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Acupuncture for Insomnia and Sleeplessness

 by Jillian L Capodice, LAc

Background

Insomnia is characterized as the acute or chronic inability to initiate or maintain adequate nighttime sleep (1).
There are many reasons that insomnia may occur and a careful history of the severity, duration and consistency of the reported sleepless nights are important to ascertain.  Generally insomnia is classified according to disruption and duration of the complaint such as difficulty falling asleep, frequent or sustained awakenings during the night, early morning awakenings, or persistent sleepiness despite adequate sleep.  Some biomedical differential diagnoses of insomnia include:

• Acute causes due to: emotional stress, physical discomfort, jet lag
• Alcohol use
• Circadian rhythm disorder
• CNS disease:  e.g.: brain tumor, complex partial seizures, neurosyphilis
• Depression
• Mania or bipolar disorder
• Menopause
• Medications:  e.g.: corticosteroids, benzodiazepine withdrawal, selective serotonin reuptake inhibitors
• Medical illnesses: e.g.: chronic obstructive pulmonary disease, hyperthyroidism, hepatic encephalopathy, gastro esophageal reflux disease
• Nocturia:  e.g.: use of diuretics, benign prostatic hyperplasia, urinary incontinence, congestive heart failure
• Poor sleep hygiene:  e.g.: too many daytime naps, watching TV in bed
• Restless leg syndrome
• Stimulants:  e.g.: caffeine, nicotine

Traditional Oriental Medicine (TOM) views insomnia similarly and the potential etiologies listed above can cause classic zang-fu or meridian theory disruptions. Common TOM differential diagnoses for insomnia often include:
- Waking up easily during the night:  Heart yin deficiency
- Waking at a specific time of the night or early morning awakening:  Liver, lung, or kidney meridian disorders
- Dream-disturbed sleep:  Heart or shen imbalance, spleen deficiency, liver xue deficiency
- Difficulty falling asleep:  Stomach, liver, gallbladder replete patterns

Not surprisingly, treatment of insomnia and sleeplessness with acupuncture and herbal formulas is quite common.  However treatment of insomnia is complex and requires the practitioner to focus on the root of the imbalance/condition causing the sleep disruption.  For example classic texts that discuss imbalances that cause disease in the Wen bing school state one potential cause of sleeplessness:  “ In the case of one who cannot sleep and also wheezes at night, the yangming or stomach qi is rebelling upward.  Normally the qi of the three yang channels of the foot flows downward ” (2).

With all of the above factors in mind below is a short list of questions that must be asked before beginning to treat the patient reporting sleeplessness (Note:  list is not exhaustive and full list of questions will contain all general questions that pertain to any first patient visit)

- Primary complaint with regard to sleep
o difficulty falling asleep
o sustained awakenings
o early morning awakening
o persistent sleepiness despite adequate sleep
o nightmares and excessive dreaming
- Duration/frequency
o a few days to a few weeks
o associated with particular event
o lasting greater than months or years
- Current medications, dietary supplements, diet and lifestyle
- Assessment of sleep hygiene
o noise, light, television, use of computers or mobile phones
o partners sleeping habits

Acupuncture for insomnia and sleeplessness

Acupuncture may be an excellent treatment option for many types of sleeplessness.  While there are many factors to consider when creating acupuncture prescriptions for sleeplessness, many point prescriptions include some of the most commonly used traditional points for sleeplessness such as:
- Auricular shenmen
- HT 7 shenmen
- Extra point Anmian
- Yintang
- Yinqiao and yangqiao opening or meridian points
- PC 6 Neiguan

Currently there are a number of clinical studies that have looked at acupuncture for the treatment of insomnia.  The Cochrane review in 2007 assessed 7 trials of 590 participants and a variety of causes of insomnia and treatment strategies (3).  For example duration of insomnia varied largely in the analysis from 6 months to 19 years and a variety of co-existing medical conditions possibly related to insomnia included pregnancy, stroke, and end-stage renal disease.  Thus, the 2007 review was unable to draw any strong conclusion statistically supporting the use of acupuncture as treatment for insomnia (see Table 1).  However, since then a number of studies have been published.

A few recent studies of interest

1. Sjoling M et al, Auricular acupuncture versus sham acupuncture in the treatment of women who have insomnia.  J Altern Complement Med, 14; 2008.

Overall:  This study was performed to investigate whether or not auricular acupuncture had an effect on sleep parameters in women with insomnia.

Study design: Randomized, single blind pilot study.  Treatment group received auricular acupuncture (AA) on active points versus the control group received AA on sham points.  Treatment period:  6-week treatment period.

Subjects: n=28 women

Points used:  N/A

Outcome Measures: Sleep parameters using the Karolinska Sleep Diary

Results: No statistically significant differences were observed between the groups relating to parameters associated with the definition of insomnia. Treatment group reported that it was easier to wake up in the morning versus the control group (repeated-measures analysis of variance, p = 0.04). Both groups showed a statistically significant recovery in subjective sleep parameters during the study period (weeks 1–6) compared with baseline values (week 0).

Conclusions: Only limited evidence found supporting AA treatment in women with insomnia.

2. Wang XY, Yuan SH, Yang HY, Sun YM, Cheng FP, Zhang CL, Huang XC. Abdominal acupuncture for insomnia in women: a randomized controlled clinical trial. Acupunct Electrother Res. 2008;33(1-2):33-41.

Study design:  Randomized single-blind trial to evaluate the efficacy of short-term abdominal acupuncture as a novel treatment for insomnia in Chinese women

N= 44

Intervention:  Acupuncture (n = 23) versus medication group (n = 21)
o The acupuncture group received abdominal acupuncture once a day for the first three days and once every three days for the remaining 11 days. In addition, every subject in acupuncture group also received a placebo pill once daily.
o Abdominal acupuncture points:  CV 12 Zhongwan, C10 Xiawan, CV 4 Guanyuan and CV 6 Qihai, KI 17 Shangqu, ST 24 Huaroumen
o Subjects in the medication group were treated with sham acupuncture at the same time as the acupuncture group and received estazolam QD.

Outcome measure:  The Leeds Sleep Evaluation Questionnaire (LSEQ).

Results:  Subjects who received abdominal acupuncture lowered their LSEQ scores by an average of 26.32 points (95% CI: 37.34, 15.30) versus medication only.

Conclusions:   This paper appears to demonstrate that abdominal acupuncture was effective for women suffering from insomnia.  However since I was unable to retrieve the entire manuscript, other potentially confounding factors and greater detail on the subjects and intervention could not be reported. 

3.  Cerrone R, Giani L, Galbiati B, Messina G, Casiraghi M, Proserpio E, Meregalli M, Trabattoni P, Lissoni P, Gardani G. Efficacy of HT 7 point acupressure stimulation in the treatment of insomnia in cancer patients and in patients suffering from disorders other than cancer. Minerva Med. 2008 Dec;99(6):535-7.

Overall:  This trial assess acupressure at the HT 7 Shenmen point for insomnia related to cancer and other illnesses.

Study design:  All subjects received acupressure devices that were applied to both writs at 10:00pm each night for at least two weeks.

Points:  HT Shenmen

Results:  Quality of sleep was reported to be improved in 15 of 25 subjects after 10 days (60%).  It appears that the device worked better on subjects reporting insomnia from cancer versus those that had anxiety and depression.

Conclusions:  This pilot study reports that acupressure with a device that stimulates the acupuncture point HT 7 was able to increase quality of sleep in subjects suffering from insomnia.  However the study was quite small and there was neither statistical significance recorded nor use of any validated questionnaire.
 

Table 1. Some trials highlighted in the Cochrane Review, 2007

Year    Authors          Title                        Description                 Comments                            Points

1999

Chen et al

A systematic review of the clinical effectiveness of acupuncture for allergic rhinitis.

N=28

Sham acupressure vs no treatment

Males only

High risk of bias.  Differences were reported between the groups as measured by the mean PSQI scores

 

Acupressure at DU 20, GB 20 and Anmian in head.  Auricular acupressure shen men in ear

 

2003

Cui et al

Acupuncture for male outpatients suffering from insomnia due to “interior-stirring by phlegm-heat”

Treatment versus medication control.  Randomization was not mentioned.

 

Sleep was improved in treatment group by 75% versus 40% in the control group.  No validated questionnaire was used.  

Acupuncture plus estazolam 1-2mg, at Baihui (GV 20), Shenting (GV 24), Sishencong (EX-HN1), Shenmen (HT 7), Neiguan (PC 6), Zhongwan (CV12), Fenglong (ST 40) and Gongsun (SP 4).

Control: Estazolam 1-2mg

Duration of treatment: 30 days (once a day, 10 days of treatment as a course, 3 courses in total).

2003

Tsay et al

Double blind acupuncture versus usual care

N=35.  Males suffering from insomnia due to end-stage renal disease.  Needed PSQI score >5 to participate

Treatment group had considerably better scores on the PQSI than the control group.  However one limitation reported was a distinct difference in the education level and working status between the acupuncture versus control groups.

Acupressure plus usual care, finger pressure on the Shenmen in ears and hand (HT 7) and yougchuan (K 11). 

The time of interventions consisted of 5 min of massage to relax the person and 9 min of acupoint massage (3 min per acupoint)

Control 1: Sham acupressure plus usual care

Control 2: Usual care

Duration of treatment: 3 times a week for 4 weeks

PSQI: Pittsburg sleep quality index   

Conclusion

From a research perspective, a lot more research needs to be done in order to determine if acupuncture is effective for various types of insomnia in adult patients.  However practitioners of acupuncture have commonly used acupuncture treatment for a variety of sleeplessness disorders and a number of classical acupuncture points distinctly classify function with regard to calming shen, quieting the mind and improving sleep.  Thus the potential utility of acupuncture as a treatment utilized alone or in combination with a variety of potential agents might also include pharmacotherapy, behavioral therapy and attention to improving sleep hygiene.  Finally acupuncture plus other Traditional Oriental Medical modalities may include moxibustion and/or herbal medicine that can also work together to provide a supportive and powerful approach to treating a patient suffering from this often chronic and debilitating condition.

References

1.  Harrison’s Principles of Internal Medicine. 17th Edition, McGraw Hill.

2. The Yellow Emperor’s Classic of Medicine:  A new translation of the Neijing su wen with commentary.  Ni Maoshing (Ed), 1995; Shambhala Press, Massachusetts.

3. Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005472.

4. Sjöling M, Rolleri M, Englund E.  Auricular acupuncture versus sham acupuncture in the treatment of women who have insomnia. J Altern Complement Med. 2008 Jan-Feb;14(1):39-46

5.  Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. 5. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005472.



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