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A systematic review of the effects of acupuncture in treating insomnia

W Huang, N Kutner, and DL Bliwise.

Review published: 2009.

CRD summary

This review concluded that acupuncture was potentially effective at treating insomnia, but the differences between studies and poor study quality meant that there was not yet sufficient evidence to support its use. The review suffered several limitations and the conclusions should be interpreted with extreme caution.

Authors' objectives

To determine whether research evidence supported the use of acupuncture for the treatment of insomnia.

Searching

Medline, CINAHL, PsychINFO, Evidence-Based Medicine Reviews, The Cochrane Library, DARE, and American College of Physicians Journal Club were searched from inception to 2007. Search terms were reported. References of retrieved articles were screened. The review was limited to studies published in English or Chinese in peer reviewed journals.

Study selection

Case series or clinical trials of patients with insomnia treated with acupuncture were eligible for inclusion. Studies that mentioned acupuncture, but in which the main treatment modality was complementary alternative medicine were excluded. Studies that focused on other sleep disorders such as sleep apnea, night terrors or somnambulism were excluded.

Control interventions in the included studies consisted of sham control (with or without other control groups), usual care, conversation, education, medication and soaked seeds. Patients had primary insomnia, comorbid insomnia (post-stroke, pregnancy, end-stage renal disease), unspecified insomnia and insomnia associated with a particular traditional Chinese medicine diagnosis (interior-stirring by phlegm heat). Acupuncture treatments included regular body acupuncture, rolling needle or intradermal needle, acupoint taping with herbal preparation, auricular treatment with seed pressing or magnetic pearls and acupressure. Studies included a wide range of co-interventions. Treatment points ranged from one to the entire meridian. Most studies used a standardised treatment paradigm; some used an individualised approach. Treatment duration ranged from one to 60 treatments. Outcome measures assessed were single administration sleep questionnaires (for example, Pittsburgh Sleep Quality index), clinical global impression, sleep diary, actigraphy and polysomnography.

The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection.

Assessment of study quality

Studies were assessed for quality according to the methods described in the Cochrane Handbook: selection bias (randomisation/control of confounders); performance bias (treatment blinding process or measurement of exposure); attrition bias (differences in withdrawals/drop-outs between groups); and detection bias (outcome measure blinding process or bias of measurements). Studies were given a grading of A (low risk of bias), B (moderate risk of bias) or C (high risk of bias). The authors do not state how many reviewers performed the validity assessment.

Data extraction

The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.

Methods of synthesis

A narrative synthesis was reported.

Results of the review

Thirty studies were included: 12 (n=1,355) clinical trials (three of which were randomised); and 18 case series (n=3,776). In eight of the 12 clinical trials the method of treatment allocation was not reported. Of the three randomised controlled trials, one used random digits, one used random block and one used computerised random number generation. Three studies were double blinded and three were single blinded; none adequately evaluated the blinding process. Six studies graded B and six graded C. All case series were Grade C.

Nine of the clinical trials reported significantly greater effects of acupuncture on sleep compared to education control (one study), medication control (four studies) and sham control (four studies). One study reported that auricular acupuncture was significantly better than body acupuncture. One study reported no difference between acupuncture and sham control. The final clinical trial reported no difference between acupressure and transcutaneous electrical acupoint stimulation. Two studies reported results at three to six-month follow up and both found that improvements reported at the end of the intervention were maintained.

The case series generally showed positive effects of acupuncture on both subjective and objective outcome measures. One case series that included a control group reported a significantly better outcome with acupuncture compare to the combination of Western and herbal medications. Four studies reported that beneficial outcomes were maintained at follow-up of between two months and one year.

Authors' conclusions

The evidence showed that acupuncture was potentially effective in treating most forms of insomnia, but the evidence was limited by the poor quality of the studies and significant heterogeneity of included studies.

CRD commentary

The review addressed a broad question with clearly defined inclusion criteria. The literature search was adequate, but the review was limited to studies published in English and Chinese and so there was a possibility of language and publication bias. A detailed quality assessment was undertaken, but the assessment results were not clearly reported or considered in the synthesis of results. Details on the review methods, such as the number of reviewers involved in the different stages of the review, were lacking and so it was not possible to determine whether appropriate steps were taken to minimise bias and errors. A narrative synthesis was appropriate given the differences between studies in terms of acupuncture methods, control groups and outcomes assessed. However, some indication of the magnitude and significance of the findings reported would have helped with interpretation of the results. Given the poor reporting and substantial heterogeneity between studies the authors' conclusions should be interpreted with extreme caution.

Implications of the review for practice and research

Practice: The authors stated that acupuncture was safe, but that there was not yet sufficient evidence to support its use as the main medical modality in treating insomnia.

Research: the authors stated that there was a need for high-quality randomised clinical trials of acupuncture with proper sham and blinding procedures. They also stated that mechanistic evaluation of acupuncture in treating insomnia was required.

Funding

Southeast Center of Excellence in Geriatric Medicine, Hartford Foundation Grant #97333-G.

Bibliographic details

Huang W, Kutner N, Bliwise D L. A systematic review of the effects of acupuncture in treating insomnia. Sleep Medicine Reviews 2009; 13(1): 73-104. [PubMed: 19097814]

Indexing Status

Subject indexing assigned by NLM

MeSH

Acupuncture Therapy /methods; Controlled Clinical Trials as Topic; Evidence-Based Medicine; Humans; Polysomnography; Sleep Initiation and Maintenance Disorders /psychology /therapy; Treatment Outcome

AccessionNumber

12009102753

Database entry date

29/07/2009

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19097814

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