Multiple acupuncture therapies, especially acupoints catgut embedding (ACE), auricular acupuncture plus manual acupuncture (AP + MA), and electroacupuncture plus acupoint application (EA + APA) may benefit patients with primary insomnia (PI), a recent meta-analysis suggests. 1
With moderate to low certainty of evidence, investigators found better effects on Pittsburgh Sleep Quality Index (PSQI) scores for acupuncture-treated patients compared with those on usual treatment. Additionally, with low or very low certainty of evidence, there were small or insignificant differences between the several therapies evaluated.
In the final analysis, senior author Long Ge, PhD, researcher, Institute of Health Data Science, Lanzhou University, and colleagues included 57 randomized clinical trials (RCTs) involving 4678 participants with a range of mean age of 31-70 years. A total of 14 acupuncture therapies and 2 control treatments—usual treatment and sham acupuncture—were evaluated, with Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system used to assess certainty of evidence and interpret results.
On PSQI, ACE proved to be the most effective acupuncture therapy relative to usual treatment among those with high or moderate certainty evidence. For others, like head penetration needling (HPN), ACE + MA, plum blossom needle (PBN) + MA, ACE + AP, and MA, these approaches were inferior to the most effective but superior to the least effective acupuncture therapies.
Effective rate, assessed in 39 RCTS, was significantly improved in patients who underwent ACE, ACE + MA, MA, AP + MA, HPN, and PBN + MA, relative to those on usual treatment, although certainty of evidence was moderate. With low certainty, evidence showed that EA and EA + APA were better than usual treatment. No significant differences were found between acupuncture therapies.
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“We found EA + APA is better than IN, AP, EA, PBN, BA, sham acupuncture, and usual treatment. EA could better control the intensity of stimulation through extremely thin electrodes and may be a wider range of applications in the future, “Ge et al wrote. “Limited evidence suggests that, compared with usual treatment, BA is no difference in improving the effective rate and PSQI score. BA may not be considered as a treatment strategy for primary insomnia until more high-quality studies are available to demonstrate its efficiency.”
Traditional Chinese medicine syndrome score, another secondary outcome, was improved in the AP + MA (mean difference, 6.57; 95% CI, 0.19-13.17) and ACE + MA (mean difference, 5.87; 95% CI, 0.69-11.34) groups with moderate certainty relative to placebo. Epworth Sleepiness Scale, recorded in 3 RCTs, showed significantly better benefit in the AP + MA (mean difference, 2.99; 95% CI, 1.18-4.80) and fire needle (mean difference, 1.20; 95% CI, 0.07-2.33) groups with MA.
Athens insomnia scale (AIS) was reported in 4 RCTS, involving 406 participants and 1 acupuncture therapies. With low certainty, MA was significantly more effective (mean difference, 3.36; 95% CI, 0.81-6.31) when compared with usual treatment. The only difference in reduction of recurrence rates, observed in 5 RCTs, was between ACE + AP and AP (RR, 0.23; 95% CI, 0.07-0.80). No significant differences were found among other comparisons.
Due to the sparse data and heterogeneity, investigators did not perform meta-analysis for adverse events (AEs); however, they did summarize the incidence of what was observed among a larger cohort of 22 RCTs enrolling 3382 participants. Of these, the most common AEs from acupuncture interventions included hematoma, pain, headache, and bleeding. No serious AEs related to acupuncture were observed, leaving the study investigators to conclude that “the safety of acupuncture is reliable.”
1. Lu Y, Zhu H, Wang Q, et al. Comparative effectiveness of multiple acupuncture therapies for primary insomnia: a systematic review and network meta-analysis of randomized trial. Sleep Med. 2022;93:39-48. doi:10.1016/sleep.2022.03.012