Research Progress of Acupuncture-moxibustion for Insomnia: An Analysis of Literature in Recent 5 Years

Fang Chao-jun, Yang Wen-jia, Chen Yun-fei

Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China

Research Progress of Acupuncture-moxibustion for Insomnia: An Analysis of Literature in Recent 5 Years

Fang Chao-jun, Yang Wen-jia, Chen Yun-fei

Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China

By searching and analyzing the literature related to acupuncturemoxibustion in treating insomnia in both Chinese and English databases from 2007 to 2012, this paper systematically elaborated the up-to-date research progress of acupuncture-moxibustion therapy in treating insomnia, i.e. acupuncture, electroacupuncture, auricular point, abdominal acupuncture, scalp acupuncture, acupoint injection, and moxibustion. It also analyzed the existing problems and highlighted the future studies.

Acupuncture-moxibustion Therapy; Acupuncture Therapy; Moxibustion Therapy;Electroacupuncture; Acupoint Injection; Ear Acupuncture; Insomnia; Review

Insomnia is a disease severely interfering with human health, manifested by difficulty falling asleep, light sleep, difficulty staying asleep, difficulty falling asleep again after early wake-up[1]. Severe cases may present with psychological problems such as anxiety and depression, even inducing social or work interference, such as traffic accidents[2]. Western medication may lead to drug dependence or withdrawal symptoms in treating insomnia[3]. Acupuncturemoxibustion is significantly effective and produces little adverse effect in managing this condition. This article collected literature of acupuncturemoxibustion in treating insomnia from 2007 to 2012 and reviewed as follows.

1 Materials and Methods

1.1 Inclusion and exclusion criteria

Clinical study, case study, experience summary associated with acupuncturemoxibustion in treating insomnia were included, without limitation of method. Systemic review, articles for public health popularization, reviews, and repeatedly published articles were excluded.

1.2 Literature retrieval

We searched Databases including CNKI, CBMdisc, CQVIP and Wanfang from January of 2007 to December of 2012, with ‘acupuncture’, ‘acupuncturemoxibustion’, ‘electroacupuncture’, ‘auricular acupuncture’, ‘auricular point’,‘scalp acupuncture’, ‘cupping”, ‘acupoint injection’, ‘abdominal acupuncture’,‘insomnia’, ‘sleeplessness’, ‘sleep’, and ‘sleep disorder’ as subject terms (in Chinese). We also searched MEDLINE database from January 2007 to December 2012, with ‘acupuncture’, ‘acupoint’, ‘meridian’, ‘acup*’,‘electroacupuncture’, ‘auricular acupuncture’, ‘scalp acupuncture’,‘moxibustion’, ‘blood pricking’, ‘meridian pricking’, ‘cupping’, ‘injection’,‘abdominal acupuncture’, ‘insomnia’, ‘sleep’, and ‘sleep disorder’ as subject terms.

2 Treatment Methods

We found that the majority of researchers used combined acupuncture methods, while others used monotherapies, such as acupuncture and moxibustion, and the total effective rate were usually above 80.0%. The representative treatment methods were summarized below.

2.1 Acupuncture

2.1.1 Brain-centered treatment

Through generations, medical practitioners all paid great attention to treating insomnia based on the principle that brain governs mind. Yi Zong Jin Jian (The Golden Mirror of Medicine) pointed out that head is the joint of yang aspects, containing brain (the house of mind) and governing the whole body. Brainactivating mind-calming needling method by Han XR, et al[4], brain-caring mind-calming needling method by Liu XJ[5], and tranquilizing needling method by Jiang CH, et al[6]all treated with brain-mind as the center, Baihui (GV 20) and Sishencong (EX-HN 1) as the major acupoints, and they added adjunctive points according to syndrome differentiation. Yu XP, et al[7]took brain-tranquilizing mind-regulating needling method, by needling Shenmen (HT 7), Sanyinjiao (SP 6), Anmian [Extra, locates at the midpoint between Yifeng (TE 17) and Fengchi (GB 20)], Yintang (GV 29), and Taiyang (EX-HN 5) as major acupoints, plus tongue acupuncture by vertically and transversely slashing for several times. Jinjin (EX-HN 12) and Yuye (EX-HN 13) were pricked additionally if there was blood stasis under the tongue. The total effective rate was 100%.

2.1.2 Treatment based on Back-Shu acupoints

Back-Shu acupoints were closely related to five Zang and six Fu organs. Five-zang organs house five spirits. Back-Shu acupoints can regulate the function of five Zang organs and calm mind and thus can treat insomnia. Zhang W, et al[8]treated intractable insomnia by needling Back-Shu acupoints of five Zang organs. According to syndrome differentiation, 1-2 Back-Shu acupoints were selected as major points, and the rest Back-Shu acupoints were intervened by reinforcing and reducing methods based on the excess and deficiency conditions of corresponding organs. The control group was intervened by conventional point selection. The total effective rate was 88.3% in the Back-Shu acupoint group, versus 73.2% in the conventional acupuncture group. Liu L, et al[9]treated insomnia by tonifying and reducing Back-Shu acupoints of five Zang organs. Xinshu (BL 15) was reduced and Shenshu (BL 23) was tonified by twisting manipulation. At the end of the first treatment course, the total effective rate was 68.0%, and it’s 77.0% and 85.0% after the second and third course respectively. It indicates that the clinical effect of needling Back-Shu acupoints increases with the extension of treatment course.

2.1.3 Treatment from the Heel Vessels

Through research, we found that clinical practitioners always reduce Shenmai (BL 62) and tonify Zhaohai (KI 6) when they treat insomnia by regulating Yin and Yang Heel Vessels. Besides, Xinshu (BL 15) and Pishu (BL 20) were added for heart-spleen deficiency; Xinshu (BL 15) and Shenshu (BL 23) were added for heart-kidney disharmony; Taichong (LR 3), Xingjian (LR 2), and Ganshu (BL 18) were added for fire due to liver depression; Fenglong (ST 40) and Gongsun (SP 4) were added for internal interference by phlegm heat. Yin HB, et al[10]randomized insomnia patients into a group of reducing Shenmai (BL 62), a group of tonifying Zhaohai (KI 6), and a group of reducing Shenmai (BL 62) and tonifying Zhaohai (KI 6) simultaneously. A control group composed of healthy subjects was also set up. In the reducing Shenmai (BL 62) group, bilateral points were needled with reducing method by twisting manipulation; in tonifying Zhaohai (KI 6) group, bilateral points were needled with tonifying method by twisting manipulation; in the reducing Shenmai (BL 62) and tonifying Zhaohai (KI 6) group, Zhaohai (KI 6) were reinforced first followed by reducing Shenmai (BL 62), with the same manipulations and methods as described above. The changes of polysomnograms in the four groups were observed. Results showed that the compatibility of the two acupoints can produce a better result in improving the process and structure of sleep than use of the acupoints separately, and it’s not significantly different from that of the healthy subject group. It indicates that by reducing Shenmai (BL 62) and tonifying Zhaohai (KI 6), it can inhibit yang and reinforce yin, and the normal state can be restored by regulating the Yin and Yang Heel Vessels.

2.1.4 Treatment from the liver

Insomnia patients are often in co-morbid with anxiety, depression, and other psychological conditions. Poor sleep quality can easily cause or exacerbate psycho-somatic symptoms, which in turn worsen sleep quality, and patients are thus in a vicious cycle. Liver governs dredging and dispersing, and manages emotion. Therefore, liver is closely related to regulation of emotion. To treat insomnia from the liver is to modulate emotion and produce psycho-somatic bliss by modulating liver qi. Luo WZ, et al[11]treated insomnia patients in co-morbid with depression with acupuncture. The observation group was intervened by needling Shenmen (BL 62), Baihui (GV 20), Yintang (GV 29), Hegu (LI 4), and Taichong (LR 3). The control group was managed by oral Trazodone after dinner. After 4-week treatment, the markedly effective and recovery rate was 72.7% in the acupuncture group versus 46.8% in the Western medication group, and the differencewas statistically significant (P＜0.05). Yang DH, et al[12]and Zhang YL, et al[13]used Taichong (LR 3) when treating insomnia in addition to needling Baihui (GV 20) and Shenmen (HT7). The treatments all concord with the principle that to anti-depression by dredging the liver and regulating mind.

2.1.5 Treatment in accordance with time

Traditional Chinese medicine (TCM) pays great attention to the treatment in accordance with three factors, i.e. time, place, and human. Of acupuncturemoxibustion methods, Zi Wu Liu Zhu (midnight-noon ebb-flow) and Ling Gui Ba Fa (eightfold method of the sacred tortoise) are methods by selecting acupoints according to time. Up-to-date, there are not many clinical reports on time therapies. Wang L, et al[14]treated insomnia by adopting multiple-time acupuncture, which is to activate acupoints according to the visiting time of patients, and to puncture acupoints in the order of Sanyinjiao (SP 6), Shenmen (HT 7), Wangu (SI 4), Houxi (SI 3), Feiyang (BL 58), Shenmai (BL 62), Zhaohai (KI 6), Taixi (KI 3), Neiguan (PC 6), Waiguan (TE 5), Yanglingquan (GB 34), Zulinqi (GB 41), Taichong (LR 3), Chize (LU 5), Lieque (LU 7), Quchi (LI 11), Hegu (LI 4), and Zusanli (ST 36). In the conventional acupuncture group, the same acupoints were selected but not punctured by the meridian sequence. After treatment, the improvement of Pittsburgh Sleep Quality Index (PSQI) in the multiple-time acupuncture group was better than that in the conventional acupuncture group. Wen JJ, et al[15]divided insomnia patients into two groups. In the treatment group, the daily initiating acupoints were selected by using Ling Gui Ba Fa, and were paired as follows: Shenmai (BL 62) and Houxi (SI 3); Zhaohai (KI 6) and Lieque (LU 7); Waiguan (TE 5) and Zulinqi (GB 41); Gongsun (SP 4) and Neiguan (PC 6). The control group was managed by conventional acupuncture method. The total effective rate was 91.1% in the observation group versus 86.0% in the control group. Although there was no significant difference in comparing the total effective rate between the two groups, the treatment group was significantly better than the control group in improving sleep latency, sleep duration and daytime function (P＜0.01 or P＜0.05), indicating that the treatment group should be superior to the control group in improving insomnia.

2.2 Electroacupuncture (EA)

There are numerous reports on EA for insomnia. It’s found that the therapeutic efficacy is somehow influenced by intervention time, frequency, and wave of EA. Xiao XL, et al[16]discovered that with the same parameters, the night EA group was better than the morning EA group in reducing the use of sleeping pills. Cai LB, et al[17]compared the therapeutic efficacies among EA with different waves and found that the intense wave group was better than both sparse wave group and sparse-intense wave group in improving PSQI score, and sparse wave group had similar therapeutic efficacy to the sparse-intense wave group.

2.3 Auricular point treatment

According to the research result, auricular point therapy was used with other therapies in 70% out of the literature on auricular point for insomnia, and the rest 30% of literature were about single use of auricular point. Of the selected auricular points, Shenmen (TF4), Heart (CO15), Kidney (CO10), and Subcortex (AT4) were the most frequently selected ones. Different physicians would choose different mediums to stimulate auricular points. For example, Wu XL, et al[18]adopted Wang Bu Liu Xing (Semen Vaccariae), Hu JB[19]used Bai Jie Zi (Semen Brassicae), and Xiang YC[20]used magnetic pearls, and the results all showed effectiveness of auricular point in the treatment of insomnia.

2.4 Abdominal acupuncture

The literature on abdominal acupuncture for insomnia was found adopting the abdominal acupuncture therapy developed by Prof. Bo Zhi-yun. As a micro-acupuncture system based on the hypothesis of Shenque (CV 8) distributing qi, abdominal acupuncture treats diseases by restoring the balance of Zang-fu organs through stimulating abdominal acupoints. Ye TS, et al[21]and Li Y, et al[22]all adopted abdominal acupuncture to treat insomnia. Treatment group was intervened by selecting a group of acupoints especially for inducing qi going back to the origin [Zhongwan (CV 12), Xiawan (CV 10), Qihai (CV 6), and Guanyuan (CV 4)], adjusting the assisting acupoints according to syndrome differentiation of TCM. Results showed that abdominal acupuncture group was better than both medication treatment and conventional acupuncture treatment in improving PSQI score.

2.5 Scalp acupuncture

Huang LN, et al[23]employed Shaanxi scalp acupuncture to treat insomnia patients. In the treatment group, scalp acupuncture needles were swiftly inserted into Fuxiangtou, Fuzang, Shangjiao, Siwei, Xinhao, Jiyi, etc., and heavy pressure and vibrating manipulations were performed to induce qi arrival. The control group was intervened by oral Estazolam every night. The total effective rate was 96.7% in the treatment group versus 66.7% in the control group. The research conducted by Zhou ZL, et al showed that point-toward-point needling method used with scalp points had better therapeutic efficacy than conventional acupuncture[24].

2.6 Moxibustion

According to the included literature, there are only 4 using moxibustion alone in treating insomnia. Baihui (GV 20) is the essential point. Li ZP, et al[25]found that moxibustion at Baihui (GV 20) can promote the efficacy in treating insomnia. Zhang PL, et al[26]believe that moxibustion at Baihui (GV 20) and Sishencong(EX-HN 1) can produce better effect than moxibustion at bilateral Zusanli (ST 36). Three weeks later, the total effective rate was 82.3% in the observation group versus 67.2% in the control group, indicating that moxibustion can produce a marked therapeutic effect for insomnia.

2.7 Other treatments

2.7.1 Blood-letting therapy

Chen H, et al[27]adopted blood-letting method of Zhuang nationality to treat 85 insomnia patients. In the blood-letting group, Baihui (GV 20), Fengchi (GB 20), Fengfu (GV 16), and reaction spots nearby spine were punctured and let out 2-3 drops of blood. In the Chinese medication group, Bai He Fu Shen decoction was used; oral tranquilizer was used in the Western medication group. The total effective rate was 96.5% in the blood-letting group, versus 81.3% in the Chinese medication group and 80.0% in the Western medication group. The total effective rate in the bloodletting group was significantly different from that in the Chinese medication group and the Western medication group (P＜0.05); improvements of subjective sleep quality and sleep latency in PSQI of blood-letting group were better than those in the Chinese medication group and Western medication group (P＜0.05).

2.7.2 Acupoint injection

Zou X, et al[28]used acupoint injection with Vit B12to treat insomnia. The control group was intervened by oral Oryzanol, Pavlovs mixture, and Estazolam. The total effective rate was 90.0% in the acupoint injection group versus 70.0% in the control group, and the difference was statistically significant (P＜0.05); the inter-group comparison of subjective sleep quality and use of sleeping medication in PSQI showed statistically significant differences (P＜0.01 or P＜0.05). It suggests that the treatment group has a better therapeutic efficacy than the control group.

2.7.3 Cupping therapy

Ma GM, et al[29]employed balance cupping for 68 insomnia patients. In the treatment group, positive reaction points were first found on back, then cups of big size were used to conduct flash cupping for 30 times along the Bladder Meridian, followed by moving cupping moved either in a straight line or a circle. Afterwards, the positive reaction points were treated with shaking cupping for 10-15 times to produce skin reaction, and the cups were retained for 5 min. Shaking cupping was performed to Anmian (Extra) point with a small-size cup for 10-15 times and then the cup was retained for 5 min. The force used for cupping should be within the patient’s endurance. The control group was managed by modified An Shen Ding Zhi decoction. After 20-day treatment, the total effective rate was 91.2% in the treatment group, versus 69.1% in the control group, the difference was statistically significant (P＜0.05).

3 Practical Problems

3.1 Low quality of literature

Throughout literature analyses, we have discovered some problems existed in the literature on acupuncture-moxibustion in treating insomnia, which are classified into four types below.

3.1.1 Lack of sample size estimate

A majority of domestic clinical trials did not estimate sample size or they did not declare clearly in context.

3.1.2 Incomplete randomization or control

Some scholars didn’t set up a proper control group when conducting a clinical trial, and it thus affected the assessment of therapeutic efficacy. Most of the literature mentioned randomization but yet did not tell which randomized method was used.

3.1.3 Lack of allocation concealment or blinding

Currently, most of the domestic researchers were still unfamiliar with allocation concealment and blinding methods. Therefore, the methods were merely told in the literature. However, lack of allocation concealment or insufficient performance will bring a risk of exaggerated result by more than 42%[30].

3.1.4 Not enough attention to long-term effect

A large proportion of investigators paid attention to the short-term therapeutic efficacy of acupuncturemoxibustion (within 1-4 weeks after treatment), but did not conduct an investigation on long-term efficacy and relapse rate.

3.2 Deficient mechanism research

At present, studies on acupuncture-moxibustion for insomnia are still focused on clinical trials, especially on its effectiveness. Its associated mechanism studies were seldom published. According to the knowledge, neurotransmitters are the key point in current studies, typically 5-hydroxytryptamine (5-HT) and its metabolism product 5-hydroxy indole acetic acid (5-HIAA). Nevertheless, the pathways formed by stimulation from acupuncture to these neurotransmitters have not yet proved.

3.3 Deficient knowledge about classics

Clinical trials are to verify the practicability of ancient acupuncture-moxibustion formulae, and to select the most effective, reasonable, and secure treatment protocol through comparing different protocols. However, modern physicians’ understandings towards classics are still too superficial, which seems restricted to the theory that sleeplessness results from failure of Wei-Defensive qi to enter the yin aspect, or that brain houses primordial spirit. It is short of firm classical theories to be the study basis when it’s going more detailed. Liu LG, et al[31]points out that there are many methods to treat insomnia told in classics, e.g., Tai PingSheng Hui Fang (Peaceful Holy Benevolent Prescriptions) records treating insomnia with Yixi (BL 45), which is not found in any modern studies.

4 Solution and Expectation

According to the analysis of literature over the last 5 years, it’s found that most of the domestic data on acupuncture-moxibustion in treating insomnia are not standard or do not concord with international requirements, which make it difficult to determine the effectiveness of acupuncture-moxibustion in treating insomnia. On the contrary, the clinical trials from abroad are all based on randomized-controlled principles. Therefore, domestic researchers should take an active manner to ameliorate research methods and report clinical design and results according to the universally agreed Consolidated Standards of Reporting Trials (CONSORT). Meanwhile, they should also report the details of clinical trials from acupoint, acupuncture depth, qi arrival, needle-retaining time, reinforcing-reducing manipulations, materials, background of physicians, and so on, according to the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA).

Second, with the development of modern scientific technologies, various advanced technologies should be adopted in studying acupuncture-moxibustion for insomnia, such as functional magnetic resonance imaging (fMRI), micro-movement sensitive mattress sleep monitoring system (MSMSMS), and body activity electrogram. Moreover, laboratory investigations and clinical trials should be combined properly to systematically explore the action mechanism of acupuncture-moxibustion in treating insomnia.

Last but not least, profound exploration of TCM classics should be stressed to consolidate the theoretical basement of acupuncture-moxibustion treatment. Otherwise, clinical trials can only be woods without roots and be easily taken down by doubts and tests.

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Translator: Hong Jue

R246.1

A

Date: March 5, 2013

Author: Fang Chao-jun, master degree candidate

Yang Wen-jia, M.M., attending physician.

E-mail: yangwenjia1030@163.com Chen Yun-fei, M.D., researcher,

E-mail: icyf1968@yahoo.com.cn