Chinese Medical Journal 2009;122(23):2869-2873 2869

Original article
Electroacupuncture treatment of chronic insomniacs
RUAN Jing-wen, WANG Chu-huai, LIAO Xin-xue, YAN Ying-shuo, HU Yue-hua, RAO Zhong-dong,
WEN Ming, ZENG Xiao-xiang and LAI Xin-sheng

Keywords: electroacupuncture; chronic insomnia; sleep quality; sleep architecture; safety

Background Due to the quick rhythm of life and work pressure, more and more people suffer from sleep quality
problems. In this study, we investigated the effect of electroacupuncture on sleep quality of chronic insomniacs and the
safety of electroacupuncture therapy.
Methods Four courses of electroacupuncture treatment were applied to 47 patients. With pre-treatment and
post-treatment self-control statistical method, Pittsburgh sleep quality index (PSQI) scores were used for evaluating sleep
quality. Polysomnogram was used for detecting insomniacs′ changes in sleep architecture. The safety of
electroacupuncture was evaluated by monitoring the self-designed adverse events and side effects during treatment and
post-treatment.
Results Electroacupuncture considerably improved insomniacs′ sleep quality and social function during the daytime.
Electroacupuncture had certain repairing effect on the disruption in sleep architecture. At the same time,
electroacupuncture prolonged slow wave sleep (SWS) time and relatively rapid eye movement sleep (REM sleep) time.
There was no hangover, addiction or decrements in vigilance during the daytime (incidence rate was 0). However,
insomnia rebound rate was about 23% within one month.
Conclusions These results suggest that electroacupuncture has beneficial effect on sleep quality improvement in the
patients with chronic insomnia, which may be associated with repairing sleep architecture, reconstructing sleep continuity,
as well as prolonging SWS time and REM sleep time. Electroacupuncture treatment for chronic insomnia is safe.
Therefore, electroacupuncture therapy could be a promising avenue of treatment for chronic insomnia.
Chin Med J 2009;122(23):2869-2873

W hen visiting doctors, many patients with chronic

insomnia complain about their sleeplessness or
restless sleep during the whole night. In fact,
polysomnogram shows that those patients′ subjective
insomnia is inconsistent with objective insomnia.1-10
According to polysomnogram, a lot of patients have some
sleep instead of total sleeplessness all night long.
However, their sleep architecture is disrupted. In some
cases, their slow wave sleep (SWS) time of S3 and S4
stage was shortened. Some patients may have no S3 or S4
stage or even both stages. Mostly, patients′ sleep is
fragmented and belongs to light sleep (S1, S2 stage),
which results in no strong feeling of sleep by patients.
Although some patients continuously use hypnotics to
prolong sleep time, their sleep quality is still poor, and
they are low-spirited and tired during the daytime.
Therefore, concerning the curative effect and toxic action
or side effects after long-term medication, lots of
insomniacs turn to the help of acupuncture and the other
treatments. In this study, we investigated the effects of
electroacupuncture on sleep quality of chronic insomniacs
and the safety of electroacupuncture therapy.
METHODS
Participants
There were 67 volunteers, who were from outpatient
clinic, participated in the insomnia study. Twenty of them
exited midway during the treatment because they were
unable to continue the treatment. The rest 47 patients
participated in all the processes of the research. Their age
ranged from 27 to 65 years (32 women and 15 men; mean
age 47.5 years), which met the research standard.
Professional types of the patients included 29 of mental
laborer, 8 of manual worker and 10 of the unemployed.
Twenty-five patients had sleeping disorder for 6 to 12
DOI: 10.3760/cma.j.issn.0366-6999.2009.23.013
Department of Acupuncture and Moxibustion (Ruan JW, Hu YH,
Rao ZD and Wen M), Department of Rehabilitation (Wang CH),
Department of Cardiology (Liao XX), Department of Respiratory
Medicine (Yan YS), First Affiliated Hospital of Sun Yat-sen
University, Guangzhou, Guangdong 510080, China
Zhuhai People′s Hospital, Zhuhai, Guangdong 519000, China
(Zeng XX)
College of Acupuncture and Moxibustion of Guangzhou
University of Traditional Chinese Medicine, Guangzhou,
Guangdong 510405, China (Lai XS)
Correspondence to: Dr. RUAN Jing-wen, Department of
Acupuncture and Moxibustion, First Affiliated Hospital of Sun
Yat-sen University, Guangzhou, Guangdong 510080, China (Tel:
86-20-87755766-8390. Fax: 86-20-87332698. Email:
ruanjw@163.com); Dr. LAI Xin-sheng, College of Acupuncture
and Moxibustion of Guangzhou University of Traditional Chinese
Medicine, Guangzhou, Guangdong 510405, China
RUAN Jing-wen and WANG Chu-huai contributed equally to this
work.
This research was supported by the grants from the Science and
Technology Planning Project of Guangdong Province (No.
2004B3300102) and Research Grant of the Administrative Bureau
of Traditional Chinese Medicine of Guangdong Province (No.
1040058).
2870
months and the rest 22 for more than 12 months.
Diagnostic criteria
Refer to Insomnia′s definition, diagnosis as well as the
consensus view among experts on drug treatment
(Protocol)11 was used.
Inclusion criteria
Subjects should have experienced insomnia for more than
6 months plus the following subjective criteria: (1) major
complaint of sleep physiological dysfunction (sleep
interruption or sleep disorder by decrease in sleep time);
(2) sleep disorder due to fatigue, distention of head,
dizziness and other symptoms during the daytime.
Objective criteria (results from polysomnogram): (1)
prolongation of sleep latency (over 30 minutes); (2)
increase in awareness time (over 30 minutes per night); (3)
decrease in actual sleep time (less than 6 hours per night).
Exclusion criteria
Patients were specially excluded if one of the following
condition occurred: (1) patients with general diseases,
such as pain, fever, cough, operation and so on or with
which induced by interference factors from the external
environment; (2) patients′ age below 18 or above 65
years, women during their pregnancy or lactation; (3)
patients with severe primary diseases such as
cardiovascular, lung, liver, kidney and hematopoietic
system diseases or psychotics;12,13 (4) decrease in sleep
time without discomfort in the daytime (short sleeper); (5)
score from the Hospital Anxiety and Depression (HAD)
scale14 reaches the severe degree;15 (6) patients who fall
short of the standard, or without getting the treatment, or
are unable to assess the curative effect or without
complete records.
Electroacupuncture (EA) treatment
Some main acupoints “Sishenchong, Neiguan (PC6),
Shenmen (HT7), Sanyinjiao (SP6), Taixi (KI3), Zhaohai
(KI6), Shenmai (BL62)” were selected during EA
treatment. According to traditional Chinese medicine
(TCM) syndrome differentiation, the acupoints were
modified. For example, Pishu (BL20) and Xinshu
(BL15) acupoints were added when blood deficiency of
the heart and spleen occurs; Daling (PC7) and Taichong
(LR3) acupoints were added when asthenic yin causing
excessive fire occurs; Shenting (DU24), Qihai (RN6), and
Yinjiao (RN7) acupoints were added when fright due to
asthenia of the heart occurs; Zhongwan (RN12),
Fenglong (ST40), Lidui (ST45) and Yinbai (SP1)
acupoints were added when disorder of the stomach
occurs; Quchi (LI11), Fenglong (ST40), and Jiexi (ST41)
acupoints were added when phlegm-heat attacking the
heart occurs; Daling (PC7), Yintang, Taichong (LR3) and
Hegu (LI4) acupoints were added when emotional
activities disturbing the mind occurs. The stainless silver
needles of 0.25 mm in diameter were inserted into main
points. The needles were connected with the output
terminals of an EA apparatus (KWD-808-1). The
Chin Med J 2009;122(23):2869-2873
continuous wave with the frequency (80/min) was used.
The intensity of EA was adjusted to induce a slight twitch
of the muscles (about 1–3 mA) and lasted for 30 minutes.
Continuous 10 days of treatment was considered as a
course of treatment. There were four courses of treatment
in total for each patient. After each course of treatment,
the patients had 3 days for relaxation.
Evaluation of curative effect and observation of
adverse events and side effects
Evaluation was made according to Pittsburgh sleep
quality index (PSQI).6,16 PSQI comprises 23 items.
Excluding the 5 other-evaluated items in the 10th articles,
the other items were summarized into 6 questions
including sleep quality, sleep latency, sleep time, sleep
efficacy, hypnotic, function during the daytime. PSQI
evaluation and polysomnogram test were respectively
performed 2 times at 2 weeks before and after the
treatment by a specialist for each patient.
PARAD ISE P&D9600 Type (USA) polysomnogram
respiration monitoring analytical system was applied in
polysomnogram test. Simultaneous monitoring items
include electroencephalogram (EEG), electro-oculogram
(EOG), electromyogram (EMG). Insomniacs may take
hypnotic before treatment, but they should have no
noontime rest in the treatment day. Subjects were set
sleep monitor from 10:00 – 11:00 at night to 06:00 –
07:00 the next morning. Sleep time, sleep efficacy,
awareness time, non-rapid eye movement (NREM) sleep
including S1, S2, S3, and S4 stages, rapid eye movement
(REM) sleep and the percentage of different stages were
continuously monitored for more than 7 hours. The data
were automatically stored and processed by a computer.
Attentions were paid during the nocturnal sleep
monitoring referring to the results reported by Shao et
al.17
During the treatment and one month after treatment, the
patients were inquired some questions by a questionnaire,
such as hangover, addiction, tolerance, fatigue after
wakeup, insomnia rebound state, vigilance during the
daytime, cognitive function and behavioural capability.
Statistical analysis
Data of all items were analyzed by adopting SPSS11.0
package processing. In terms of PSQI scores and the
parameters in sleep architecture, the paired t test
(self-contrast control of pre-treatment and post-treatment)
was used. The constituent ratio of sleep architecture was
analyzed by chi-square of numeration data. The statistical
significance level was set at P <0.05.
RESULTS
Effects of electroacupuncture on sleep quality and
function during the daytime
As showed in Table 1, the changes in sleep quality
Chinese Medical Journal 2009;122(23):2869-2873 2871

Table 1. The comparison of PSQI between pre-treatment and Table 3. The comparison of parameters in sleep architecture
post-treatment of 47 patients (means ± SD) between pre-treatment and post-treatment of 47 patients
PSQI Number Pre-treatment Post-treatment (means ± SD)
Sleep quality 47 2.63±0.56 1.21±0.74 * Sleep parameters Number Pre-treatment Post-treatment
Sleep latency (minutes) 47 69.74±15.73 37.36±11.33* Total sleep time (minutes) 47 291.50±23.51 375.73±37.45*
Sleep time (minutes) 47 291.5±54.86 375.73±36.43* NREM (minutes)
Sleep efficacy (%) 47 69.04±8.01 84.96±6.69* S1 stage 47 24.74±3.50 19.11±2.31*
Times of awareness 47 10.57±4.86 4.36±3.17* S2 stage 47 173.81±8.73 208.09±19.76*
(>5 minutes/every night ) S3 stage 47 10.91±2.15 25.09±3.10*
Function during the daytime 47 2.27±0.80 1.15±0.72* S4 stage 47 9.89±1.82 23.72±3.47*
Paired t test: *P <0.05 vs pre-treatment. REM stage (minutes) 47 72.15±7.28 99.72±8.81*
Paired t test: *P <0.01 vs pre-treatment.
between pre-treatment and post-treatment were
Table 4. The percentage of sleep parameters in sleep architecture
significant (P <0.05) in the PSQI scores, sleep latency, between pre-treatment and post-treatment of 47 patients
sleep time and sleep efficacy. In addition, the sleep The percentage of The percentage of
efficacy was improved from 69.04% to 84.96%, and the Sleep parameters Number
pre-treatment (%) post-treatment (%)
sleep latency shortened obviously. Moreover, the time of Total sleep 47 100 100
nocturnal awareness (more than 5 minutes) was obviously NREM
S1 stage 47 8.49±1.21 5.09±0.61*
reduced. All the above mentioned changes suggest that
S2 stage 47 59.63±2.99 55.37±5.26*
EA may improve the sleep quality of insomniacs. At the S3 stage 47 3.74±0.74 6.68±0.83*
same time, patients′ function during the daytime was also S4 stage 47 3.39±0.62 6.32±0.92*
improved obviously, suggesting that EA could improve REM stage 47 24.75±2.50 26.54±2.34*
the sleep quality and work efficiency by shortening sleep Paired t test: *P <0.01 vs pre-treatment.
latency, improving patients′ fragmented sleep and
enhancing sleep continuity. provided room for prolonging NREM and REM. This is
the reason why some patients did not have longer total
Effect of EA on sleep architecture sleep time but had improvement in their sleep quality.
As demonstrated in Table 2, the pre-treatment sleep
architecture in the large part of patients was incomplete. Incidence rate of adverse events and side effects
Some patients lost S3 or S4 stage or both stages. After Table 5 shows the incidence rate of adverse events and
treatment, the sleep architecture in some patients was side effects. Insomnia rebound occurred only in about
repaired to some extent with the constituent ratio of 23% patients. The other events were 0 in all listed adverse
pre-treatment and post-treatment sleep architecture (P events and side effects of EA treatment. This suggests
<0.05). All these indicated that acupuncture has certain that EA treatment for insomnia has its unique advantages.
repairing effect on patients with sleep architecture Unlike sedative hypnotic, it has no side effects such as
disruption. In addition, it can restore the sleep continuity. hangover, addiction, cognitive function or decrease in
behavioral capability.
Table 2. The comparison of sleep architecture between
pre-treatment and post-treatment of 47 patients Table 5. The incidence rate of adverse events and side effects
Sleep architecture Number Pre-treatment Post-treatment Positive Incidence
Manifestation Number
REM 47 47 47 number (n) rate (% )
NREM Hangover 47 0 0
S1 47 47 47 Insomnia rebound 47 11 23
S2 47 47 47 Tolerance 47 0 0
S3 47 21 41* Addiction 47 0 0
S4 47 16 35* Fatigue after wakeup 47 0 0
Decrement in vigilance during the daytime 47 0 0
Chi-square test: *P <0.05 vs pre-treatment.
Decrease in cognitive function 47 0 0
Decrease in behavioral capability 47 0 0
Moreover, Table 3 shows the comparison of parameters in
sleep architecture between pre-treatment and post- DISCUSSION
treatment of the 47 patients. The results showed that EA
treatment obviously improved sleep quality. Especially, Effects of EA treatment on sleep quality and social
the increase in SWS (S3+S4) and prolongation of REM function during the daytime and its safety
release ensured good sleep. Table 4 also shows the Sedative hypnotics and anti-anxiety drugs are mostly
percentage of S3 and S4 stage in total sleep time was used clinically in the treatment for insomnia. However,
increased. Table 4 shows that the percentages of S1 and S2 these two types of drugs have obvious advantages as well
stage time in post-treatment were significantly lower than as disadvantages. In terms of advantages, they all have
those in pre-treatment. Although the time of S2 stage in immediate effects which can obviously shorten patients′
post-treatment was longer than that in pre-treatment sleep latency and prolong patients′ sleep time. In terms of
(Table 3), the percentage of S2 stage in total sleep time in disadvantages, they mainly prolong the light sleep time
post-treatment was lower than that in pre-treatment and reduce the sleep quality by shortening the deep sleep
(Table 4). The relatively shorter light sleep (S1+S2) and REM sleep in varying degrees in over 95% of the
2872
patients. As a result, lack of sleep during the daytime (or
hangover), social dysfunction during the daytime, drug
dependence and abstinent symptom18 still occurred even
under therapeutic dosage. Therefore, the aim of the
present clinical research was to find safer and more
effective therapeutic strategies.
As a natural treatment with long history, EA is regarded
as a kind of treatment with little toxic action or side
effects and basically without permanent lesion.19 It has
been applied in insomnia for a long time with good
curative effects.7,8 In addition, it has become an important
means and object in the clinical research of chronic
insomnia treatment.
The results of this study revealed that sleep quality could
be improved by EA on certain acupoints. Similar to
hypnotics, it could shorten sleep latency, prolong sleep
time and improve sleep efficacy, which was demonstrated
by comparison among PSQI scores. Unlike hypnotics, EA
treatment prolongs deep sleep time (Table 3). Therefore,
although some patients did not have obvious increase in
their total sleep time, their sleep quality was improved by
prolonging their deep sleep time (comparatively longer
than that of pre-treatment). Another difference from using
hypnotics is that EA treatment does not have immediate
effect and it needs the accumulation of therapeutic dose.20
In addition, our previous study also revealed that EA has
the effect of reducing the time and dosage of hypnotics
even let the patient become drug-free.21 Moreover, there
is no abstinent symptom during the course, which is
consistent with the previously reported study.22 At the
same time, there are no side effects such as hangover,
dependence, decrease in cognitive function and
behavioral capability, which occur in hypnotic users. All
these data demonstrated that EA treatment is safe.
However, insomnia rebound occurred in some patients
soon after treatment (about one month). So, further
research is still needed for long-term curative effect of EA
on the treatment for insomnia.
Effect of EA on sleep architecture
The continuity and integrity of sleep architecture is the
fundamental guarantee for sleep quality. It is well known
that REM sleep and NREM sleep are the connotation of
sleep architecture. A complete sleep contains 4 to 6 cycles
of REM sleep and NREM sleep per night with 90 minutes
for each cycle. Clinically, due to sleep architecture
disruption (Table 2), many insomniacs lacked sleep
integrity and reduced their sleep quality. Therefore, the
aim of developing new hypnotic at present is to maintain
or repair the integrity of sleep architecture and effectively
prolong SWS time at the same time. As a natural
treatment, EA induced patients′ sleep to go into a natural
sleep state, which was different from exogenous
hypnotics′ compulsory sleep. Hypnotics achieved the aim
of passively falling asleep mainly by forcedly inhibiting
brain cells′ excitability through drugs. The length of sleep
time dependeds on drugs′ demi period, which had no
Chin Med J 2009;122(23):2869-2873
circadian rhythm. This artificially impaired the
physiological function of sleep, which would disrupt
sleep architecture and induce lots of adverse effects. On
the contrary, this study showed the simulative effect of
EA on sleep was basically the same as the research and
development of the present new hypnotics. EA could
repair the disrupted sleep architecture instead of further
disrupting it. It could also reduce the times of nocturnal
awareness, which could help in the sleep continuity. All
these results were proved by the significant difference in
constituent ratio between pre-treatment and
post-treatment sleep architecture.
In addition, our data (Table 3 and Table 4) showed that
the reason why most insomniacs had poor sleep was that
their S3, S4 and REM sleep time was proportionally or
actually shortened.23 Although EA treatment was not a
real drug treatment, sleep latency, S1+S2 stage sleep time
relatively was shortened after 4 courses of treatment. As a
result, S3, S4 stage sleep time and REM sleep time were
absolutely prolonged, which was the fundamental cause
for the improvement of sleep efficacy and sleep quality. It
was important to emphasize that though some patients did
not have obvious prolongation of sleep time, S3 and S4
stages were comparatively prolonged and REM sleep was
comparatively released. Therefore, patients′ sleep quality
was comparatively improved. This is why some patients
felt delightful and fresh and obvious improvement of
social function during the daytime without having
obvious prolongation of sleep time. This indicated that
the prolongation of S3+S4 stage time was more important
than prolongation of total sleep time (mainly light sleep).
Material basis of EA treatment for chronic insomnia
It is obvious that the main mechanism of EA treatment for
chronic insomnia is repair of sleep architecture and
prolongation or release deep sleep time and REM sleep
time in S3 and S4 stages, which leads their proportion
back to normal. All these functions of EA may be related
to certain neurotransmitters secreted by the brain center
through stimulating some special acupoints by EA. For
example, scalp acupoints (Sishenchong, Taiyang point,
Yintang point and so on) can obviously increase the
content of 5-HT, γ-aminobutyric acid in rat′s brain and
obviously decrease norepinephrine (NE).2,24 As reported
by Li et al,5 the substance P in rabbit′s cerebrospinal fluid
was obviously increased by electrically acupuncturing its
certain scalp points. At the same time, it was reported that
the release of substance P could be promoted by
acupuncturing certain body points (such as Neiguan
point).9,25 The modern research indicated that human
sleep is closely related to hormones, transmitters and
neuropeptides mentioned above and so on.3,26 Their
content directly influences sleep, awareness and the sleep
architecture. For example, NE and 5-HT have decisive
effects on maintaining sleep-awareness state. The normal
or up-regulating of NE content and down-regulating of
5-HT content in the brain can cause insomnia. The
normal or up-regulating of 5-HT content and
Chinese Medical Journal 2009;122(23):2869-2873
down-regulating of NE content in the brain can cause
lethargy.4,27 Another study proved that total sleep time can
be increased (awareness time lessens) by micro-injecting
substance P into rat′s lateral cerebral ventricle.28 Total
sleep time (especially deep sleep) can also be increased
by directly injecting into ventrolateral preoptic region
(POA). When γ-aminobutyric acid content is increased or
the activity of γ-aminobutyric acid aminotransferase is
inhibited, deep sleep time can be prolonged and REM
sleep time can be shortened. In addition, NE and
dopamine can increase the awareness time, prolong sleep
latency and REM sleep latency, as well as shorten the
total sleep time, etc. Therefore, we speculated that when
EA stimulated certain acupoints, some insomnia-related
neurotransmitters could be secreted by the brain, and
further improved the sleep quality. It is clear that EA
treatment for insomnia has material basis, but further
studies are necessary.
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(Received April 27, 2009)
Edited by WANG Mou-yue and LIU Huan