Review ArticleTraditional needle acupuncture treatment for insomnia: A systematic review of randomized controlled trials
Introduction
Insomnia is the most common sleep complaint, with approximately 9–15% of the general population worldwide suffering from insomnia symptoms accompanied by daytime consequences [1]. The prevalence of insomnia according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria is roughly 6% [1]. Primary insomnia and insomnia related to mental disorders are the two most frequent diagnoses among subjects with insomnia complaints [1], [2], [3]. The literature suggests that relationships exist between insomnia and major depression, anxiety disorders, substance abuse, suicide, decreased immune functioning, and cardiovascular disease [4]. Insomnia may lead to fatigue, irritability, and impaired concentration. It is associated with reduced quality of life, increased risk of traffic accidents, absenteeism, and impaired job performance [5], [6]. The economic impact of insomnia is high. A recent study found that the 6-month direct and indirect costs for adults with insomnia in the United States were $1,253 greater than that for matched controls without insomnia [7].
Although psychological, behavioral, and pharmacological therapies are effective treatments for insomnia, they have their own limitations. Psychological and behavioral therapies have remained largely underutilized, perhaps due to their time intensiveness and because they require significant expertise for effective implementation [8]. Pharmacotherapies such as benzodiazepines and non-benzodiazepine hypnotics are associated with dependence and potential abuse. Moreover, adverse effects such as sedation, cognitive impairment, and lack of motor coordination could be troublesome. Faced with the limitations of currently available treatments, patients have been using alternative therapies for insomnia [9].
A national survey in the United States showed that use of complementary and alternative medicine in treating insomnia has increased from 20.6% in 1990 to 26.4% in 1997 [9]. Among the complementary treatment modalities, acupuncture has been one of the most popular and safest procedures [10]. The acupuncturists insert fine needles at special points on the body, called acupoints, followed by manual or electrical stimulation. Traditional needle acupuncture (TNA) is usually performed according to the traditional Chinese medicine (TCM) theory [11]. Modified forms of acupuncture include laser acupuncture, acupressure, auricular therapy, and transcutaneous electrical nerve stimulation. The overall TCM model for the action of acupuncture is that normal body functioning involves regulation of Yin and Yang, Qi, along with blood and body fluids; while any disturbance of the homeostasis would lead to diseases [11]. Acupuncture treatment is able to restore the balance between Yin and Yang and normalize the flow of Qi, blood and body fluid by stimulating the acupoints on the meridian [11]. There are two main acupuncture approaches. The more commonly used individualized acupuncture requires the acupuncturists to select acupoints based on patients’ clinical state and response to acupuncture treatment [12]. The standardized acupuncture refers to the use of a set of fixed acupoints throughout the treatment course [13].
Because of the significant health risk of insomnia and the limitations of currently available treatments, there have been multiple anecdotal reports and controlled studies over the past decade to examine the efficacy of acupuncture for insomnia. Systematic reviews [14], [15], [16] on acupuncture for insomnia have also been published recently. However, previous reviews only covered English language literature and had not evaluated the standard in reporting acupuncture treatment. Auricular acupuncture, introduced by Paul Nogier in the 1950s, was also used in the treatment of insomnia. Recently, Chen et al. provided a systematic review on randomized controlled trials (RCTs) of auricular acupuncture for insomnia [17], in which the majority of the RCTs included were in Chinese. Although the review suggests that auricular acupuncture may be effective for treating insomnia, the qualities of the RCTs were low [17].
As many studies of TNA for insomnia have been published in non-Western scientific literature and have not been reviewed, it is therefore worthwhile to undertake a systematic review of RCTs using TNA as treatment for insomnia that were published in either English or Chinese. This study aimed to examine the efficacy of TNA for insomnia, the acupuncture regime used, the quality of the RCTs, and the standard in reporting acupuncture treatment [13]. Although TNA and auricular acupuncture are commonly used acupuncture options for treating insomnia and sometimes used concomitantly in clinical practice [11], auricular acupuncture was not included in this review because it is not based on the TCM theory [18] and its effects appear to be associated with stimulation of the vagal afferent nerve, which is not involved in body acupuncture [19], [20]. Other modified acupuncture practices such as acupressure and laser acupuncture were also not included in this review because the techniques used for acupoint stimulation are different from that in TNA.
Section snippets
Methods
We searched MEDLINE (1966–2006), EMBASE (1980–2006), Cochrane Central Register of Controlled Trials (1997–2006), PsycINFO (1887–2006), Dissertation Abstracts International (1861–2006), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982–2006), and Allied and Complementary Medicine (AMED) (1985–2006) in September 2006 using the grouped terms (acupuncture*, acupunc*, meridian* or acupoint*) and (sleep*, insomnia*, wakeful* or sleepless*). The search included Chinese Scientific
Description of the studies
The search yielded 577 potential article titles for review, of which 536 articles were excluded for reasons of irrelevance (Fig. 1). Forty-one clinical trials assessing the application of needle acupuncture for insomnia were retrieved for further assessment. Among these 41 trials, 18 did not include sham or placebo control, Western medication or non-treated control [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41]. One of the studies was
Discussion
The study reviewed the efficacy of TNA in treating insomnia. The results of this review seemingly suggested that TNA was overall superior to benzodiazepine, sleep hygiene counseling, and sham acupuncture in the acute treatment of insomnia. Of the 20 RCTs that were reviewed, 18 studies were conducted in China [46], [47], [48], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64]. These studies all scored 2 or less by the modified Jadad scale and were deemed to
References (82)
Epidemiology of insomnia: what we know and what we still need to learn
Sleep Med Rev
(2002)Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders
J Psychiatr Res
(1997)- et al.
Role of acupuncture in the treatment of insomnia: a comprehensive review
Complement Ther Clin Pract
(2007) - et al.
Investigation of specificity of auricular acupuncture points in regulation of autonomic function in anesthetized rats
Auton Neurosci
(2008) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996) - et al.
Observations on the efficacy of mind-tranquilizing acupuncture for treating 32 insomnia patients
J Tradit Chin Med Chin Mater Med Jilin
(2004) - et al.
A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality
Fertil Steril
(2006) - et al.
Characteristics of electroacupuncture-induced analgesia in mice. variation with strain, frequency, intensity and opioid involvement
Brain Res
(2002) - et al.
Noradrenergic neurons: morphine inhibition of spontaneous activity
Eur J Pharmacol
(1974) - et al.
Variation in diagnosis and treatment of chronic low back pain by traditional Chinese medicine acupuncturists
Complement Ther Med
(2001)
Introducing a placebo needle into acupuncture research
Lancet
Acupuncture: a promising treatment for depression during pregnancy
J Affect Disord
Diagnostic concordance for DSM-IV sleep disorders: a report from the APA/NIMH DSM-IV field trial
Am J Psychiatry
Insomnia as a health risk factor
Behav Sleep Med
Professional correlates of insomnia
Sleep
Clinical and socioeconomic correlates of insomnia
J Clin Psychiatry
The direct and indirect costs of untreated insomnia in adults in the United States
Sleep
The changing perspective on chronic insomnia management
J Clin Psychiatry
Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey
JAMA
ABC of complementary medicine. Acupuncture
BMJ
Acupuncture: theory, efficacy, and practice
Ann Intern Med
Standards for reporting interventions in controlled trials of acupuncture: the STRICTA recommendations. Standards for reporting interventions in controlled trails of acupuncture
Acupunct Med
Effects of acupuncture therapy on insomnia
J Adv Nurs
Auricular acupuncture treatment for insomnia: a systematic review
J Altern Complement Med
Auricular acupuncture
CMAJ
Effect of tragus clips on gastric peristalsis: a pilot study
J Altern Complement Med
A systematic review of randomized controlled trials of acupuncture for neck pain
Rheumatology
Bias in meta-analysis detected by a simple, graphical test
BMJ
Clinical observations on the treatment of insomnia by a Yang-reducing and Yin-reinforcing method
Shanghai J Acupunct Moxibustion
Controlled study on acupoint group prescription for electroacupuncture treatment of insomnia
Chin Acupunct Moxibustion
Comparison of the curative effects of electroacupuncture on insomnia between different points
Shanghai J Acupunct Moxibustion
Clinical observation on head acupuncture treatment on insomnia of 40 cases
J Zhe-jiang Chin Med
Observation on therapeutic effect of acupuncture at points Daling (PC 7) and Shimian in 48 cases of refractory insomnia
Chin Acupunct Moxibustion
Clinical observation on acupuncture treatment on insomnia at Shishenchong
Bull Med Res
A comparison of acupuncture treatment effect on insomnia at Chen and Xu hour
J Clin Acupunct Moxibustion
Clinical observation on acupuncture at Zhohai (KI 6) and Shenmai (BL 62) for treatment of insomnia
Chin Acupunct Moxibustion
Observations on the efficacy of mind-tranquilizing acupuncture for treating 63 insomnia patients
Shanghai J Acupunct Moxibustion
Mind-tranquilizing needling technique & insomnia: therapeutic efficacy observation of 63 cases
J Acupunct Tuina Sci
Cited by (69)
Adjunctive and alternative treatment of insomnia
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second EditionCan acupuncture improve objective sleep indices in patients with primary insomnia? A systematic review and meta-analysis
2021, Sleep MedicineCitation Excerpt :Types of intervention were restricted to traditional needle acupuncture (MA and EA). The following three types of trials were excluded: (1) trials in which the acupuncture methods were electro-spoon needle, laser acupuncture, acupoint injection, auricular acupressure, transcutaneous electrical acupoint stimulation, or other modified/special forms of acupuncture, because the techniques used for acupoint stimulation are different from those in traditional needle acupuncture [40]. The pathophysiological effects underlying those modified forms of acupuncture differ to traditional needle acupuncture as well [14]; (2) trials only comparing different acupuncture techniques/acupoints, or only comparing the different treatment dosage within the same acupuncture technique; and (3) trials in which acupuncture was an adjunct therapy with other interventions (eg., behavior therapy, psychotherapy, pharmacotherapy, etc.) provided the control groups also received other interventions.
Acupuncture for treatment of insomnia: An overview of systematic reviews
2019, Complementary Therapies in MedicineCitation Excerpt :All the outcomes were biased in randomness, allocation, concealment and blindness, and some outcomes have the problem of heterogeneity and the publication bias caused by the lack of inclusion of the study. The overview of SRs/MAs is a comprehensive research method for evaluating factors related to the treatment, etiology, diagnosis and prognosis of the same health problem.14,36 the purpose of us was to provide a comprehensive overview of the evidence obtained from the SRs/MAs to determine the effectiveness of acupuncture in the treatment of insomnia.
Electroacupuncture for tapering off long-term benzodiazepine use: A randomized controlled trial
2019, Journal of Psychiatric ResearchCitation Excerpt :The inserted acupuncture needles can be connected by an electric-stimulator to deliver electric-stimulation and is termed as electroacupuncture. Emerging evidence suggested that acupuncture could be effective for relieving insomnia (Cheuk et al., 2012; Yeung et al., 2009) and alleviating anxiety symptoms (Pilkington et al., 2007), which may be useful for reliving the benzodiazepine withdrawal symptoms and hence facilitate tapering. However, only a handful of case-series studies had examined the use of acupuncture to enhance benzodiazepine discontinuation rates (Qiao, 2002; Ruan and Zheng, 2002; Zhang et al., 2001).
Acupuncture and moxibustion for primary insomnia: A systematic review and meta-analysis of randomized controlled trials
2017, European Journal of Integrative MedicineCitation Excerpt :Acupuncture combined with moxibustion is commonly used concurrently for many diseases including primary insomnia and has been reported to be a successful treatment approach [13]. Systematic reviews and meta-analyses have reported positive reports of acupuncture and/or moxibustion for insomnia compared with routine care, western medicine, sham, massage, and oral Chinese medicine [14–18], but the objective assessment of acupuncture and/or moxibustion for insomnia provided insufficient evidence. After carefully reading the previous meta-analysis reviews on acupuncture and/or moxibustion for primary insomnia, we found some detailed limitations of previous reviews.