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By Elad Schiff, MD
With a prevalence of 30-35% in adult Americans—10% of which is assessed as chronic (more than six months) and/or severe—insomnia is the most common sleep complaint reported to physicians.1 Insomnia is a perception that sleep quality is inadequate or nonrestorative, despite adequate opportunity to sleep, and encompasses many problems, including difficulty falling asleep, sleeping too lightly, sleep being easily disrupted by multiple spontaneous awakenings, or early morning awakenings with inability to fall back asleep.
It is important to note that insomnia is a symptom, not a disease. It is associated with a diversity of medical, psychiatric, and sleep disorders, and usually results from a combination of biological, physical, psychological, and environmental factors. Insomnia is linked with significant morbidity and mortality, including impaired ability to concentrate, poor memory, irritability, decreased ability to enjoy family and social relationships, a doubled risk for fatigue-related motor vehicle accidents, and a higher mortality rate in patients who get fewer than 5 hours of sleep per night as compared to the general population.
Complaints of sleep disruption often are managed by the use of medications such as benzodiazepines and tricyclic antidepressants. Sedatives and oral hypnotics have high abuse potential and can be addicting, in addition to their long list of serious adverse effects. Non-pharmacological interventions for insomnia may be employed to modify sleep hygiene, habits, and expectations (i.e., cognitive behavioral therapy).
TCM for Insomnia
In traditional Chinese medicine (TCM), symptoms are a manifestation of an underlying qi (vital energy) imbalance. Insomnia is one such symptom, reflecting imbalance of the mind and its different mental aspects. There are nine major patterns of qi disharmony that may manifest with insomnia.2 Traditionally, patients are categorized into their pattern of qi disharmony and treated accordingly with acupuncture and/or herbs. In addition, patients may receive lifestyle recommendations such as diet, exercise, body position for sleep, and meditative practices as stress reduction techniques.
Within the paradigm of acupuncture, however, other approaches have evolved in recent centuries. Formulations of acupoints that have been empirically and traditionally associated with powerful hypnotic effects are used in protocols for insomnia treatments. These protocol-based acupuncture treatments for insomnia do not attempt to address the underlying qi disharmony. More recently, following the development of French auricular acupuncture therapy and its endorsement in China, many protocols also combine auriculotherapy.
A MEDLINE search using the terms acupuncture, acupressure, auricular, sleep, and insomnia yielded a significant number of case reports and case series from the Chinese literature.3-7 Definition of insomnia, patient age and population, duration of insomnia, underlying disease, acupuncture technique, assessment tools, and outcome measures vary widely between and within these reports; all reported significant positive results.
In the English medical literature several case reports on acupuncture treatment for insomnia exist. Good therapeutic results were stated for a variety of endpoints. For example, in a study by Lee, 16 patients with severe insomnia were treated with auricular acupuncture protocol.8 Seven auricular points were used in this study: heart, kidney, adrenal, sub-cortex, endocrine, san chiao, and shen men. Additional auricular points (sympathetic, occiput, and gallbladder) were added if tender. Patients were treated three times weekly for an average of 10-12 treatments. Improved subjective outcomes for the treatment of sleep disorder were reported in 15 of 16 patients treated. Beneficial effects were still present three months following the conclusion of treatment.
Shi reported a case series of 28 patients with moderate-to-severe insomnia of at least three months duration.9 Patients were treated with a combination of individualized and empirical acupuncture. Sixty percent of patients had complete relief of insomnia and the rest experienced marked subjective improvement.
Sleep frequently is disrupted in all stages of HIV disease. In a case series reported by Phillips and Skelton, acupuncture was found to be effective in the treatment of 21 HIV patients, 29-50 years of age, with moderate-to-severe insomnia.10 Patients were assessed for treatment response using wrist actigraph analysis (used for ambulatory sleep monitoring) and current sleep quality index as a self-reported score. Acupuncture was performed twice weekly for five weeks and was individualized based on TCM pattern differentiation. Auricular and body points were used. Statistically significant improvement was noted for amount of sleep, time awake, and sleep quality in all patients following intervention.
In another open clinical trial, 18 volunteers, age 30-50, with chronic insomnia and subsyndromal anxiety (scoring high in an anxiety rating scale but not fulfilling DSM criteria for anxiety disorder), were treated with individual acupuncture twice weekly for five weeks.11 Patients were assessed for treatment effectiveness using polysomnography, urinary melatonin sampling, Stanford Sleepiness Questionnaire, anxiety inventory, and a fatigue scale. Following treatment, anxiety and fatigue scores improved significantly. Several polysomnographic parameters also improved, including sleep onset latency, sleep arousal, total sleep time, and sleep efficiency. Additionally, urine analysis showed increases in melatonin production at night and decreases in its production in the morning and afternoon, reflecting normalization of melatonin secretion. The authors of the study concluded that acupuncture may be of value as a therapeutic intervention for insomnia in anxious subjects.
This study also sheds some light on the mechanism by which acupuncture affects sleep. The melatonin urinalysis results suggest that acupuncture may exert its therapeutic effects in the setting of insomnia through regulation of melatonin secretion. This finding was also confirmed in rats.12 In another article, it was postulated that acupuncture, via its effect on the endogenous opioid system, reduces stress and anxiety, enabling better sleep.13
Comparison studies of varying acupuncture styles for the treatment of insomnia represent an interesting research path yet to be vigorously pursued in peer-reviewed medical literature. Additionally, comparison studies of acupuncture and medication for the treatment of insomnia have not yet been published in peer-reviewed literature. Currently, there are only two randomized controlled trials of acupuncture/acupressure treatment for insomnia in the English medical literature.
The first study evaluated the effectiveness of acupressure in the treatment of insomnia in hemodialysis patients.14 A high prevalence of sleep complaints is reported in patients with end-stage renal disease (ESRD). In a randomized controlled trial, Tsay and colleagues assessed effectiveness of acupressure in alleviating insomnia in 98 ESRD patients, age 18-65, who scored 5 points or higher on the Pittsburgh Sleep Quality Index (PSQI). Eligible patients were randomized into experimental (n = 35, receiving acupressure plus usual care), placebo (n = 32, receiving sham acupressure, 1 cm from the true acupoints, plus usual care), or control (n = 31, usual care) groups. Three acupoints were chosen from the ears, hands, and feet and massaged for a total of 15 minutes, three times per week for four weeks, when patients received hemodialysis. Assessment tools included the PSQI, a daily sleep log, and the Medical Outcome Study-Short Form 36 (SF-36).
Results indicated that compared to the control groups patients in the true acupressure group improved significantly with respect to subjective sleep quality, sleep duration, habitual sleep efficiency, and sleep sufficiency. There also was a significant difference in subjective sleep quality between the sham acupressure and control groups, possibly due to the non-specific effects of non-acupoint acupressure. Data obtained from the sleep log showed that the acupressure group had significantly decreased awake time and improved quality of sleep at night in comparison with the control groups. SF-36 analysis showed significant improvement for body pain, vitality, social function, role function, total physical component, and total mental component in the acupressure group compared with the control groups.
In the second randomized controlled trial, Suen et al compared different techniques of auricular acupoint stimulation for the treatment of insomnia.15 In auriculotherapy, either needles are inserted or small seeds are attached to the acupoint. Patients are then asked to intermittently stimulate them manually, to prevent "fatiguing" of the acupoint. It is theorized that magnetic pearls do not need further stimulation after their attachment and are thus more convenient. One hundred twenty elderly participants with chronic insomnia were randomized to three groups. In the first group, 30 patients received auriculotherapy, using junci medulla (the dried stem of perennial plant Juncus effusus). Due to its soft texture, it will not induce any physical pressure on the acupoints of the ear. In the second group, 30 patients received seed attachment without manual stimulation. In the final group, 60 patients received magnetic pearls stimulation with each magnetic pearl producing an average of 6.58 mT/~66 Gauss per pearl of magnetic flux.
Seven auricular points that are thought to have an effect on promoting sleep were selected in this study: shenmen, heart, kidney, liver, spleen, occiput, and subcortex. The total treatment course lasted three weeks. Objective assessment of sleep using actigraphic monitoring, and subjective assessment with sleep questionnaires and sleep diary were used. The results of the study showed that only the magnet auriculotherapy group showed significant improvement in terms of the nocturnal sleep time and sleep efficiency. Both the junci and seeds without stimulation groups showed no difference from baseline in these measures. The authors concluded that auricular therapy using magnetic pearls is an effective means for improving the quantity and quality of sleep in the elderly.
A follow-up study showed that treatment effectiveness was maintained at one, three, and six months after initial treatment.16
MacPherson et al conducted a prospective postal audit of acupuncture treatments administered by 574 professional acupuncturists who were members of the British Acupuncture Council.17 They found no serious adverse events after 34,407 acupuncture treatments. In 2001, White et al reported prospective data from 78 physicians and physiotherapists who administered 31,822 acupuncture treatments.18 Altogether, only 43 significant events were reported, giving a rate of 14 per 10,000 (95% confidence interval [CI] 8-20/10,000). All adverse events had cleared within one week, except for one incident of pain that lasted two weeks and one report of sensory symptoms that lasted several weeks. None of these events was serious. A total of 2,135 minor events was reported, giving an incidence of 671/10,000 (CI 42-1,013/10,000) consultations. The most common events were bleeding (310/10,000 [CI 160-590/10,000] consultations) and needling pain (110/10,000 [CI 49-247/10,000] consultations).
Most recently, Melchart et al conducted a prospective investigation of adverse effects of acupuncture in 97,733 patients receiving more than 760,000 acupuncture sessions.19 The mean (SD) number of inserted needles per session was 12.6 (± 5.1). Mild adverse effects were reported in 6,936 patients (7.10%; 99% CI 6.88%-7.32%). The most frequently reported adverse effects were needling pain and hematoma. Comparison of this adverse event rate for acupuncture with those of drugs routinely prescribed in primary care suggests that acupuncture is a safe form of treatment.20
Acupuncture has a history in China of being an effective treatment for insomnia for hundreds of years. Recent studies conducted in Western countries assessing acupuncture’s effectiveness for this indication support those historical observations.
There is a paucity of methodologically sound studies on the effectiveness of acupuncture in the treatment of insomnia. However, based on its well-established safety profile, numerous case reports/series, and a few randomized trials, acupuncture treatment may be recommended to patients with insomnia as part of an initial intervention.
Dr. Schiff is a Fellow in the Program in Integrative Medicine, University of Arizona, in Tucson.
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