A Systematic Review of the Effects of Acupuncture

CLINICAL REVIEW A systematic review of the effects of acupuncture in treating insomnia Wei Huang a, *, Nancy Kutner b , Donald L. Bliwise c a VA Medical Center at Atlanta, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine, 1670 Clairmont Road, Decatur, GA 30033, USA b Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA c Department of Neurology, Emory University Sch
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  CLINICAL REVIEW A systematic review of the effects of acupuncturein treating insomnia Wei Huang a, *, Nancy Kutner b , Donald L. Bliwise c a VA Medical Center at Atlanta, Department of Physical Medicine and Rehabilitation,Emory University School of Medicine, 1670 Clairmont Road, Decatur, GA 30033, USA b Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA c Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA KEYWORDS Acupuncture;Insomnia;Sleep;Traditional ChineseMedicine Summary  To examine the extent to which research supports the use of acupunc-ture in treating insomnia, a systematic review was conducted that included not onlyclinical trials, but also case series in both English and Chinese literature. Thirtystudies were included in the review, 93% of which showed positive treatmenteffects of acupuncture in improving various aspects of sleep. Although acupuncturehas been demonstrated to be safe and holds great potential to be an effectivetreatment modality for insomnia, the evidence is limited by the quality of thesestudies and mixed results from those with sham (or unreal treatment) controls.Of the thirty studies, twelve were clinical trials with only three double-blinded.Only five used sham controls, and of these, four showed statistically significantdifferences favoring real treatments; however, none evaluated the adequacy ofsham assignment. Three studies used actigraphy or polysomnography as objectiveoutcome measures. The considerable heterogeneity of acupuncture techniquesand acupoint selections among all studies made the results difficult to compareand integrate. High-quality randomized clinical trials of acupuncture in treatinginsomnia, with proper sham and blinding procedures will be required in the future.This review highlights aspects of acupuncture treatments important to guide futureresearch and clinical practice.Published by Elsevier Ltd. Introduction Insomnia is defined as sleep onset, sleep mainte-nance, and early awakening problems in thepresence of adequate opportunity and circum-stance for sleep. 1 It affects more than 60 millionAmericans each year. Approximately 1/3 of * Corresponding author. E-mail addresses: (W.Huang), (N. Kutner), (D.L. Bliwise).1087-0792/$ - see front matter Published by Elsevier Ltd.doi:10.1016/j.smrv.2008.04.002Sleep Medicine Reviews (2009)  13 , 73 e  general population 2 and half of managed carepatients report insomnia. 3 Many risk factors havebeen identified for insomnia including femalegender, older age, comorbid chronic medicalconditions and psychiatric disorders, variousmedications, and life style factors, e.g., caffeineintake, smoking, and reduced physical activity. 1 Due to limitations and concerns with currentavailable insomnia treatments, a sizable propor-tion of the population, especially in Europe andChina, has turned to complementary alternativemedicine, including acupuncture, in searching for a treatment modality with potential efficacy andfew side effects. 4 In the US, acupuncture has seenvery limited use in sleep and there have beenlimited literature reviews to examine this modal-ity. 5 e 7 The most recent review of acupuncture insleep 5 attempted a meta-analysis and failed todemonstrate significant efficacy of acupuncturecompared with various control treatments. Thatreview was limited because the studies includedwere selected from English literature only anddifferent acupuncture techniques, control groups,and outcome measures were not reviewedsystematically.Acupuncture is a clinical treatment modality inan independent medical system of TraditionalChinese Medicine (TCM), 8 which was developedover 3000 years ago under the influence of orientalphilosophical theories, such as Yin-Yang, FiveElements and Dialectical Unity. It has progressedthrough many years of clinical observations andpractice. In TCM, there is no concept of isolatedorgan function but rather a focus on interactionsamong different organ systems. TCM ‘‘diagnoses’’connote syndromes in Western medicine, witha combination of symptoms. For instance, ‘‘heart’’is not just the 4-chambered blood-pump. It notonly controls vascular circulation but also isdefined as the center of life as well as mind, withits external manifestations on tongue and face.Although these connections are not intuitive inWestern medicine, they arise from long-termclinical observations. For example, TCM teachesthat people with cardiac conditions often haveabnormal facial complexion and tongue color,anxiety, sleep problems and cognitive dysfunc-tion. 9 ‘‘Heart deficiency’’ is one of the TCM‘‘diagnoses’’ for insomnia (Table 1). Interestingly,in Western medicine, such associations also playa role in physical diagnosis. For instance, blue lipsand fingers in children may indicate cyanosis asa part of congenital heart disease. In addition,Western medicine increasingly acknowledges therelationship of insomnia to both cardiovascular diseases and psychological disturbances. 10,11 In TCM, poor sleep can also be associated withother organ system dysfunction. By performinga complete review of all symptoms, in combinationwith physical examination, particularly pulse andtongue examinations, one arrives at a TCM ‘‘diag-nosis’’ for insomnia (Table 1). 9,12 The TCM ‘‘diag-noses’’ can also change from time to time due toprogression or resolution of various symptoms.Therefore, TCM treatments, including acupunc-ture, are targeted towards regulating andbalancing the functions of different organ systems.In clinical practice, patients with the same sleepproblem can get different acupuncture treat-ments, depending on individual differences in bothpresumed etiology and dynamic changes of symp-toms over time.Basic acupuncture technique is to insertacupuncture needles into selected acupoints alongmeridians, which are the channels believed toguide the flow of bio-energy in human bodies.Through many years of practice, with variousinterpretations and innovations worldwide,acupuncture has evolved into numerous treatmenttechniques with acupoint selections varying frompractitioner to practitioner  13 (see Table 2 for thosetechniques included in this review).Given the challenge of this complex diagnosticand therapeutic system for treating insomniausing acupuncture, a more complete andsystematic review of available literature isnecessary to further guide future clinical andresearch directions. By widening our perspectiveon the range of study designs and types of broadlydefined acupuncture techniques, we hope, in thisreview, to highlight critical areas that should beaddressed in future clinical trials and studies ofunderlying mechanisms. Materials and methods Search methods for identification of studies Computerized databases, including MEDLINE(1950 e 2007), All Evidence-Based Medicine (EBM)Reviews d Cochrane Database of SystematicReviews (DSR), American College of Physicians(ACP) Journal Club, Database of Abstracts ofReviews of Effects (DARE), and CochraneControlled Trials Register (CCTR) (through July2007), PsycINFO (1806 e 2007), CINAHL d Cumula-tive Index to Nursing & Allied Health Literature(1982 e 2007) were searched under key words‘‘acupuncture’’, and ‘‘insomnia or sleep’’. Inaddition, relevant references in the reviewedarticles were also included, if obtainable via74 W. Huang et al.
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