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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Auricular acupuncture treatment for insomnia: a systematic review

HY Chen, Y Shi, CS Ng, SM Chan, KK Yung, and QL Zhang.

Review published: 2007.

CRD summary

This review concluded that the use of auricular acupuncture (AA) to treat insomnia appeared to produce better rates of recovery and improvement than control. However, given the lack of information, it is not possible to draw conclusions about the long-term efficacy and safety of using AA to treat insomnia. The authors’ cautious conclusions appear to reflect the limitations of the evidence presented.

Authors' objectives

To evaluate the efficacy and safety of auricular acupuncture (AA) in the treatment of insomnia.

Searching

MEDLINE, EMBASE, AMED, CINAHL, the Cochrane Library, VIP Information, CBM-disc and CNKI were searched from inception to April 2006 for studies in Chinese or English; the search terms were reported. In addition, bibliographies were screened and handsearches conducted.

Study selection

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion.

Specific interventions included in the review

Studies of AA as the sole intervention in comparison with no treatment, sham AA, placebo or Western medicine were eligible for inclusion. Studies comparing different groups of auricular acupoints, different times for receiving treatments and different ways of stimulating the auricular acupoints were excluded. The included interventions were Semen vaccariae ear seeds, needle, acupoint pressure, pellets and magnet pearls, either alone or in combination. The controls included estazolam, diazepam, barbiturates or methaqualone in varying doses, routine unit care and sham AA. The duration of treatment ranged from 1 to 24 days.

Participants included in the review

Studies of participants with insomnia were eligible for inclusion. The studies were conducted in mainland China or Hong Kong.

Outcomes assessed in the review

Inclusion criteria were not specified in terms of the outcomes, but it was clear that studies assessing sleep time and reduction of insomnia were included. The methods used to assess outcomes varied in the included studies, and included self-setting measurements, published scales and wrist actigraphy.

How were decisions on the relevance of primary studies made?

Two reviewers independently selected the studies from full papers.

Assessment of study quality

Validity was assessed using the Jadad scale (randomisation, blinding and withdrawals), with a maximum score of 5 points being possible. Studies scoring 3 or more points were considered high quality; studies scoring 1 to 2 points were considered low quality. In addition, the following predetermined criteria were used for assessment: randomisation, allocation concealment, blinding, and withdrawals and drop-outs. Each study was awarded points for each criterion and then classified into one of three grades: 1) low risk of bias with adequate grade for all items; 2) moderate risk of bias with one or more inadequate grades; 3) high risk of bias with one or more grades unclear. Two reviewers independently assessed validity.

Data extraction

One reviewer extracted the data and a second reviewer verified the extraction. Any discrepancies were resolved by reference to the original papers.

Methods of synthesis

How were the studies combined?

The studies were pooled in a meta-analysis using a random-effects model. Relative ratios (RRs) and 95% confidence intervals (CIs) were calculated.

How were differences between studies investigated?

The studies were pooled in a meta-analysis using a random-effects model. Relative ratios (RRs) and 95% confidence intervals (CIs) were calculated.

Results of the review

Six RCTs (673 participants: 402 in the AA group and 271 in the control group) were included.

All studies were reported to be at high risk of bias. Five studies scored 1 on the Jadad scale, one scored 2, and none scored 3 or above (high quality). Only 2 studies reported diagnostic criteria for the patients.

AA was significantly more effective than control for total rate of recovery and improvement (RR 1.93, 95% CI: 1.40, 2.66, p<0.0001; 5 studies, n=553) and for improvement of sleep time to 6 hours or more (RR 2.64, 95% CI: 1.22, 5.72; 2 studies, n=253). However, there was evidence of statistical heterogeneity for both analyses (p<0.001 and p<0.05, respectively).

Use of Semen vaccariae ear seeds for AA was significantly more effective than control in terms of rates of recovery and improvement (RR 1.80, 95% CI: 1.42, 2.28, p<0.00001; 3 studies, n=313). There was no evidence of heterogeneity. However, there were no statistically significant differences observed between the use of magnetic pearls for AA and control (p=0.28) (2 studies, n=150).

AA was significantly more effective than diazepam in relieving insomnia (RR 1.41, 95% CI: 1.12, 1.77, p=0.003; 2 studies, n=120). There was no evidence of significant heterogeneity.

None of the studies reported any information about adverse effects associated with AA.

Authors' conclusions

AA treatment of insomnia appears to be better than controls. However, given the low quality of the studies and the lack of information on longer-term follow-up, it is not possible to draw conclusions about the long-term efficacy and safety of AA treatment for insomnia.

CRD commentary

Inclusion criteria were clearly defined in terms of the intervention, outcomes and study design, and broadly defined in terms of the participants. Several relevant sources were searched, but the restriction to studies in English and Chinese might have resulted in the loss of some relevant data. Appropriate methods were used in the study selection, validity assessment and data extraction processes, thus reducing the potential for reviewer bias and error. Validity was assessed using specified criteria and the results of this assessment reported. The analyses seem appropriate and statistical heterogeneity was assessed, though the source of the heterogeneity was not fully investigated. There was evidence of clinical heterogeneity with differences in the interventions and between the control groups. In addition, all the studies were of a poor quality. However, the authors did discuss the limitations of the evidence, and their cautious conclusions therefore appear to reflect the limitations of the evidence presented.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further good-quality RCTs should be conducted using internationally recognised and validated effectiveness measurements.

Funding

Hong Kong Baptist University, Hong Kong.

Bibliographic details

Chen H Y, Shi Y, Ng C S, Chan S M, Yung K K, Zhang Q L. Auricular acupuncture treatment for insomnia: a systematic review. Journal of Alternative and Complementary Medicine 2007; 13(6): 669-676. [PubMed: 17718650]

Indexing Status

Subject indexing assigned by NLM

MeSH

Acupuncture Points; Acupuncture, Ear /methods /statistics & numerical data; Humans; Research Design; Sleep; Sleep Initiation and Maintenance Disorders /epidemiology /therapy; Treatment Outcome

AccessionNumber

12007003164

Database entry date

03/11/2008

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: 17718650