Acupuncture for insomnia: Cochrane systematic review

Abstract

Assessed as up to date: 2011/10/13

Background

Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are widely practised. However, it remains unclear whether current evidence is rigorous enough to support acupuncture for the treatment of insomnia.

Objectives

To determine the efficacy and safety of acupuncture for insomnia.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts International, CINAHL, AMED, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the World Health Organization (WHO) Trials Portal (ICTRP) and relevant specialised registers of the Cochrane Collaboration in October 2011. We screened reference lists of all eligible reports and contacted trial authors and experts in the field.

Selection criteria

Randomised controlled trials evaluating any form of acupuncture for insomnia. They compared acupuncture with/without additional treatment against placebo or sham or no treatment or same additional treatment. We excluded trials that compared different acupuncture methods or acupuncture against other treatments.

Data collection and analysis

Two review authors independently extracted data and assessed risk of bias. We used odds ratio (OR) and mean difference for binary and continuous outcomes respectively. We combined data in meta-analyses where appropriate.

Main results

Thirty-three trials were included. They recruited 2293 participants with insomnia, aged 15 to 98 years, some with medical conditions contributing to insomnia (stroke, end-stage renal disease, perimenopause, pregnancy, psychiatric diseases). They evaluated needle acupuncture, electroacupuncture, acupressure or magnetic acupressure.

Compared with no treatment (two studies, 280 participants) or sham/placebo (two studies, 112 participants), acupressure resulted in more people with improvement in sleep quality (compared to no treatment: OR 13.08, 95% confidence interval (CI) 1.79 to 95.59; compared to sham/placebo: OR 6.62, 95% CI 1.78 to 24.55). However, when assuming that dropouts had a worse outcome in sensitivity analysis the beneficial effect of acupuncture was inconclusive. Compared with other treatment alone, acupuncture as an adjunct to other treatment might marginally increase the proportion of people with improved sleep quality (13 studies, 883 participants, OR 3.08, 95% CI 1.93 to 4.90). On subgroup analysis, only needle acupuncture but not electroacupuncture showed benefits. All trials had high risk of bias and were heterogeneous in the definition of insomnia, participant characteristics, acupoints and treatment regimen. The effect sizes were generally small with wide confidence intervals. Publication bias was likely present. Adverse effects were rarely reported and they were minor.

Authors' conclusions

Due to poor methodological quality, high levels of heterogeneity and publication bias, the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia. Larger high-quality clinical trials are required.

Author(s)

Cheuk Daniel KL, Yeung Wing-Fai, Chung KF, Wong Virginia

Summary

Acupuncture for insomnia

Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are widely practised. This review was conducted to examine the efficacy and safety of acupuncture in treating insomnia. Thirty-three randomised controlled trials were eligible for inclusion in the review, involving 2293 participants. We considered all studies to have a high risk of bias. They were diverse in the types of participants, acupuncture treatments and sleep outcome measures used, which limited our ability to draw reliable conclusions. Currently there is a lack of high-quality clinical evidence to inform us about the efficacy and safety of acupuncture.

Reviewer's Conclusions

Implications for practice

This review suggests that there is insufficient high-quality evidence to support or refute the use of acupuncture to improve people's self rated sleep quality. Although some forms of acupuncture might improve sleep parameters in the short term in some people, the current evidence is not rigorous enough to allow recommendation to be made about the wide application of any form of acupuncture with or without additional therapies for the treatment of insomnia of any aetiology in people of any age group. The long-term effect of acupuncture is not known and its potential adverse effects are not entirely clear. People who seek to receive acupuncture for insomnia should be informed of the uncertainty of its effectiveness and potential risks.

Implications for research

Existing randomised controlled trials of acupuncture for treatment of insomnia are of small size and low methodological quality. Further high-quality studies of larger sample size are needed to assess the effectiveness of acupuncture for treating insomnia. Randomisation methods need to be more rigorous and concealed. Although blinding of the therapist who applied acupuncture might be very difficult, blinding of the patients, the other care providers and outcome assessors should be attempted as far as possible to minimise performance and assessment biases. In the current review, only three included studies achieved blinding of patients, care takers and outcome assessors. They employed sham acupuncture methods in the control group that were essentially indistinguishable from real acupuncture by lay people without good knowledge about genuine acupoints. We advise future studies to employ a similar design, such that only the acupuncturist knows who receives genuine acupuncture and who receives sham acupuncture; and the acupuncturist should not be involved in other aspects of participants' care or assessment of outcomes.

Analysis of outcomes based on intention-to-treat principle is important. All outcomes specified in the trial protocol should be reported. A standardised set of outcome measures is important for comparison among different trials. These should include measurements of sleep parameters objectively using actigraphy or polysomnography so that even if the person administering and receiving acupuncture is not blind, the outcome assessors could be blinded to treatment. Other well-known standardised sleep scores such as the Pittsburgh Sleep Quality Index could also be used. Daytime functioning and quality of life are also important outcomes to be included in future trials, and these should be measured using validated instruments. Adverse effects should be closely monitored prospectively and reported.

Since insomnia is a highly heterogeneous disease with different aetiology and severity, acupuncture is likely to have different effects on different subgroups of patients. Therefore, future clinical trials should be focused on a particular subgroup or include a very large sample size to delineate the effect of acupuncture on different types of patients. In addition, well-defined diagnostic criteria, such as DSM-IV or ICSD, should be employed to make a precise clinical diagnosis of insomnia, and hence increase the comparability between studies. Since insomnia may wax and wane with or without treatment, a longer follow-up period with serial measurements of outcomes is important to determine the genuine effectiveness of acupuncture and its long-term effect. It might also be worthwhile to further examine the effectiveness of combination therapy for insomnia using acupuncture with other non-pharmacological or pharmacological treatments.

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