Read the complete DynaMed Resident Focus.
Reference: Evid Based Complement Alternat Med 2013;2013:163850 (level 1 [likely reliable] evidence)
Primary care physicians frequently manage insomnia. Disorders of sleep initiation, sleep maintenance, and non-restorative sleep affect millions of people. Consequences of poor or inadequate sleep include fatigue, decreased alertness, impaired concentration, and disturbed mood. Insomnia is detrimental to one’s health (mental and physical), personal, social, as well as occupational life, and leads to avoidable accidents. According to the National Highway Traffic Safety Administration drowsy driving has been linked to 1,550 fatalities and 40,000 nonfatal injuries annually (National Highway Traffic Safety Administration, http://www.nhtsa.gov/people/injury/drowsy_driving1/Drowsy.html). Typical first line therapies for chronic insomnia include cognitive behavioral therapy and hypnotic medications such as benzodiazepines. These medications carry risks of residual daytime sedation, cognitive impairment, and dependence. Acupuncture has been used for thousands of years to treat a variety of ailments including insomnia, thought to help by regulating and restoring the natural flow of Qi (energy power). But is it effective in the treatment of insomnia?
To test the efficacy of acupuncture in the treatment of primary insomnia, a single-blinded, randomized double-dummy placebo controlled clinical trial was conducted by the Acupuncture and Moxibustion Department at Beijing Hospital of Traditional Chinese Medicine. Three groups of 60 patients each received treatments for a total of 6 weeks consisting of either (1) verum (real) acupuncture plus placebo pill, (2) sham acupuncture plus placebo pill, or (3) sham acupuncture plus estazolam 1 mg. Acupuncture treatments were performed every other day, and pills were given 30 minutes prior to bedtime on days without acupuncture. Verum acupuncture was applied at body points considered to be therapeutic for insomnia based on a prior study, along with needle manipulation intended to achieve “De Qi” (a sensation described as a tingling, burning, heaviness, fullness, numbness, soreness, or aching). Sham acupuncture was applied at points thought to have no therapeutic value for insomnia, and needle manipulation and “De Qi” were avoided. Participation criteria included age 25-75 years, insomnia for ≥ 4 weeks as diagnosed by DSM IV-TR, and no prior use of psychoactive medications. Exclusion criteria were depression, anxiety, schizophrenia, sleep apnea, serious disease of the heart, brain, kidney, or liver, pregnancy or breast-feeding, previous treatment with investigational drugs within 6 months, treatment with any acupuncture within the past year, or treatment with acupuncture for insomnia at any time in the past. Patients, outcome assessors, and statisticians were all blinded to group assignments. Acupuncturists, who could not be blinded, each had at least 15 years experience, and underwent special training (including diagnosis, selection criteria, point locations, needling techniques, and case report forms). “De Qi” experienced by patients was also documented. Patient-oriented outcomes of sleep measures, daytime functioning, and quality of life were measured at baseline, post-treatment, and 2 months follow-up using the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the 36-item short-form health survey (SF-36), all validated questionnaires.
9.4% of patients did not complete the study, but all patients were included in analyses. “De Qi” was achieved in 85% of verum acupoints compared to only 21% and 24% of sham acupoints (based on subject report), showing needle manipulation was well controlled in the trial. After treatment, all 3 groups showed improvement in PSQI score compared to baseline. However, in comparison to both sham acupuncture and estazolam, verum acupuncture was associated with lower daytime dysfunction scores, higher sleep quality scores (based on the PSQI and subscale scores, p < 0.05 for all), greater vitality scores (based on SF-36, p < 0.002 for both), and reduction in ESS (p < 0.05) which were maintained at the 2 month follow-up.
This study demonstrates that acupuncture is an effective treatment of insomnia with potential for less adverse effects and longer lasting results. The study leaves clinicians with an effective alternative to offer patients, especially those who prefer to not take more pills.
For more information, see the Insomnia in adults topic in DynaMed.