Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

Figures & data

Figure 1. Flow diagram of search results.

Table 1. Evidence table of included studies.

Study	Sample size	Age^a	Percent male	Country	Baseline PTSD	Acupuncture regimen	Acupoints	Comparator
Engel (2014)	55	Mean: 35 years	69%	US	Mean PCL (SD): 56.1 (11.8) Mean CAPS (SD): 72.9 (16.7)	TCM: 60 minutes, 2x a week/4 weeks	Urinary Bladder 13, 14, 15, 18, 20, 23; Liver 3; Large Intestine 4; Heart 5, 7; Pericardium 6; Kidney 3, 9; Ren 4, 15; Du 24; Ear Shenmen; and Yintang	TAU
Hollifield (2007)	84	Mean: 42 years	32%	US	Mean PSS-SR (SD): Acupuncture: 31.33 (10.10) CBT: 32.52 (6.63) WLC: 30.79 (9.54)	TCM: 60 minutes, 2x a week/12 weeks	LR3, PC6, HT7, ST36, SP6, Yintang, GB20, and BL14, 15, 18, 20, 21, 23	CBT, WLC
King (2015)	29	Mean: 33 years	100%	US	Mean duration of PTSD diagnosis (SD): 5.4 (5.1) years	AA: 30 minutes, 3x a week/3 weeks	Shen Men, Point Zero, Brain, Thalamus Point, Pineal Gland, Master Cerebral, Insomnia Points 1 and 2, Kidney, Heart, Occiput, and Forehead	TAU
Prisco (2013)	35	Mean: 38 years	71%	US	Mean duration of PTSD symptoms (SD): 5.2 (3.0) years	AA: 45 minutes, 2x a week/8 weeks	Shen Men, Kidney (KI, under flap), Sympathetic (under flap), Liver (LR), and Hippocampus	Sham, TAU
Wang (2012)	138	Mean: 48 years	39%	China	Mean CAPS (SD): 65.8 (19.7)	EA: 30 minutes, 3-4x a week/12 weeks	Baihui (GV 20), Sishencong (EX-HN 1), Shenting (GV 24), Fengchi (GB 20)	Paroxetine
Zhang (2010a)	92	Range: 18–65 years	35%	China	Minimum duration of PTSD diagnosis of 3 months	EA: 30 minutes, 3x a week/12 weeks	Shenyu, Mingmen, Zhishi, Shenting, Shencong points, Baihui, and Fengchi	Paroxetine
Zhang (2010b)	276	Range: 18–65 years	NR	China	Minimum duration of PTSD diagnosis of 3 months	TCM: 30 minutes, 3x a week/12 weeks	Shenting, 4 Shencong points, Baihui, and Fengchi	Paroxetine

Notes: AA = auricular acupuncture, CAPS = Clinician-administered PTSD Scale, CBT = cognitive behavioral therapy, EA = electro-acupuncture, NR = not reported, PCL = PTSD checklist, PSS-SR = Posttraumatic Symptom Scale-Self Report, PTSD = Posttraumatic Stress Disorder, SD = standard deviation, TAU = treatment as usual, TCM = Traditional Chinese Medicine, US = United States, WLC = wait-list control.

Age of participants is reported either as a mean or a range depending on the information provided in included studies.

Table 2. Overall effect and subgroup analyses for PTSD symptoms.

Outcome	Studies	SMD (95% CI)	Risk of Bias	Consistency	Directness	Precision	Publication Bias	QoE
PTSD symptoms. (post-intervention)	k = 6 n = 508	−0.80 (−1.59 to −0.01)	Downgrade 1^a,f	Downgrade 1^b	No downgrade	Downgrade 1^d	τ = −0.29, p = 0.43 t (4) = −0.31, p = 0.77	Very low
PTSD symptoms (follow-up)	k = 4 n = 387	−0.46 (−0.85 to −0.06)	Downgrade 1^g	No downgrade	No downgrade	Downgrade 1^d	τ = −1.00, p = 0.06 t (2) = −4.17, p = 0.18	Low
Physical health-related quality of life (follow-up)	k = 1 n = 55	−0.47 (−1.01 to 0.07)	No downgrade	Downgrade 2^e	No downgrade	Downgrade 1^c	Insufficient evidence to investigate	Very low
Mental health-related quality of life (follow-up)	k = 1 n = 55	−0.33 (−0.87 to 0.21)	No downgrade	Downgrade 2^e	No downgrade	Downgrade 1^c	Insufficient evidence to investigate	Very low
Functional status (post-intervention)	k = 1 n = 56	−0.83 (−1.38 to −0.29)	Downgrade 1^a	Downgrade 2^e	No downgrade	Downgrade 1^d	Insufficient evidence to investigate	Very low
Functional status (follow-up)	k = 1 n = 56	−0.97 (−1.53 to −0.42)	Downgrade 1^a	Downgrade 2^e	No downgrade	Downgrade 1^d	Insufficient evidence to investigate	Very low
Depressive symptoms (post-intervention)	k = 6 n = 508	−0.58 (−1.18 to 0.01)	Downgrade 1^a	Downgrade 1^b	No downgrade	Downgrade 1^c	τ = 0.14, p = 0.70 t (4) = 0.29, p = 0.62	Very low
Depressive symptoms (follow-up)	k = 4 n = 387	−0.56 (−0.88 to −0.23)	Downgrade 1^g	No downgrade	No downgrade	Downgrade 1^d	τ = −0.55, p = 0.28 t (2) = 0.53, p = 0.54	Low
Anxiety symptoms (post-intervention)	k = 4 n = 424	−0.82 (−2.16 to 0.53)	Downgrade 1^a	Downgrade 1^b	No downgrade	Downgrade 1^c	τ = −0.60, p = 0.25 t (2) = −1.25, p = 0.34	Very low
Anxiety symptoms (follow-up)	k = 3 n = 332	−0.35 (−1.17 to 0.47)	Downgrade 1^a	Downgrade 1^b	No downgrade	Downgrade 1^c	τ = −0.82, p = 0.22 t (1) = −2.52, p = 0.24	Very low
Sleep quality (post-intervention)	k = 2 n = 53	−0.46 (−3.95 to 3.03)	Downgrade 1^a	No downgrade	No downgrade	Downgrade 1^c	τ = 1.00, p = 1.00	Low

Notes: k = number of randomized controlled trials (RCTs). n = number of participants. SMD < 0 favors needle acupuncture. τ = Kendall’s tau for Begg’s rank correlation test for funnel plot asymmetry. t = Egger’s regression test for funnel plot asymmetry.

^a High attrition bias and/or no intention-to-treat analysis. ^b Statistically significant and/or substantial heterogeneity. ^c Wide confidence interval indicating benefit and harm. ^d Wide confidence interval spanning clinically meaningful differences. ^e Cannot judge consistency (only one RCT). ^f Results sensitive to inclusion of poor quality study (see Online Supplement 6). ^g High risk of performance bias from unblinded participants in all trials underpinning analysis due to lack of sham acupuncture comparators.

Figure 2. Forest plot for needle acupuncture versus any comparator on PTSD symptoms at post-intervention.

Notes: Standardized Mean Difference (SMD) = Hedges’ g. SMD < 0 favors needle acupuncture. The reported percentages indicate the weight each study contributes to the meta-analysis. The right hand figures report the SMD [95% Confidence Interval] for each individual study and (at the bottom) the overall estimate from the meta-analysis.

Figure 3. Forest plot for needle acupuncture versus any comparator on PTSD symptoms at one-to-six months follow-up.

Notes: Standardized Mean Difference (SMD) = Hedges’ g. SMD < 0 favors needle acupuncture. The reported percentages indicate the weight each study contributes to the meta-analysis. The right hand figures report the SMD [95% Confidence Interval] for each individual study and (at the bottom) the overall estimate from the meta-analysis.

Table 3. Adverse events in included studies.

Study	Reported adverse events
Engel (2014)	Explicitly reported that no study-related adverse events were reported or observed
Hollifield (2007)	One participant receiving TCM acupuncture reported kidney pain, which was not reported by any participant in the group CBT and wait-list control comparator groups
King (2015)	One participant in auricular acupuncture dropped out due to uncomfortable feelings while receiving acupuncture. Five other auricular acupuncture participants experienced adverse events during the study period, including one fall, two alcohol-related events, one wrist injury, and one incident of suicidal ideation; four of these adverse events occurred before participants received acupuncture, whereas another (not specified in the report) occurred 3 days after receipt of acupuncture. The study investigators concluded that none of these adverse events were directly related to the acupuncture intervention
Prisco (2013)	One participant receiving sham acupuncture dropped out because the acupuncture needles were uncomfortable, which was not reported by any participant in the true auricular acupuncture group
Wang (2012)	One participant refused to continue acupuncture for being afraid of pain; in contrast, one participant in the active comparator reported symptoms of giddiness, a second reported symptoms of constipation, and a third reported symptom of blurred vision. In the acupuncture group, the following adverse events on behavior, the autonomic nervous system, and the cardiovascular system were experienced during acupuncture (in order of frequency, out of 69 acupuncture participants): minor superficial bleeding (27 participants), minor needle pain (24 participants), minor hematoma (9 participants), and one case of moderate pain. Participants in the active comparator (12 weeks of paroxetine) reported numerous adverse events (in order of frequency, out of 69 paroxetine participants): xerophthalmia (36 participants), insomnia (28 participants), appetite loss/anorexia (21 participants), constipation (17 participants), sweat (11 participants), nausea and vomiting (11 participants), headache (11 participants), saliva increase (8 participants), fatigue (7 participants), activity declined (6 participants), diarrhea (6 participants), dizziness (5 participants), excitement or agitation (4 participants), depression (3 participants), blurred vision (3 participants), tachycardia (3 participants), activity increased (2 participants), skin allergy symptom (1 participants), and stuffy nose (1 participant).
Zhang (2010a)	Monitored adverse events: did not report any but did not explicitly state that no adverse events were observed
Zhang (2010b)	Some patients (exact number unknown) reported roughness of operational practices, fear of needles, bleeding, hematoma, pain, and fainting; no serious adverse events were reported

Engel, C. C., Cordova, E. H., Benedek, D. M., Liu, X., Gore, K. L., Goertz, C., … Ursano, R. J. (2014). Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Medical Care, 52 (12 Suppl 5), S57–64. doi:10.1097/mlr.0000000000000237

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Hollifield, M., Sinclair-Lian, N., Warner, T. D., & Hammerschlag, R. (2007). Acupuncture for posttraumatic stress disorder: A randomized controlled pilot trial. The Journal of Nervous and Mental Disease, 195 (6), 504–513. doi:10.1097/NMD.0b013e31803044f8

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King, H. C., Spence, D. L., Hickey, A. H., Sargent, P., Elesh, R., & Connelly, C. D. (2015). Auricular acupuncture for sleep disturbance in veterans with post-traumatic stress disorder: A feasibility study. Military Medicine, 180 (5), 582–590. doi:10.7205/MILMED-D-14-00451

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