Prescription of Chinese Herbal Medicine and Selection of Acupoints in Pattern-Based Traditional ...

17 Pages·2014·1.33 MB·English

HindawiPublishingCorporation
Evidence-BasedComplementaryandAlternativeMedicine
Volume2012,ArticleID902578,16pages
doi:10.1155/2012/902578
Review Article
Prescription of Chinese Herbal Medicine and Selection of
Acupoints in Pattern-Based Traditional Chinese Medicine
Treatment for Insomnia: A Systematic Review
Wing-FaiYeung,1Ka-FaiChung,1MaggieMan-KiPoon,1FionaYan-YeeHo,1
Shi-PingZhang,2Zhang-JinZhang,3EricTat-ChiZiea,4andVivianWongTaam4
1DepartmentofPsychiatry,UniversityofHongKong,PokfulamRoad,HongKong
2SchoolofChineseMedicine,HongKongBaptistUniversity,HongKong
3SchoolofChineseMedicine,UniversityofHongKong,HongKong
4ChineseMedicineSection,HospitalAuthority,HongKong
CorrespondenceshouldbeaddressedtoKa-FaiChung,[email protected]
Received13July2012;Revised13October2012;Accepted20October2012
AcademicEditor:JianpingLiu
Copyright©2012Wing-FaiYeungetal. This is an open access article distributed under the Creative Commons Attribution
License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperly
cited.
TraditionalChinesemedicine(TCM)treatmentsareoftenprescribedbasedonindividuals’patterndiagnoses.Asystematicreview
ofChineseandEnglishliteraturesonTCMpatterndifferentiation,treatmentprinciple,andpattern-basedtreatmentforinsomnia
hasthereforebeenconducted.Atotalof227studies,17916subjects,and87TCMpatternswereanalyzed.Therewasalimited
consistencyinpattern-basedTCMtreatmentofinsomniaacrosspractitioners.ExceptforGuiPiTang,AnShenDingZhiWan,
andWenDanTangwhichwereusedmorecommonlyfordeficiencyofboththeheartandspleen,internaldisturbanceofphlegm-
heat,andqideficiencyoftheheartandgallbladder,respectively,theselectionofherbalformulaforotherpatternsandpattern-
based prescription of individual herbs and acupoints were not consistent. Suanzaoren (Semen Z. spinosae), Fuling (Poria),
Yejiaoteng (Caulis P. multiflori), Gancao (Radix Glycyrrhizae), Baishao (Radix P. alba), Shenmen (HT7), Yintang (EX-HN3),
Sanyinjiao(SP6),Baihui(GV20),Anmian(EX-HN22),andSishencong(EX-HN1)werecommonlyused,butnonspecificallyfor
manypatterns.Treatmentprinciplesunderlyingherbandacupointselectionwereseldomreported.Althoughmanystudieswere
reviewed,thestudyqualityanddiagnosticprocesswereinadequate.Morehighqualitystudiesareneededtoexaminetheadditional
benefitsofpatterndifferentiationandpattern-basedTCMtreatment.
1.Introduction for insomnia [4], they have remained underused because
of the time-intensive nature and treatment nonadherence.
Insomnia is a frequent clinical complaint. Nearly one-third Sincethecurrentlyavailabletreatmentshavetheirlimitation,
of the general population worldwide presents with insom- complementary and alternative medicine has been sought
nia symptoms, and the prevalence of insomnia symptoms to treat insomnia. According to a national survey, over 1.6
accompanied by daytime consequences is approximately millionadultsintheUnitedStatesusedcomplementaryand
9–15% [1]. Insomnia is a risk factor of a number of alternativemedicinetotreatinsomniaintheyear2002[5].
negative health consequences, including major depression, TraditionalChinesemedicine(TCM),aformofcomple-
suicide, anxiety disorders, and alcohol and substance abuse mentaryandalternativemedicine,isoneoftheoldestmed-
or dependence [2]. Effective pharmacological treatments icalsystemsintheworld.TheuseofTCMforinsomniacan
for insomnia are available. However, their uses are limited betracedmorethan2000yearsagoinChinesemedicaltexts
due to concerns about long-term efficacy and potential for [6,7].Inclinicalpractice,TCMtreatmentsareindividualized
dependence, abuse, and adverse effects [3]. Although psy- according to the TCM pattern diagnosis. TCM pattern, in
chologicalandbehavioraltherapieshaveempiricalevidence terms of TCM theory, is defined as a diagnostic conclusion
2 Evidence-BasedComplementaryandAlternativeMedicine
of the pathological changes of a disease state based on an CochraneCentralRegisterofControlledTrials,Cumulative
individual’s symptoms and signs, including pulse form and IndextoNursingandAlliedHealthLiterature,andAlliedand
tongue appearance [8]. The patterns of bodily disharmony ComplementaryMedicinefrominceptiontoMay2010using
can be described in terms of eight major parameters: yin thegroupedterms(insomnia∗ orwakeful∗ orsleepless∗ or
andyang,externalandinternal,hot andcold,andexcessand sleep∗) and ((acupuncture∗ or acupoints∗ or acupressure∗
deficiency. Additional systems, such as qi, blood and body- ormeridian∗ ortranscutaneouselectricalnervestimulation
fluid differentiation, and zang fu (organ) differentiation are or TENS or moxibustion or tuina) or (herb∗ or herbal
also used [9]. For a given disease there may be different medicine∗ or traditional Chinese medicine∗ or TCM)).
presentations of various symptoms and signs; hence, many The search also included China Academic Journals Full-
TCM pattern diagnoses are possible and this forms the Text Database, China Proceedings of Conference Full-Text
rationalethatdifferentTCMtreatmentscanbegivenforthe Database, Chinese Biomedical Literature Database, China
same disease. On the other hand, different diseases may be DoctorDissertationsFull-TextDatabase,ChinaMasterThe-
treatedwiththesameTCMtreatmentiftheysharethesame ses Full-Text Database, Chinese Science and Technology
pattern. The TCM patterns used today and the selection of DocumentsDatabase,ChineseDissertationDocumentBib-
herbal formulas and acupoints for specific TCM patterns liography Database, Chinese Academic Papers Conference
aredevelopedbasedonclinicalexperience,ancientmedical Database, Digital Periodical, and Taiwan Electronic Period-
texts, and some recently published TCM textbooks. It has icalServices.Thereferencelistsoftheretrievedpaperswere
tobeacknowledgedthatmostTCMconceptsandtherapies furthersearchedforrelevantarticles.
havenotyetbeenprovenbyscientificmethod.
Although it is believed that pattern-based TCM treat-
2.1. Selection Criteria. Studies included in this paper were
mentwillprovidebetterefficacy,previousstudiesregarding
case series or clinical trials that described TCM patterns
the additional benefit of TCM pattern differentiation are
of subjects who received TCM treatment for their chief
scarce. One randomized controlled trial (RCT) found that
complaint of insomnia. In order to obtain a full coverage
thetherapeuticeffectofChineseherbaltreatmentaccording
of the topic, we had not set any specification for sampling
to TCM pattern was more sustainable than the standard
procedure,treatmentmethod,outcomemeasure,andstudy
formulaintreatingirritablebowelsyndrome[10].Ithasalso
quality. In addition, to derive a general picture of TCM
been reported in rheumatoid arthritic patients that TCM
patternutilization,studieswereexcludedifthey(1)hadless
pattern diagnoses can guide the use of Western medicine
than 30 subjects; (2) examined male or female only; (3)
[11]. However, other RCTs found that the efficacy of
focused on subjects aged below 18 or above 70 years; (4)
pattern-based individualized acupuncture was not superior
focused on a specific medical and psychiatric condition, a
tostandardizedacupunctureforchronicshoulderpain[12],
particular life transition period, or a specific TCM pattern;
chronicbackpain[13],andhypertension[14].
(5)hadnostatisticalinformationregardingthefrequencyof
A previous survey in a Chinese medicine clinic in
individualTCMpattern;or(6)wereduplicatedpublications.
Taiwan has summarized the commonly prescribed single
Asamplesizeof30isconsideredastheminimumtoexamine
Chinese herbs and herbal formulas for insomnia [15].
theTCMpatterndiagnosisinindividualswithinsomnia.
Anotherstudyhasreviewedtherandomizedcontrolledtrials
of acupuncture for insomnia and determined the most
frequentlyusedacupoints[16].Tothebestofourknowledge, 2.2. Data Extraction Process. Two authors (W. Yeung and
there has been no systematic review on the TCM patterns M. Poon) searched the databases and selected the relevant
for insomnia. Information regarding pattern-based TCM publicationsindependently.Iftherewereanydisagreements
treatments for insomnia is also lacking. Given the high abouttheeligibilityofastudy,thetwoauthorswouldcheck
prevalence of insomnia in the general population and its thestudyagainsttheinclusionandexclusioncriteria,discuss
frequentpresentation toTCM practitioners,it isimportant itseligibility,andcometoafurtherdecision.Oneauthor(M.
toreviewthecurrentapplicationofsyndromedifferentiation Poon)extractedthedataandtheother(W.Yeung)checked
in TCM treatments for insomnia. The objectives of this the extracted data. For each study, the following variables
paperwere(1)tosummarizethecommonlydiagnosedTCM were extracted: study design, sample size, mode of recruit-
patterns in patients with insomnia and (2) to find out ment, sampling and diagnostic procedure, inclusion and
the current practice of pattern-based TCM treatments for exclusioncriteria,andparticipants’characteristicsincluding
insomnia. age, gender, and duration of insomnia. TCM patterns,
treatment principles, treatment regimen, and outcome of
TCMtreatmentswereobtained.Inamajorityofthereviewed
2.Method studies, effective rate was the only outcome measure. The
definition of effective rate was not standardized, but it was
The present study was part of our systematic review on mostoftendefinedastheproportionofsubjectswhohadat
TCM treatments for insomnia. Chinese herbal medicine, least some improvement of sleep or at least 30% reduction
traditionalneedleacupuncture,andvariantsofacupuncture, in the severity of insomnia by rating scales. We calculated
includingacupressure,moxibustion,transcutaneouselectri- the mean, standard deviation, and 95% confidence interval
calnervestimulation,auricularacupressure,andreflexology of dichotomous outcome measure. All Chinese to English
were reviewed [17]. We searched the MEDLINE, EMBASE, translations were deduced primarily from the World Health
Evidence-BasedComplementaryandAlternativeMedicine 3
Organization (WHO) International Standard Terminologies basedonTCMtextbooks,17(7.5%)studiesusedtheClinical
onTraditionalMedicineintheWesternPacificRegion[8],and ResearchGuidelinesofNewChineseHerbalMedicine[21],
additionallyfromTraditionalChineseInternalMedicine[18], 16 (7.0%) used the Criteria of Diagnosis and Therapeutic
acommonlyusedEnglish-languageTCMtextbookinChina. Effect of Diseases and Syndromes in TCM [22], 6 (2.6%)
usedsomeself-definedcriteria,3(1.3%)adoptedthecriteria
usedbyotherTCMexperts,and1usedacombinationofthe
2.3. Quality Assessment. For RCTs of Chinese herbal
CriteriaofDiagnosisandTherapeuticEffectofDiseasesand
medicine, methodological quality will be assessed using
SyndromesinTCMandatextbook.Onehundredandsixty-
Jadad scale. The Jadad scale evaluates a study in terms of
three studies (71.8%) did not report the diagnostic criteria
the description of randomization, blinding, and dropouts.
used.
Points are awardedif the study is described as randomized,
1 point; has appropriate randomization method, 1 point;
3.1. TCM Pattern and Chinese Herbal Medicine. Eighty-
is described as double-blind, 1 point; uses appropriate
nine of the 227 included studies examined Chinese herbal
blinding method, 1 point; has description of withdrawals
medicine for insomnia: 54 of the 89 studies (60.7%) were
and dropouts, 1 point. For RCTs involving acupuncture,
caseseries,8(9.0%)werecontrolledstudies,and27(30.3%)
a modified Jadad scale will be used. The modified Jadad
scale takes into consideration the difficulty in blinding the were RCTs. Of the 27 RCTs, 15 (55.6%) compared Chinese
herbal medicine with Western medication, 9 (33.3%) with
acupuncturist to the treatment process. Points are awarded
another Chinese herbal medicine, and 3 (11.1%) with
ifthestudyisdescribedasrandomized,1point;hasappro-
Western medication and another Chinese herbal medicine.
priate randomization method, 1 point; subjects blinded to
Twenty-six (96.3%) of the 27 RCTs were described as
intervention, 1 point; evaluator blinded to intervention, 1
randomized but the randomization method, blinding, and
point;hasdescriptionofwithdrawalsanddropouts,1point
dropouts were not presented; hence, these 26 RCTs had
[19,20].BoththeJadadscaleandmodifiedJadadscalescores
a Jadad score of 1. Only 1 (3.7%) of the 27 RCTs had
rangefrom1to5;RCTswithascorefrom3to5areregarded
appropriate randomization and double-blind design and
asbetterqualitytrials.
obtainedaJadadscoreof3.
GuiPiTangoritsmodificationwasthemostfrequently
2.4. Statistical Analysis. We used SPSS version 16.0 for
usedChineseherbalformulaforthetreatmentofinsomnia
statisticalanalysis.Effectiveratewassummarizedusingmean
in patients diagnosed with deficiency of both the heart and
(SD)and95%confidenceintervals(CIs).
spleen(Table2);forhyperactivityoffireduetoyindeficiency,
Huang Lian E Jiao Tang was the most frequently used
3.Results formula.ModifiedLongDanXieGanTangandDanZhiXiao
YaoSanwerethemostoftenusedherbalformulaforliver-qi
The search yielded 14045 potential titles for review, of stagnation transforming into fire. For internal disturbance of
which 4924 were duplicate records and 6249 were excluded phlegmheat,themostfrequentlyusedformulawasmodified
for reasons of irrelevance. The full text of 2872 articles to Wen Dan Tang; lastly, for qi deficiency of the heart and
was retrieved for detailed assessment, of which 2645 were gallbladder, modified An Shen Ding Zhi Wan was the most
excluded for various reasons (Figure1). Of the 227 studies frequently used. There was a great variation in Chinese
which fulfilled the inclusion and exclusion criteria, 89 were herbal treatment among patients diagnosed with heart-
on Chinese herbal medicine, 64 on acupuncture, 40 on kidneynoninteractionandheartdeficiencywithtimidity,with
a combination of two acupuncture treatments, 24 on a no single formula being studied twice. Studies on liver fire
combination of Chinese herbal medicine and acupuncture, flamingupward,disharmonybetweenspleenandstomach,and
and 10 on other TCM treatments. Sample size of the 227 stomachdisharmonyweresolimitedthatreliableinformation
studiesrangedfrom30to400.TCMdiagnosiswasavailable wasnotpossible(Table2).
in17916subjects.Atotalof87differentTCMdiagnoseswere The TCM treatment principles and ingredients of the
examinedinthe227studies.Themostcommonpatternwas Chineseherbalformulasfortreatinginsomniaarepresented
deficiencyofboththeheartandspleen,whichwasdiagnosed in Table2. Due to a wide variation in the composition
in 4056 subjects or 22.6% of the 17916 subjects; it was of herbal formulas, we only listed those individual herbs
followed by hyperactivity of fire due to yin deficiency (N = that were used in at least 20% of the studies on the TCM
2926,16.3%),liver-qistagnationtransformingintofire(N = pattern. Suanzaoren (Semen Z. spinosae), Danggui (Radix
1817,10.1%),heart-kidneynoninteraction(N =1157,6.5%), A. sinensis), Yuanzhi (Radix Polygalae), Dangshen (Radix
internal disturbance of phlegm heat (N = 904, 5.0%), qi Condonopsis), Huangqi (Radix Astragali), Fuling (Poria),
deficiencyoftheheartandgallbladder(N = 838,4.7%),liver Baizhu (Rhizoma A. macrocephalae), Yejiaoteng (Caulis P.
fire flaming upward (N = 456, 2.5%), heart deficiency with multiflori),Fushen(PoriacumRadixPini),Muxiang(Radix
timidity (N = 356, 2.0%), disharmony between spleen and Aucklandiae), Longyanrou (Arillus longan), Honey-toasted
stomach (N = 325, 1.8%), and stomach disharmony (N = Gancao(RadixGlycyrrhizae),Gancao(RadixGlycyrrhizae),
162, 0.9%). The top 10 TCM patterns accounted for 72.5% Baishao (Radix P. alba), Dazao (Fructus Jujibae), Wuweizi
ofthe17916subjects(Table1). (FructusS.Chinensis),Hehuanpi(CortexAlbiziae),Baiziren
The criteria used for diagnosis of TCM pattern varied (Semen Platycladi), and Shengjiang (Rhizoma Zingiberis)
betweenstudies.Twenty-oneofthe227studies(9.3%)were werecommonindividualherbsforthetreatmentofinsomnia
4 Evidence-BasedComplementaryandAlternativeMedicine
13896 records identified through 149 records identified through
database searching other sources
Identical citations: 4924
9121 records after duplicates removed
Irrelevant papers: 6249
2872 full-text articles assessed for eligibility Excluded (n=2645)
Not a case-series study or
clinical trial: 643
Not primarily on
insomnia: 46
227 studies examined TCM interventions for
Without TCM patterns:
insomnia with TCM pattern diagnosis 919
Without statistical
information regarding
TCM patterns : 603
Chinese Acupuncture Combined and
Specific medical and
mheedribcainl e Ac(unpu=n6ct4u)re otr(tehnaet=rm T7eC4nM)ts pPasyrctihciualtarric d ceovneldoiptimone:n 4t 9or
(n=89) abnasde dit so vna riants Chinese herbal life transition period: 4
medicine plus Specific TCM pattern:
meridian
acupuncture, 237
anc=up5o7ints, n=24 Aged below 18 or above
Combination 70: 15
Auricular treatment of 2 Specific gender: 2
acupressure, different forms Cases<30: 61
n=7 onf =ac4u0puncture, Duplicate publication: 46
Non-English, non-
Other TCM
Chinese languages: 12
treatments,
n=10 Failure to retrieve: 8
Figure1:Studyselectionflowchart.
Table1:The10mostcommonTCMpatternsdiagnosedinpatientswithinsomnia.
Numberofsubjectsdiagnosed Numberofstudiesthatexamined
TCMpattern Chinesename withtheTCMpattern(%) theTCMpattern(%)
(totalN=17916) (totalN=227)
Deficiencyofboththeheartandspleen 心脾兩虛 4056(22.6) 180(79.3)
Hyperactivityoffireduetoyindeficiency 陰虛火旺 2926(16.3) 132(58.1)
Liver-qistagnationtransformingintofire 肝鬱化火 1817(10.1) 91(40.0)
Heart-kidneynoninteraction 心腎不交 1157(6.5) 60(26.4)
Internaldisturbanceofphlegmheat 痰熱內擾 904(5.0) 78(34.4)
Qideficiencyoftheheartandgallbladder 心膽氣虛 838(4.7) 63(27.8)
Liverfireflamingupward 肝火上擾 456(2.5) 25(11.0)
Heartdeficiencywithtimidity 心虛膽怯 356(2.0) 31(13.7)
Disharmonybetweenspleenandstomach 脾胃不和 325(1.8) 19(8.4)
Stomachdisharmony 胃腑不和 162(0.9) 17(7.5)
in patients with deficiency of both the heart and spleen, and Huangbo (Cortex Phellodendri) were commonly used
and the most frequently used TCM treatment principle individual herbs for insomnia and the most frequently
was to nourish heart and spleen. For hyperactivity of fire used TCM treatment principle was to nourish yin and
due to yin deficiency, Suanzaoren (Semen Z. spinosae), suppress fire. For liver-qi stagnation transforming into fire,
Shengdihuang (Radix Rehmanniae), Yejiaoteng (Caulis P. Chaihu (Radix Bupleuri), Zhizi (Fructus Gardeniae), Gan-
multiflori), Ejiao (Colla C. asini), Huanglian (Rhizoma cao (Radix Glycyrrhizae), Danggui (Radix A. sinensis),
Coptidis), Gancao (Radix Glycyrrhizae), Baishao (Radix P. Suanzaoren (Semen Z. spinosae), Baishao (Radix P. alba),
alba), Hehuanpi (Cortex Albizziae), Fuling (Poria), Zhimu Yejiaoteng (Caulis P. multiflori), Longdancao (Radix Gen-
(RhizomaAnemarrhenae),Wuweizi(FructusS.Chinensis), tianae), Yujin (Radix Curcumae), Fuling (Poria), Shengdi-
Fushen(Poria cumRadixPini), Yuanzhi(Radix Polygalae), huang (Radix Rehmanniae), Hehuanpi (Cortex Albizziae),
Evidence-BasedComplementaryandAlternativeMedicine 5
Heartdeficiencywithtimidity心虛膽怯() =N15 Noformulawasmostfrequentlyused =N1 Tonifyqiandsettlefright(1,100.0%) =N13 69.2%23.1%61.5%30.8%23.1%38.5%46.2%38.5%38.5%23.1% / // / / // /
aatterns. Qideficiencyoftheheartandgallbladder心膽氣虛() =N20 ModifiedAnShenDingZhiWan(7,35.0%) =N5 Tonifyqiandsettlefright(5,100.0%) =N16 68.8%62.5%37.5%37.5%/50.0%/62.5%// / /43.8% / 25.0% // 31.3%
p
M n
ffwithdierentTC Internaldisturbanceofphlegmheat痰熱內擾() =N34 ModifiedWenDaTang(10,29.4%) =N6 Clearheatandresolvephlegm(5,83.3%) =N29 58.6%75.9%41.4%44.8%20.7%/27.6%41.4%// / // / / /51.7% /
d
nsubjectsdiagnose Heart-kidneynoninteraction心腎不交() =N13 Noformulawasmostfrequentlyused =N1 Nourishyin,clearfire,andcoordinateheartandkidney(1,100.0%) =N11 45.5%27.3%//27.3%///27.3%27.3% 27.3% // / / 27.3%/ /
i
a
edicineforinsomni Liver-qistagnationtransformingintofire肝鬱化火() =N43 ModifiedLongDanXieGanTang(6,14.0%);DanZhiXiaoYaoSan(6,14.0%) =N8 Sootheliverandpurgefire(4,50.0%) =N39 48.7%33.3%41.0%51.3%46.2%23.1%30.8%/// 30.8% 51.3%/ 20.5% / // /
m
bal fire ao d
sedChineseher Hyperactivityofduetoyindeficiency陰虛火旺() =N53 HuangLianEJiTang(5,9.4%) =N9 Nourishyinansuppressfire(5,55.6%) =N43 58.1%34.9%46.5%39.5%39.5%25.6%34.9%23.3%27.9%/ 48.8% // / / /41.9% 30.2%
u
e2:Thecommonly Deficiencyofbothheheartandspleen心脾兩虛() =64N ModifiedGuiPiTang(19,29.7%) =11N Nourishheartandspleen(5,45.5%) =54N 75.9%40.7%33.3%27.8%24.1%33.3%22.2%53.7%24.1%20.4% / 63.0%51.9% 38.9% 29.6% 24.1%/ /
l t
Tab NumberofstudiesthatexaminedtheTCMpattern CommonlyusedChineseherbalformula(N,%ofstudiesthatexaminedtheTCMpattern) NumberofstudiesthatprovidedTCMtreatmentprinciple Mostcommonlyusedtreatmentprinciple(N,%ofstudiesthatprovidedTCMtreatmentprinciple) Numberofstudiesthatprovidedthecompositionofherbalformula Compositionofherbalformula(%ofstudiesthatprovidedthebformula’scomposition)Suanzaoren(SemenZ.spinosae)Fuling(Poria)Yejiaoteng(CaulisP.multiflori)Gancao(RadixGlycyrrhizae)Baishao(RadixP.alba)Fushen(PoriacumRadixPini)Hehuanpi(CortexAlbizziae)Yuanzhi(RadixPolygalae)Wuweizi(FructusS.Chinensis)Baiziren(SemenPlatycladi)Shengdihuang(RadixRehmanniae)Danggui(RadixA.sinensis)Dangshen(RadixCodonopsis)Baizhu(RhizomaA.acrocephalae)Honey-toastedGancao(RadixGlycyrrhizae)Dazao(FructusJujibae)Huanglian(RhizomaCoptidis)Zhimu(RhizomaAnemarrhenae)
6 Evidence-BasedComplementaryandAlternativeMedicine
y
rtdeficienchtimidity心虛膽怯) 23.1%// 46.2% 46.2% 30.8%////////// / / / / / / // / 23.1%
Heawit(
e
h
t
ofdr虛)
eficiencyheartanallbladde心膽氣 /// / 56.3% 50.0%////////// / / / / / / 25.0%37.5% 25.0% /
d g(
Qi
nalnceofheat內擾) % % % % % %
Interdisturbaphlegm痰熱(/27.6/ / / /////////// / 27.6 44.8 58.6 41.4 44.8 // / /
art-kidneynteraction心腎不交) //27.3% / / /////////// 27.3% / / / / / // / /
Heoni(
n
d.
e
u
Table2:Contin Liver-qistagnationtransformingintofire肝鬱化火()64.1%53.8%23.1% 23.1% / ///////35.9%33.3%23.1%28.2% / / / / / / // / / arebolded.
n
offiren 旺) patter
Hyperactivityduetoyideficiency陰虛火(/// / / /////20.9%41.9%//// / / / / / / // / / articularTCM
Deficiencyofbotheheartandspleen心脾兩虛() /// / / /50.0%20.4%31.5%31.5%////// / / / / / / // / / studiesarepresented.%ofthestudiesonap
h 50
t n5
Chaihu(RadixBupleuri)Zhizi(FructusGardeniae)Zexie(RhizomaAlismatis)Zhenzhumu(ConchaMargaritifera)Shichangpu(RhizomaA.Tatarinowii)Longchi(DensDraconis)Huangqi(RadixAstragali)Ginger(RhizomaZingiberis)Longyanrou(ArillusLongan)Muxiang(RadixAucklandiae)Huangbo(CortexPhellodendri)Ejiao(CollaCasini)Longdancao(RadixGentianae)Yujin(RadixCurcumae)Danpi(CortexMoutan)Huangqin(RadixScutellariae)Shudihuang(RadixRehmanniaePraeparata)Dannanxing(RhizomeArisaematis)Chenpi(PericarpiumC.Reticulatae)Zhuru(CaulisBambusaeinTaeniam)Zhishi(FructusA.immaturus)Lime-waterprocessedbanxia(RhizomaPinelliaePreparatum)Renshen(RadixGinseng)Hupo(Succinum)Chuanxiong(RhizomaChuanxiong)Longgu(FossiliaOssisMastodi) OnlythoseTCMpatternswithmorethaIndividualChineseherbsusedinatleast
a b
Evidence-BasedComplementaryandAlternativeMedicine 7
Huangqin (Radix Scutellariae), Fushen (Poria cum Radix (HT7), Sanyinjiao (SP6), Shenshu (BL23), Taixi (Kl13),
Pini), Zexie (Rhizoma Alismatis), Zhenzhumu (Concha Xinshu (BL15), Baihui (GV20), Neiguan (PC6), Zhongwan
Margaritifera), Danpi (Cortex Moutan), and Baizhu (Rhi- (CV12),Sishencong(EX-HN1),Qihai(CV6),Yintang(EX-
zoma A. macrocephalae) were more often used and the HN3),Anmian(EX-HN22),Fengchi(GB20),Zhaohai(Kl6),
most frequently used TCM treatment principle was to and Guanyuan (CV4) were commonly used acupoints.
soothe liver and purge fire. There was no single herb being Sanyinjiao(SP6),Taichong(LR3),Shenmen(HT7),Ganshu
used in more than 50% of the studies on heart-kidney (BL18), Zhongwan (CV12), Neiguan (PC6), Qihai (CV6),
noninteraction,indicatingthattheselectionofChineseherbs Fengchi (GB20), Guanyuan (CV4), Baihui (GV20), Xiawan
varied greatly among practitioners. Suanzaoren (Semen Z. (CV10), Shenshu (BL23), and Yintang (EX-HN3) were
spinosae), Fuling (Poria), Yejiaoteng (Caulis P. multiflori), commonlyusedacupointsinpatientswithliver-qistagnation
Gancao (Radix Glycyrrhizae), and Baishao (Radix P. alba) transforming into fire. The selection of acupoints in other
were the most commonly used individual herbs, but they TCM patterns is shown in Table4. There was no acupoint
werealsothemostnonspecificandwereusedinmostofthe beingusedinmorethan50%ofthestudiesonliver-qistag-
TCMpatterns. nationtransformingintofireandheart-kidneynoninteraction,
The effective rate of pattern-based Chinese herbal indicating that the selection of acupoints for these 2 TCM
medicinetreatmentforinsomniawasprovidedin38ofthe patternsvariedgreatly.Shenmen(HT7),Yintang(EX-HN3),
89 studies on Chinese herbal medicine (Table3). Based on Sanyinjiao(SP6),Baihui(GV20),Anmian(EX-HN22),and
thefindingsfromRCTs,themeaneffectiveratesweresimilar Sishencong(EX-HN1)werethemostcommonacupointsfor
acrossTCMpatterns,withthehighestmeaneffectiverateof thetreatmentofinsomnia.
95.0% for liver-qi stagnation transforming into fire and the The effective rate of pattern-based acupuncture-related
lowestat79.4%forheartdeficiencywithtimidity.Whenthe treatmentsforinsomniawasprovidedin24ofthe64studies
case series were examined, the mean effective rates in liver- on acupuncture-related treatments (Table3). As there were
qi stagnation transforming into fire and heart deficiency with fewRCTsavailableforcomparison,basedonthecaseseries
timiditywereverysimilar(79.1%and77.8%,resp.). findings, the mean effective rates of acupuncture for the
differentTCMpatternsweresimilar,withthehighestmean
effective rate of 98.1% for disharmony between spleen and
3.2. TCM Pattern and Acupuncture-Related Treatments. stomachandthelowestat75.0%forqideficiencyoftheheart
Fifty-seven of the 227 reviewed studies examined acupunc- andgallbladder.
ture-related treatments, including traditional needle acu-
puncture (n = 35), acupressure (n = 12), moxibustion
(n=3),acupointinjection(n=3),acupointplaster(n=3), 3.3.TCMPatternandCombinedTCMTreatments
andacupointembedment(n=1).Forty-one(71.9%)ofthe
57studieswerecaseseries,4(7.0%)werecontrolledstudies, 3.3.1. Chinese Herbal Medicine Plus Acupuncture-Related
and 12 (21.1%) were RCTs. Of the 12 RCTs, 6 (50.0%) Therapies. Twenty-four studies examined Chinese herbal
comparedacupuncturewithWesternmedication,3(25.0%) medicineplusacupuncture-relatedtreatmentsforinsomnia.
withanotheracupuncturetreatment,1(8.3%)withChinese Thirteen (54.2%) of the 24 studies were case series, 1
herbalmedicine,1(8.3%)withsleephygieneeducation,and (4.2%) was a controlled study, and 10 (41.7%) were RCTs.
1 (8.3%) with sham acupuncture and another acupuncture Of the 10 RCTs, 5 (50.0%) used Chinese herbal medicine
treatment. Ten (83.3%) of the 12 RCTs were described as for comparison, 3 (30.0%) used Western medication, and
randomized but the randomization method, blinding, and 2 (20.0%) compared with usual care. All 10 RCTs had a
dropouts were not presented; hence, these 10 studies had a modified Jadad score of 1 as they were only described as
modifiedJadadscoreof1.OneRCT(8.3%)wasdescribedas randomized, but the randomization method, blinding, and
randomized and included the dropouts; hence, a score of 2 dropoutswerenotpresented.
wasgiven.AnotherRCT(8.3%)describedtherandomization WeonlypresentedtheresultsofChineseherbalmedicine
method, blinding, and dropouts but not evaluator blind; plustraditionalneedleacupunctureindeficiencyofboththe
hence,ascoreof4wasgiven. heart and spleen, hyperactivity of fire due to yin deficiency,
Table4presentstheacupointsthatwerecommonlyused andliver-qistagnationtransformingintofire,becausestudies
fortreatinginsomnia.Therewereonly7studiesonauricular on other TCM patterns and other forms of acupuncture
acupressure; hence, the use of auricular points in TCM were too few to give reliable information (Table5). For
pattern-based treatment of insomnia was not presented. deficiency of both the heart and spleen, the commonly
The treatment principles were also not presented because used herbal ingredients for insomnia were Suanzaoren
the number of studies with the data was too few, ranging (Semen Z. spinosae), Baizhu (Rhizoma A. macrocephalae),
from 0 to 3 in each TCM pattern. The commonly used Danggui (Radix A. sinensis), Huangqi (Radix Astragali),
acupoints in patients with deficiency of both the heart and Yuanzhi (Radix Polygalae), Muxiang (Radix Aucklandiae),
spleen were Xinshu (BL15), Shenmen (HT7), Sanyinjiao Fuling (Poria), Longyanrou (Arillus Longan), Hehuanhua
(SP6),Pishu(BL20),Zusanli(ST36),Neiguan(PC6),Baihui (Flos Albiziae), Dazao (Fructus Jujibae), Gancao (Radix
(GV20), Yintang (EX-HN3), Anmian (EX-HN22), Sishen- Glycyrrhizae), Yejiaoteng (Caulis P. multiflori), Wuweizi
cong (EX-HN1), Fengchi (GB20), and Zhongwan (CV12). (Fructus S. Chinensis), Renshen (Radix Ginseng), Fushen
For hyperactivity of fire due to yin deficiency, Shenmen (Poria cum Radix Pini), Honey-toasted Gancao (Radix
8 Evidence-BasedComplementaryandAlternativeMedicine
%
seseriesffMeaneectiveratein(range,SD,95%CI) 86.5(60.0–100.0,12.1,80.3–92.7)88.3(66.7–100.0,10.6,80.7–95.9)79.1(20.0–100.0,28.6,55.1–103.0)86.9(84.9–89.7,2.1,83.5–90.3)86.3(43.3–100.0,18.0,71.2–101.3)75.3(26.7–100.0,30.0,38.1–112.5)80.0/ 77.8/ 88.9/ / 90.8(69.2–100.0,8.7,85.5–96.0)88.8(41.7–100.0,18.3,74.7–102.9)81.5(50.0–100.0,19.8,60.7–102.2)96.3(87.5–100.0,5.6,89.4–103.2)
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ffaneectiverateofpatt dcontrolledtrialsffMeaneectiveratein(range,SD,95%CI) 88.9(68.8–100.0,11.4,80.2–97.7)86.1(66.7–100.0,9.8,79.1–93.1)95.0(89.5–100.0,4.7,90.1–100.0) 90.9/ 84.4(50.0–100.0,20.7,58.7–110.2) / / 79.4(42.9–100.0,22.0,52.1–106.8) / 85.7/ 94.4(91.5–100.0,3.9,88.3–100.5)81.9(50.0–96.7,21.8,47.2–116.5) 75.0/ 90.9/
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TCMpattern Chineseherbalmedicine Deficiencyofboththeheartandspleen Hyperactivityoffireduetoyindeficiency Liver-qistagnationtransformingintofire Heart-kidneynoninteraction Internaldisturbanceofphlegmheat Qideficiencyoftheheartandgallbladder Liverfireflamingupward Heartdeficiencywithtimidity Disharmonybetweenspleenandstomach Stomachdisharmony Acupuncture Deficiencyofboththeheartandspleen Hyperactivityoffireduetoyindeficiency Liver-qistagnationtransformingintofire Heart-kidneynoninteraction
Evidence-BasedComplementaryandAlternativeMedicine 9
%
seseriesffMeaneectiveratein(range,SD,95%CI)95.0(90.0–100.0,4.7,89.2–100.9)75.0(0.0–100.0,50.0,−4.6–154.6)87.9(63.0–100.0,21.0,35.7–140.1)90.1(70.0–100.0,14.1,67.6–112.6)98.1(94.4–100.0,3.2,90.1–106.2)90.0(80.0–100.0,14.1,−37.1–217.1)
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s 熱 膽 火 虛 胃 腑
Chine 痰 心 肝 心 脾 胃 udies.
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CMpattern Internaldisturbanceofphlegmheat Qideficiencyoftheheartandgallbladder Liverfireflamingupward Heartdeficiencywithtimidity Disharmonybetweenspleenandstomach Stomachdisharmony ffectiveratewasthesameinthe2
T E
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10 Evidence-BasedComplementaryandAlternativeMedicine
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monyspleemach不和) 10 %%% %% %%% % % %
Disharbetweenandsto脾胃( =N 40.030.050.0/20.030.0/20.020.030.0/20.0/////30.0 ///////////////20.0
y
Heartdeficiencwithtimidity心虛膽怯() =N6 50.0%33.3%33.3%33.3%33.3%33.3%83.3%33.3%/33.3%33.3%/////83.3%/////33.3%//////33.3%33.3%33.3%33.3%33.3%/
g
n
aMpatterns. Liverfireflamiupward肝火上擾() =N9 88.9%33.3%44.4%44.4%55.6%33.3%///22.2%44.4%///33.3%////11.1%/11.1%/100.0%//66.7%22.2%22.2%//////
C
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nt yofndr虛)
ffwithdiere Qideficienctheheartagallbladde心膽氣( =N17 47.1%23.5%29.4%35.3%23.5%/35.3%/23.5%23.5%/23.5%////35.3%//////////////////
d
e
bjectsdiagnos Internaldisturbanceofphlegmheat痰熱內擾() =N14 64.3%35.7%42.9%35.7%/21.4%42.9%57.1%57.1%50.0%50.0%42.9%21.4%42.9%21.4%28.6%/21.4%//21.4%21.4%21.4%/57.1%21.4%/////////
u
s
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Table4:Thecommonlyusedacupointsforinsomniai Liver-qiDeficiencyofHyperactivityofstagnationHeart-kidneyboththeheartfireduetoyintransformingnoninteractionandspleendeficiency心腎不交intofire()心脾兩虛陰虛火旺()()肝鬱化火()====No.ofstudiesN47N33N15N21bAcupointsShenmen(HT7)55.3%54.5%40.0%47.6%Yintang(EX-HN3)29.8%24.2%20.0%23.8%Sanyinjiao(SP6)53.2%42.4%46.7%42.9%Baihui(GV20)34.0%33.3%20.0%/Anmian(EX-HN22)25.5%24.2%/23.8%Sishencong(EX-HN1)23.4%24.2%/28.6%Xinshu(BL15)72.3%39.4%/42.9%Neiguan(PC6)34.0%30.3%33.3%/Zhongwan(CV12)21.3%27.3%33.3%/Zusanli(ST36)44.7%///Fengchi(GB20)23.4%24.2%26.7%/Qihai(CV6)/24.2%33.3%/Shenshu(BL23)/45.5%20.0%38.1%Guanyuan(CV4)/21.2%26.7%/Ganshu(BL18)//40.0%/Pishu(BL20)51.1%///Danshu(BL19)////Weishu(BL21)////Taixi(Kl13)/42.4%/42.9%Zhaohai(KI6)/21.2%//Xiawan(CV10)//20.0%/Shenmai(BL62)////Cuanzhu(BL2)////Taichong(LR3)//40.0%/Fenglong(ST40)////Qingming(BL1)////Xingjian(LR2)////Hegu(Ll4)////Xuehai(SP10)////Yanglingquan(GB34)////Yuyao(EX-HN4)////Sibai(ST2)////Daling(PC7)////Jianjing(GB21)////Tianshu(ST25)//// Studiesonstomachdisharmonyaretoofewtogivereliableinformation.Acupointsthatwereusedinatleast50%ofthestudiesonaparticularTCMpatternarebolded.
a b