Acupuncture for insomnia? An overview of systematic reviews

Figures & data

Table I. Search strategy.

1.	‘Acupuncture Therapy’ [Mesh]
2.	acupunc Field: Title/Abstract
3.	acupress Field: Title/Abstract
4.	electroacupunc Field: Title/Abstract
5.	meridian Field: Title/Abstract
6.	acupoint Field: Title/Abstract
7.	#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7
8.	‘Sleep’ [Mesh]
9.	sleep Field: Title/Abstract
10.	insomnia Field: Title/Abstract
11.	wakeful Field: Title/Abstract
12.	#8 OR #9 OR #10 OR #11
13.	systematic review Field: Title/Abstract
14.	review Field: Title/Abstract
15.	meta-analysis Field: Title/Abstract
16.	No. 13 OR no. 14 OR no. 15
17.	No. 7 AND no. 12 AND no. 16

Table II. Summary of key data in 10 systematic reviews on acupuncture for insomnia.

First author (ref) year	Country	Number of primary studies (Chinese)	Total sample size	Quality of primary studies	Overall conclusion (quote)	Meta-analysis	Quality of review (OQAQ)	Comment
Cao (10) 2009	China	46 (45)	3811	Mostly poor	Acupuncture appears to be effective in treatment of insomnia	WMD: −2.94 (95% CI: −5.77 to −0.11) compared with sham acupuncture	4	3 Chinese databases were searched, only 3 studies were sham controlled
Huang (11) 2009	US	12 (10)	1305	Variable	The currently available studies have demonstrated the safety and potential beneficial effects of acupuncture in treating most forms of insomnia	None	3	5 studies were sham-controlled of which 4 were positive
Liu (12) 2009	China	10 (10)	1387	Variable	…acupuncture is proven to be an effective treatment of insomnia	OR: 2.64 (95% CI: 2.07–3.37) compared with control treatments	1	5 RCTs and 5 CCTs were included
Yeung (13) 2009	China	20 (19)	1299	Mostly poor	…the data, while promising, do not allow a clear conclusion	None	6	Funnel plot revealed publication bias
Lee (14) 2008	South Korea, UK	10 (8)	642	Poor	…the evidence for the effectiveness of auricular acupuncture …is limited	WMD: 7.5 (95% CI: 2.2–12.9) two sham-controlled trials	7	Review focused on auricular only acupuncture
Cheuk (15) 2007	China	7 (6)	590	Poor	…the current evidence is not sufficiently extensive or rigorous to support the use of any form of acupuncture for the treatment of insomnia	SMD: −1.08 (95% CI: −1.86 to −0.31) compared to placebo	7	Several variants of acupuncture, e.g. acupressure, were included
Chen (16) 2007	China	6 (6)	673	Poor	auricular acupuncture appears to be effective for treating insomnia	RR: 1.93 (95%CI: 1.40–2.66) compared with control	4	Review was of auricular acupuncture only; high heterogeneity in meta-analysis
Kalavapalli (17) 2007	US	19 (16)	1586	Mostly poor	…acupuncture may be useful in the treatment of insomnia…	None	1	Only 6 studies were RCTs, case series were also included
Li (18) 2005	China	6 (6)	585	Poor	Acupuncture is possibly effective for insomnia	OR: 3.55 (95% CI: 2.50–5.05) compared with drug group	3	Non-English articles were excluded
Sok (19) 2003	US, South Korea	11 (9)	990	Poor	…acupuncture may be an effective intervention for the relief of insomnia	None	1	Non-English articles were excluded. All studies reported positive effects

Overview quality assessment questionnaire (OQAQ). The overall score is from 1 to 7.

OQAQ ≤ 3: having extensive or major flaws; 5 ≤ OQAQ: having minor or minimal flaws.

WMD, weighted mean difference; OR, odds ratio; RR, risk ratio; SMD, standardized mean difference.

Table III. Overview quality assessment questionnaire (OQAQ) for the included systematic reviews.

First author (Ref) Year	1Were the search methods reported?	2Was the search comprehensive?	3Were the inclusion criteria reported?	4Was selection bias avoided?	5Were the validity criteria reported?	6Was validity assessed appropriately?	7Were the methods used to combine studies reported?	8Were the findings combined appropriately	9Were the conclusions supported by the reported? data?	10Overall score
Cao (10) 2009	2	2	2	2	2	2	1	0	1	4
Huang (11) 2009	2	2	2	1	2	2	1	1	1	3
Liu (12) 2009	2	0	1	1	2	2	1	0	0	1
Yeung (13) 2009	2	2	2	1	2	2	2	2	2	6
Lee (14) 2008	2	2	2	2	2	2	2	2	2	7
Cheuk (15) 2007	2	2	2	2	2	2	2	2	2	7
Chen (16) 2007	2	2	2	2	2	2	1	0	0	4
Kalav-apalli (17) (2007)	2	1	1	0	0	0	1	1	0	1
Li (18) 2005	2	2	2	1	2	2	1	1	0	3
Sok (19) 2003	2	2	1	0	0	1	0	0	1	1

Table IV. Quality assessment and inclusion and exclusion criteria of each included systematic review.

First author (Ref) year	Quality assessment	Inclusion criteria	Exclusion criteria
Cao (10) 2009	Agency for Healthcare Research and Quality (AHRQ) quality assessment criteria	P: patients with insomniaI: acupunctureC: no treatment, placebo, basic medical therapiesO: total sleep duration, increased sleep duration,Pittsburgh Sleep Quality Index (PSQI) scores,Index of Severity of Insomnia, Sleep Quality, other validated score, adverse effectsS: RCT, acupuncture + other treatment versus other treatmentNo limitation on language and publication type	Multiple publication reporting the same group of participants
Huang (11) 2009	Cochrane criteria	P: n.r.I: n.r.C: n.r.O: n.r.S: original case series or clinical trials published in peer-reviewed journals, human studies, article written in English or Chinese language	1. Although acupuncture mentioned, the main treatment modality was complementary alternative medicine2. Treatments focused on other sleep disorders such as sleep apnoea, night terrors, or somnambulism3. Multiple publication reporting the same group of participants or their subsets
Liu (12) 2009	Jadad score	P: n.r.I: n.r.C: n.r.O: n.r.S: RCT and CCT	1. Trials which comparing the point specificity and type of acupuncture2. Trials which are testing the effects of moxibustion, electric acupuncture, Confucianism point injection, sticking points of Chinese medicine, acupressure, etc.3. Acupuncture plus other treatment4. Duplicated publication
Yeung (13) 2009	Jadad score	P: participants with chief complaint of insomniaI: acupunctureC: placebo, Western medication, no treatmentO: not set any specification for outcome measuresS: RCT and CCTNo specification for duration or study quality	n.r.
Lee (14) 2008	Jadad score	P: patients with insomniaI: treatments with semi-permanent acupuncture needle or device (bead, seed, or magnetic pellet)C: placebo auricular acupuncture, active interventions without acupuncture, no treatmentO: n.r.S: RCTNo language restrictions were imposed	1. Studies comparing two different forms of auricular acupuncture2. Trials testing auricular acupuncture with another form of acupuncture or with other treatments which have not been proved effective for treating insomnia
Cheuk (15) 2007	Cochrane criteria	P: people of any age and gender with insomnia explicitly documented by standardized measures or by reports/diaries or patients with insomnia diagnosed by standard diagnostic criteriaI: traditional acupuncture in classical meridian points, or contemporary acupuncture in non meridian or trigger points (regardless of the source or methods of stimulation – hand, laser, seed, magnetic or electrical stimulation)C: placebo or sham acupuncture, no treatmentO: subjective report of sleep quality, sleep parameters, standard scales related to sleep (Pittsburgh Sleep Quality Index), Daytime functioning (Stanford Sleepiness Scale, Epworth Sleepiness Scale), quality of life, frequency of adverse effectsS: RCT, parallel, cross-over, acupuncture versus no treatment, acupuncture vs. placebo or sham treatment, acupuncture plus baseline medication or treatment vs. baseline medication or treatment alone, acupuncture plus baseline medication or treatment vs. placebo or sham treatment plus baseline medication or treatmentNo language restrictions were imposed	n.r.
Chen (16) 2007	Cochrane criteria	P: people of any age and gender with insomnia explicitly documented by standardized measures or by reports/diaries or patients with insomnia diagnosed by standard diagnostic criteriaI: auricular acupuncture is used as sole treatment, no special restrictions on the use of needles and other TCM manipulationsC: no treatment, sham auricular acupuncture, placebo, Western medicineO: subjective report of sleep quality, sleep parameters, standard scales related to sleep (Pittsburgh Sleep Quality Index), Daytime functioning (Stanford Sleepiness Scale, Epworth Sleepiness Scale), quality of life, frequency of adverse effectsS: RCTs which are written in the Chinese or EnglishNo language restrictions were imposed	1. Quasi-randomized trials and case studies2. Auricular acupuncture is used as co-intervention3. Auricular acupuncture4. Studies comparing different groups of auricular acupuncture points, different times for receiving treatments and different ways for stimulating the auricular acupuncture points
Kalavapalli (17) 2007	n.r	P: patients with insomniaI: acupunctureC: n.r.O: n.r.S: n.r.Published between 1985 and 2005Written either in English or English translation	n.r.
Li (18) 2005	Jadad score	P: patients with insomnia (according to clinical criteria)I: acupuncture, acupuncture combined basic drugC: drug therapy (two group use of same drugs)O: n.r.S: RCTWritten either in Chinese or English	1. Trials with no clear diagnostic criteria of insomnia2. Other underlying diseases associated with insomnia3. Animal experiments4. Studies comparing different acupuncture points, massage therapy as control group
Sok (19) 2003	n.r.	P: patients with insomniaI: acupuncture therapyC: n.r.O: n.r.S: n.r.Published between 1975 and 2002Written in English	n.r.

n.r., not reported.

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