for depression and myalgia, 28 were enrolled and included in the study. The main outcome measure for depressive symptoms was Beck's Depression Inventory (BDI). For pain/myalgia, patients rated their pain on a scale from 0 to 10. Patients with a score greater than the cut-off point in either score were allocated to acupuncture treatment. The Chinese method of acupuncture was used. Treatment continued for 6 weeks.

RESULTS

At baseline, 17/44 patients (39%) had a BDI score ≥17 and 24 (55%) had a pain score ≥5. A total of 28 patients were allocated to acupuncture treatment, forming three groups: group 1, 13 patients with high BDI and high myalgia scores; group 2, 11 patients with low BDI score but high myalgia score; group 3, 4 patients with high BDI score but low myalgia score. Adherence to treatment was good; all patients completed the sessions and there were no drop-outs. Significant improvements in end-treatment BDI and in myalgia scores compared with baseline levels was found.

CONCLUSION

Acupuncture seems to be a promising treatment for patients with hepatitis. Further studies are warranted in large populations to establish the therapeutic role of acupuncture.

Auricular acupuncture for insomnia: a systematic review

OBJECTIVE

Auricular acupuncture (AA) is a therapeutic method by which specific points on the auricle are stimulated to treat various conditions. AA is often recommended as treatment for insomnia. The aim of this systematic review was to evaluate data from randomised, placebo-controlled clinical trials testing the effectiveness of AA for treating insomnia.

METHODS

We searched the literature using 18 databases from their inception to April 2008 without language restrictions. All prospective randomised clinical trials (RCTs) of AA for subjects with insomnia were considered. Methodological quality was assessed using the Jadad score.

RESULTS

We identified 433 possible relevant articles, in which include 10 acceptable RCTs. The methodological quality of the trials was generally poor. Magnetic pellets AA was compared with placebo AA in three of the studies. The results suggested beneficial effects on sleep efficiency compared with placebo AA. One RCT tested needle AA compared with placebo AA and failed to show the effectiveness of AA. Four RCTs compared Semen Vaccariae or magnetic pellet AA with conventional drugs (estazolam or diazepam). Favourable effects for AA were found. Two RCTs tested thumbtack needle AA vs. no treatment suggested beneficial effects of AA on a sleep score.

CONCLUSION

We conclude that, because of the paucity and of the poor quality of the data, the evidence for the effectiveness of AA for the symptomatic treatment of insomnia is limited. Further, rigorously designed trials are warranted to confirm these results.

The status and future of acupuncture clinical research

On November 8-9, 2007, the Society for Acupuncture Research (SAR) hosted an international conference to mark the tenth anniversary of the landmark National Institutes of Health Consensus Development Conference on Acupuncture. More than 300 acupuncture researchers, practitioners, students, funding agency personnel, and health policy analysts from 20 countries attended the SAR meeting held at the University of Maryland School of Medicine, Baltimore, MD. This paper summarizes important invited lectures in the area of clinical research. Specifically, included are: a review of the recently conducted German trials and observational studies on low-back pain (LBP), gonarthrosis, migraine, and tension-type headache (the Acupuncture Research Trials and the German Acupuncture Trials, plus observational studies); a systematic review of acupuncture treatment for knee osteoarthritis (OA); and an overview of acupuncture trials in neurologic conditions, LBP, women's health, psychiatric disorders, and functional bowel disorders. A summary of the use of acupuncture in cancer care is also provided. Researchers involved in the German trials concluded that acupuncture is effective for treating chronic pain, but the correct selection of acupuncture points seems to play a limited role; no conclusions could be drawn about the placebo aspect of acupuncture, due to the design of the studies. Overall, when compared to sham, acupuncture did not show a benefit in treating knee OA or LBP, but acupuncture was better than a wait-list control and standard of care, respectively. In women's health, acupuncture has been found to be beneficial for patients with premenstrual syndrome, dysmenorrhea, several pregnancy-related conditions, and nausea in females who have cancers. Evidence on moxibustion for breech presentation, induction of labor, and reduction of menopausal symptoms is still inconclusive. In mental health, evidence for acupuncture's efficacy in treating neurologic and functional bowel disorder is still inconclusive. For chronic cancer-related problems such as pain, acupuncture may work well in stand-alone clinics; however, for acute or treatment-related symptoms, integration of acupuncture care into a busy and complex clinical environment is unlikely, unless compelling evidence of a considerable patient benefit can be established.