J. Acupunct. Tuina. Sci. 2010, 8 (1): 12-16 DOI: 10.

1007/s11726-010-0012-0

Special Topic Study

Exploration of the Clinical Regularity of Acupuncture and Moxibustion Treatment for Insomnia
HUANG Qin-feng () Shanghai Research Institute of Acupuncture and Meridian, Shanghai 200030, P. R. China

19562007 Abstract Objective: To review year 1956-2007 literature and explore the regularity of points selection and methods for acupuncture-moxibustion treatment of insomnia. Methods: A comprehensive analysis was made by a method of metrological review according to the data from "China Modern Acupuncture-moxibustion Information Databank". Results: It is indicated that points Sanyinjiao (SP 6) and Shenmen (HT 7) were most frequently used. Acupuncture was the main treatment. Conclusion: It is suggested that Baihui (GV 20), Sishencong (Ex-HN 1), Sanyinjiao (SP 6) and Shenmen (HT 7) were used as basic points for acupuncture-moxibustion treatment of insomnia, which is combined with point selection based on syndrome differentiation. Key WordsAcupuncture-moxibustion; Insomnia; Literature Metrology; Evaluation Studies CLC NumberR246.6 Document CodeA Insomnia refers to difficulty falling or maintaining asleep, or a sleep disorder, which results in insufficient sleep. It is often caused by visceral dysfunction, deficiency of qi and blood, and yin-yang disharmony. This disease pertains to sleeplessness in traditional Chinese medicine. Modern medicine says that insomnia may result from many diseases, including malignant tumors, depression, schizophrenia, peri-menopausal syndrome, neurasthenia and heroin addiction. to 644 papers on insomnia including a total of 36 532 patients from 654 574 pieces of information collected from "China modern acupuncturemoxibustion information databank" (1954-2007) developed by Shanghai Research Institute of Acupuncture and Meridian. The mechanism of the point selection and therapeutic methods was summarized. The purpose was to understand the situation, grasp the developments, broaden the thinking and further promote the clinical application of acupuncture and moxibustion.

1 Literature Sources and Purpose 2 Results

The status of acupuncture-moxibustion treatment for insomnia was systematically analyzed according
Fund Items: Shanghai Leading Academic Discipline Project (S30304); Shanghai Municipal Education Commission (08YS64) Author: HUANG Qin-feng (1951- ), female, associate research fellow

2.1 Literature analysis Acupuncture-moxibustion treatment for insomnia first appeared in 1955[1]. Of the 644 papers, 503 were clinical reports, accounting for 78.1%; 86 were case analyses, accounting for 13.4%; 24 were literature studies, accounting for 3.7%; 13 were

12 Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2010

J. Acupunct. Tuina. Sci. 2010, 8 (1): 12-16

clinical studies, accounting for 2.0%; 1 was an experimental study, accounting for 0.2%; 24 were repeated papers, accounting for 3.7%; 143 were controlled studies, accounting for 28.4%; 143 were controlled studies in clinical reports, accounting for 28.4%; 109 papers labeled with "randomly controlled", accounting for 16.9% of total papers; and 76.2% of controlled study papers. 302 were published in the recent 5 years, accounting for 46.9%. Clinical studies of acupuncture-moxibustion treatment for insomnia predominated, accounting for 91.5%. 2.2 Summary of point selection Acupuncture-moxibustion treatment for insomnia involved a total of 209 points. Of them, there were 151 points of the fourteen meridians, 10 extraordinary points, 40 ear points and 8 scalp points. The points used in more than 5 papers were summarized and generalized. Points of the fourteen meridians and extraordinary points were Sanyinjiao (SP 6) (260, papers, the numbers below means the same), Shenmen (HT 7) (258), Zusanli (ST 36) (205), Taichong (LR 3) (188), Neiguan (PC 6) (187), Xinshu (BL 15) (182), Baihui (GV 20) (175), Taixi (KI 3) (166), Pishu (BL 20) (144), Shenshu (BL 23) (121), Sishencong (Ex-HN 1) (114), Fengchi (GB 20) (100), Fenglong (ST 40) (95), Anmian (Ex-HN 22) (92), Ganshu (BL 18) (91), Danshu (BL 19) (80), Zhongwan (CV 12) (80), Yintang (Ex-HN 3) (67), Daling (PC 7) (63), Xingjian (LR 2) (60), Zhaohai (KI 6) (51), Shenting (GV 24) (50), Taiyang (Ex-HN 5) (45), Yanglingquan (GB 34) (37), Hegu (LI 4) (35), Shenmai (BL 62) (34), Weishu (BL 21) (33), Qiuxu (GB 40) (31), Dazhui (GV 14) (30), Neiting (ST 44) (30), Yongquan (KI 1) (29), Guanyuan (CV 4) (27), Yinlingquan (SP 9) (24), Jueyinshu (BL 14) (20), Geshu (BL 17) (16), Jianshi (PC 5) (16), Qihai (CV 6) (16), Yinbai (SP 1) (15), Shangxing (GV 23) (14), Qimen (LR 14) (14), Fuliu (LI 7) (14), Danzhong (CV 17) (13), Gongsun (SP 4) (12), Touwei (ST 8) (11), Benshen (GB 13) (10), Zuqiaoyin (GB 44) (10), Laogong (PC 8) (9), Shuaigu (GB 8) (9), Xuehai (SP 10) (9), Lidui (ST 45) (9), Erjian (Ex-HN 6) (8), Waiguan (TE 5) (8), Tianshu (ST 25) (8), Fengfu (GV 16) (8), Mingmen (GV 4) (8), Shenque (CV 8) (7), Quchi (LI 11) (7), Feishu (BL 13) (6), Lieque (LU 7) (6), Zhishi

(BL 52) (6), Jianjing (GB 21) (6), Jingming (BL 1) (6), Juque (CV 14) (6), Tongli (HT 5) (6), Yaoyangguan (GV 3) (6), Shendao (GV 11) (6), Wangu (GB 12) (6), Qianding (GV 21) (5), Zhiyang (GV 9) (5), Tianzhu (BL 10) (5) and Zulinqi (GB 41) (5). Ear points often selected were Ershenmen (MA-TF 1) (162), Heart (MA-IC) (157), Kidney (MA-SC) (121), Subcortex (MA-AT 1) (119), Spleen (MA-IC) (103), Liver (MA-SC 5) (98), Sympathetic (MA-AH 7) (80), Stomach (MA-IC) (63), Occiput (MA-AT) (63), Endocrine (MA-IC 3) (56), Pancreas and Gallbladder (MA-SC 6) (50), Central Rim (MA-AT) (46), Anterior Ear Lobe (MA-L) (35), Groove of Posterior Surface (MA-PS) (15), Lung (MA-IC 1) (13), Forehead (MA-AT) (17), Small Intestine (MA-SC 2) (9), Sanjiao (MA-IC 4) (9), Large intestine (MA-SC 4) (7), Temple (MA-AT) (6). 2.3 Summary of point combination A comparison was made of every two pairs of points that ranked among the early 8 places in order of frequency at which the points were used for acupuncture-moxibustion treatment of insomnia. The points of which two were combined at a frequency of above 50% were considered as the best combination. Sanyinjiao (SP 6) in combination with Shenmen (HT 7), Zusanli (ST 36), Taichong (LR 3), Neiguan (PC 6) or Taixi (KI 3); Shenmen (HT 7) with Sanyinjiao (SP 6), Zusanli (ST 36), Taichong (LR 3), Neiguan (PC 6), Baihui (GV 20) or Taixi (KI 3); Zusanli with Taichong (LR 3), Neiguan (PC 6), Xinshu (BL 15), Baihui (GV 20) or Taixi (KI 3); Taichong (LR 3) with Neiguan (PC 6), Baihui (GV 20) or Taixi (KI 3); Neiguan (PC 6) with Xinshu (BL 15), Baihui (GV 20) or Taixi (KI 3); Xinshu (BL 15) with Taixi (KI 3). 2.4 Summary of meridians Clinically selected 161 points of the fourteen meridians and extraordinary points showed that the order of the meridians according to the frequency at which the points of each meridian were used was Bladder Meridian (778), Stomach Meridian (366), Spleen Meridian (326), Governor Vessel (324), Pericardium Meridian (280), Heart Meridian (274), Kidney Meridian (270), Liver Meridian (269), extraordinary points (248), Gallbladder Meridian (229), Conception Vessel (157), Large Intestine

Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2010 13

J. Acupunct. Tuina. Sci. 2010, 8 (1):12-16

Meridian (48), Triple Energizer Meridian (22), Small Intestine Meridian (11) and Lung Meridian (9). 2.5 Summary of regions Clinically selected 161 points showed that the order of the points according to the frequency at which the points on each region were used related to points on the head and neck (669), on the upper back (652), on the yin part of the foot (529), the yang part of the leg (343), on the palm (336), on the yin part of the leg (314), the yin part of the arm (227), on the lower back (147), on the dorsal part of the foot (130), on the chest and epigastrium (127), on the lower abdomen (63) , on the dorsal part of the hand (44) , and on the yang part of the arm (21). 2.6 Summary of therapeutic methods Acupuncture-moxibustion treatments for insomnia, arranged in descending order, were acupuncture (315), ear acupuncture (162), medication (50), moxibustion (41), tuina (36), acupuncture point injection (25), cupping (19), electroacupuncture (19), acupoint application (17), skin acupuncture (15), embedding therapy (9), scalp acupuncture (9), acupuncture-moxibustion appliances (9), psychotherapy (8), acupoint pressing (8), hand-foot acupuncture (7), pricking bloodletting therapy (6), pricking-cupping bloodletting (4), warm needling therapy (4), scraping and rubbing therapy (3), acupoint magnetotherapy (2), oxygen therapy (1), piercing method (1), fumigation and steaming method (1), acupoint ion-introduction (1), eye acupuncture (1). An analysis of the therapeutic methods showed that acupuncture and ear acupuncture were mainly used, and moxibustion and composite treatments were also administered. A twirling method of reinforcement and reduction and a method of restoring body function and removing pathogenic factors were mainly used and penetration needling (8)[2], cluster needling (2)[3], abdominal needling (2)[4], half needling (1)[5], leopard-spot needling (1)[6], long needle therapy (1)[7], contralateral meridian needling (1)[8] and surround needling (1)[9] were also used for acupuncture. Auricular point plaster therapy (143, accounting for 88.3%)[10,11] was used and auricular needle (catgut)-embedding (2)[12] also for ear acupuncture. Moxa-stick moxibustion (29, accounting for 70.7%)[13] was used

and Zhuang thread moxibustion (2)[14], gingerpartitioned moxibustion (2)[15] and salt-partitioned moxibustion (1)[16] also for moxibustion. Acupuncture plus medicine and acupuncture plus tuina were often used for a composite treatment.

3 Discussion
3.1 Characteristics of the frequently used points The points used in more than 20% of the papers on clinical reports are considered as they proved to be frequently used and effective points for the treatment of insomnia. Sanyinjiao (SP 6), Shenmen (HT 7), Zusanli (ST 36), Taichong (LR 3), Neiguan (PC 6), Xinshu (BL 15), Baihui (GV 20), Taixi (KI 3), Pishu (BL 20), Shenshu (BL 23), Sishencong (Ex-HN 1) and ear points: Ershenmen (MA-TF 1), Heart (MA-IC), Kidney (MA-SC) and Subcortex (MA-AT 1). 3.1.1Characteristics of along-meridian point selection The points of the bladder meridian were often selected. They were used 778 times (accounting for 22.0%), the most frequent among the points of all the meridians. "the brain is the house of the mind". The bladder meridian "goes into the brain from the vertex" and so its points function to tonify the brain and pacify the mind. Back-Shu points of the bladder meridian were often selected. Xinshu (BL 15), Pishu (BL 20), Shenshu (BL 23), Ganshu (BL 18) and Danshu (BL 19). Stimulation of Back-Shu points can regulate the functions of the corresponding viscera to produce a soporific effect. The points of the stomach meridian and the spleen meridian were often selected. The former were used 366 times and the latter 326 times. Stomach disharmony, internal obstruction of phlegm-heat, anxiety and fatigue, and internal injuries to the heart and spleen can cause insomnia. Points Zusanli (ST 36) and Fenglong (ST 40) and Sanyinjiao (SP 6) were often selected to harmonize the stomach. The points of the Governor Vessel were often selected. They were used 324 times. The Governor Vessel communicates with the Bladder Meridian and enters the brain. "The brain is the sea of marrow" and therefore the point Baihui (GV 20) was often selected to unblock the brain and pacify the mind.

14 Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2010

J. Acupunct. Tuina. Sci. 2010, 8 (1): 12-16

The points of the pericardium meridian and the heart meridian were often selected. The former were used 280 times and the latter 274 times. The ancients thought that "the heart dominates mental activities". Therefore, Points Neiguan (PC 6), Daling (PC 7) and Shenmen (HT 7) were often selected clinically to relieve mental stress. The points of Kidney and Liver Meridians were often selected. The former were used 270 times and the latter 269 times. Point Taixi (KI 3) was selected to reinforce the kidney and Taichong (LR 3) and Xingjian (LR 2) to purge liver fire. 3.1.2 Characteristics of regional point selection Points on the head and neck were often selected. They were used 669 times (accounting for 19.0%), the most frequent among points on all the regions. The ancients thought that "the brain is the house of the mind". Points on the head should be selected according to the principles of local point selection. Points Baihui (GV 20), Sishencong (Ex-HN 1), Fengchi (GB 20) and Yintang (Ex-HN 3) on the head were often selected clinically. Points on the back were often selected. The Back-Shu points Xinshu (BL 15), Pishu (BL 20), Ganshu (BL 18) and Danshu (BL 19), which relate to the viscera heart, spleen, liver and gallbladder, were often selected for this disease. Points on the upper back were used more frequently, a total of 652 times. Point Xinshu (BL 15) was used for most frequently among all the Back-Shu points. Points on the yin part of the lower limb were often selected. Points on the yin part of the foot were used 529 times (accounting for 11%) and points on the yin part of the leg, 314 times. Points Sanyinjiao (SP 6), Taichong (LR 3), Taixi (KI 3) and Xingjian (LR 2) were often selected clinically. 3.1.3 Application of ear points Because ear acupuncture is a convenient treatment, it was combined with acupuncture to produce a marked therapeutic effect. Ear points were used 1 273 times (accounting for 23%). Ear points Ershenmen (MA-TF 1), Heart (MA- IC), Kidney (MA-SC) and Subcortex (MA-AT 1) were often selected. 3.2 Comparison of ancient and modern literature In comparison with ancient literature on acupuncture-moxibustion treatment for insomnia

studied by LIU Li-gong, et al[17], modern literature is abundant by comparison and extensive in point selection. Two hundred and nine points were selected in modern literature compared with 65 points in ancient literature, the ratio between the two is 3.2 to 1. But in modern literature, there are no points Tianfu (LU 3), Yemen (TE 2), Yinjiao (CV 7), Daju (ST 27), Jiexi (ST 41), Yixi (BL 45) and Qiangjian (GV 18) recorded in ancient literature. The points of the Governor Vessel and the point Baihui (GV 20) on the vertex were often used in modern literature and the points of the Conception Vessel in ancient literature. Hypogastric points. Yinjiao (CV 7) and Dajv (ST 27), were often used in ancient literature, but few of them in modern literature. There were multiple therapeutic methods in the modern literature, including a twirling method of reinforcing-reducing and a method of restoring body function and removing pathogenic factors, penetration needling, cluster needling, abdominal needling, half needling, leopard-spot needling, long needle therapy, contralateral meridian needling and surround needling were used for acupuncture. Besides moxa-stick moxibustion, Zhuang thread moxibustion, ginger-partitioned and salt-partitioned moxibustion were also used for moxibustion. Meanwhile, ear acupuncture, electroacupuncture, embedding therapy, scalp acupuncture, acupuncturemoxibustion appliance and psychotherapy were also used.

4 Suggested Therapeutic Protocols

4.1 Therapeutic principle Pacify the mind. 4.2 Point selection 4.2.1 Basic prescription Baihui (GV 20), Sishencong (Ex-HN Sanyinjiao (SP 6) and Shenmen (HT 7).

1)

4.2.2Modification based on differentiation Points Xinshu (BL 15) and Pishu (BL 20) are added for heart-spleen deficiency; points Xinshu (BL 15), Shenshu (BL 23) and Taixi (KI 3), for non-interaction between the heart and kidney; points Xinshu (BL 15), Danshu (BL 19) and Taichong (LR 3), for heart deficiency with timidity; points Neiguan (PC 6) and Taichong (LR 3), for

Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2010 15

J. Acupunct. Tuina. Sci. 2010, 8 (1): 12-16

hyperactivity of heart- liver fire; points Zusanli and Fenglong (ST 40), for disorder of stomach qi. 4.3 Therapeutic methods 4.3.1 Acupuncture Baihui (GV 20), Sishencong (Ex-HN 1) Sanyinjiao (SP 6) and Shenmen (HT 7) are selected as major points, which are modified according to the symptoms. A conventional needling method is used with twirling reinforcing (restoring body function) and reducing (removing pathogenic factors). The needles are retained for 30 min after arrival of qi. Penetration needling can also be used, e.g. Baihui (GV 20) to Qianding (GV 21) and Neiguan (PC 6) to Waiguan (TE 5). 4.3.2 Moxibustion Baihui (GV 20) and Yongquan (KI 1) are selected as major points[13]. Suspended moxibustion with moxa stick is performed to the extent that the patient has a warming sensation and the local part is congested and hot. The treatment is given 30 min once daily. 4.3.3 Auricular point plaster therapy Three to five of ear points Ershenmen (MA-TF 1), Heart (MA-IC), Kidney (MA-SC), Subcortex (MA-AT 1), Liver (MA-SC 5), Spleen (MA-IC), Stomach (MA-IC) and Central Rim (MA-AT) are selected each time according to the condition. Cowherb seeds are stuck with adhesive plaster on the ear points. The patient is told to press each of the ear points 2-3 min, 3 times every day. To sum up, acupuncture-moxibustion treatment has a good effect on insomnia. Afternoon is a suitable time for treatment. Clinically points are mainly selected according to the syndrome differentiation. The points of Heart, Spleen and Kidney Meridians and the corresponding Back- Shu points are often selected.

References
[1] PANG Zhong-yan. Account of Acupuncture- moxibustion Treatment of a Patient with Over Twenty Years Insomnia. Journal of Traditional Chinese Medicine, 1955, 1(3): 37. [2] HUI Jian-ping, ZHAO Yao-dong, HUI Jian-rong, et al. The Back-Shu Points Penetrating Needling Jiaji for Intractable

Insomnia: An Observation of 30 Cases. Journal of Gansu College of Traditional Chinese Medicine, 2006, 23(2): 47. [3] LIU Zhi-bin, NIU Wen-min. Insomnia Treated by Continual Needling along the Hair Line. Shaanxi Journal of Traditional Chinese Medicine, 2007, 28(6): 716. [4] XIE Wen-xia, CAO Gao-zhong, YE Tian-shen, et al. Clinical Study of Syndrome Differentiation-based Treatment of Insomnia with Abdominal Acupuncture plus Body Acupuncture Treatment. Journal of Clinical Acupuncture and Moxibustion, 2007, 23(10): 5. [5] TANG Tao, WANG Jian-liang, GAO Jing-xian. Observations on the Efficacy of Shallow Puncture plus Cupping for Treating 30 Insomnia Patients. Shanghai Journal of Acupuncture and Moxibustion, 2006, 25(11): 10. [6] FAN Yue-you, DONG Ying-hua, ZHOU Chang-feng. Treatment of 78 Insomnia Patients by Leopard-spot Needling at Point Dazhui (GV 14) as Main Therapy. Shandong Journal of Traditional Chinese Medicine, 2001, 20(1): 34. [7] CHEN Xing-sheng. Control Observation on Treatment of 52 Cases of Insomnia by Penetration Needling with Elongated Needle. Chinese Acupuncture & Moxibustion, 2002, 22(3): 157. [8] ZHANG Yun-fei. Observations on the Efficacy of Big Needles in Treating 701 Neurosis Patients. Chinese Acupuncture & Moxibustion, 1988, 8(1): 10. [9] SUN Hong. Observations on the Efficacy of "Head Five Needles" in Treating 150 Insomnia Patients. Beijing Journal of Traditional Chinese Medicine, 1997, 16(4): 39. [10] JI Yong-rong. Treatment of 64 Insomnia Patients by Auricular Plaster with Mung Bean. Guangxi Journal of Traditional Chinese Medicine, 1981, 4(4): 18. [11] YAO Xue-ying. Treatment of 202 Insomnia Patients with Acupuncture plus Auricular Plaster Therapy. Shanghai Journal of Acupuncture and Moxibustion, 2007, 26(11): 27. [12] WANG Ru-ping. Preliminary Analysis of Treatment of 100 Insomnia Patients by Auricular Needle Embedding. Journal of New Chinese Medicine, 1982, 14(6): 28. [13] YUAN Guang-yu. Observations on the Efficacy of Moxibustion in Treating 80 Insomnia Patients. Journal of Clinical Acupuncture and Moxibustion, 2007, 23(10): 37. [14] WANG Jia-zhen. Treatment of 30 Insomnia Patients by Zhuang Thread Moxibustion. Guangxi Journal of Traditional Chinese Medicine, 1987, 10(3): 40. [15] FU Xiao-min. Treatment of 45 Insomnia Patients by Ginger-partitioned Moxibustion on Point Xinshu (BL 15). Beijing Journal of Traditional Chinese Medicine, 1998, 17(3): 37. [16] PENG Liang. Treatment of 85 Insomnia Patients with Crossing Points. Shanghai Journal of Acupuncture and Moxibustion, 2004, 23(3): 28. [17] LIU Li-gong, GU jie. Review of Classics in Acupuncture-moxibustion Treatment for Refractory Diseases. Shanghai: Shanghai Science and Technology Press, 2007: 148. Translator: WANG Si-you () Received Date: December 15, 2009

16 Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2010