Sommaire

Posttraumatic Stress Disorder

Trouble de stress post-traumatique : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
☆ Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Bisson 2020

Bisson JI, van Gelderen M, Roberts NP, Lewis C. Non-pharmacological and non-psychological approaches to the treatment of PTSD: results of a systematic review and meta-analyses. Eur J Psychotraumatol. 2020;11(1). [212589]. doi

BackgroundNon-pharmacological and non-psychological approaches to the treatment of post-traumatic stress disorder (PTSD) have often been excluded from systematic reviews and meta-analyses. Consequently, we know little regarding their efficacy.
ObjectiveTo determine the effect sizes of non-pharmacological and non-psychological treatment approaches for PTSD.
MethodWe undertook a systematic review and meta-analyses following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
Results30 randomised controlled trials (RCTs) of a range of heterogeneous non-psychological and non-pharmacological interventions (28 in adults, two in children and adolescents) were included. There was emerging evidence for six different approaches (acupuncture, neurofeedback, saikokeishikankyoto (a herbal preparation), somatic experiencing, transcranial magnetic stimulation, and yoga).
ConclusionsGiven the level of evidence available, it would be premature to offer non-pharmacological and non-psychological interventions routinely, but those with evidence of efficacy provide alternatives for people who do not respond to, do not tolerate or do not want more conventional evidence-based interventions. This review should stimulate further research in this area.

1.1.2. Grant 2018 ∅

Grant S, Colaiaco B, Motala A, Shanman R, Sorbero M, Hempel S. Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis. J Trauma Dissociation. 2018;19(1).39-58. [168629].

Objectives Acupuncture has been suggested as a treatment for posttraumatic stress disorder (PTSD), yet its clinical effects are unclear. This review aims to estimate effects of acupuncture on PTSD symptoms, depressive symptoms, anxiety symptoms, and sleep quality for adults with PTSD.
Methods We searched 10 databases in January 2016 to identify eligible randomized controlled trials (RCTs). We performed random effects meta-analyses and examined quality of the body of evidence (QoE) using the GRADE approach to rate confidence in meta-analytic effect estimates.
Results Seven RCTs with 709 participants met inclusion criteria. We identified very low QoE indicating significant differences favoring acupuncture (versus any comparator) at post-intervention on PTSD symptoms (standardized mean difference [SMD] = -0.80, 95% confidence interval [CI] [-1.59, -0.01], 6 RCTs), and low QoE at longer follow-up on PTSD (SMD = -0.46, 95% CI [-0.85, -0.06], 4 RCTs) and depressive symptoms (SMD = -0.56; 95% CI [-0.88, -0.23], 4 RCTs). No significant differences were observed between acupuncture and comparators at post-intervention for depressive symptoms (SMD = -0.58, 95% CI [-1.18, 0.01], 6 RCTs, very low QoE), anxiety symptoms (SMD = -0.82, 95% CI [-2.16, 0.53], 4 RCTs, very low QoE), and sleep quality (SMD = -0.46, 95% CI [-3.95, 3.03], 2 RCTs, low QoE). Safety data (7 RCTs) suggest little risk of serious adverse events, though some participants experienced minor/moderate pain, superficial bleeding, and hematoma at needle-insertion sites.
Conclusions To increase confidence in findings, sufficiently-powered replication trials are needed that measure all relevant clinical outcomes and dedicate study resources to minimizing participant attrition.

1.1.3. Metcalf 2016 ∼

Metcalf O, Varker T, Forbes D, Phelps A, Dell L, DiBattista A, Ralph N, O'Donnell M. Efficacy of Fifteen Emerging Interventions for the Treatment of Posttraumatic Stress Disorder: A Systematic Review. J Trauma Stress. 2016;29(1):88-92. [190597].

Objectives Although there is an abundance of novel interventions for the treatment of posttraumatic stress disorder (PTSD), often their efficacy remains unknown. This systematic review assessed the evidence for 15 new or novel interventions for the treatment of PTSD.
Methods Studies that investigated changes to PTSD symptoms following the delivery of any 1 of the 15 interventions of interest were identified through systematic literature searches. There were 19 studies that met the inclusion criteria for this study. Eligible studies were assessed against methodological quality criteria and data were extracted.
Results The majority of the 19 studies were of poor quality, hampered by methodological limitations, such as small sample sizes and lack of control group. There were 4 interventions, however, stemming from a mind-body philosophy (acupuncture, emotional freedom technique, mantra-based meditation, and yoga) that had moderate quality evidence from mostly small- to moderate-sized randomized controlled trials. The active components, however, of these promising emerging interventions and how they related to or were distinct from established treatments remain unclear.
Conclusions The majority of emerging interventions for the treatment of PTSD currently have an insufficient level of evidence supporting their efficacy, despite their increasing popularity. Further well-designed controlled trials of emerging interventions for PTSD are required.

1.1.4. Wahbeh 2014

Wahbeh H, Senders A, Neuendorf R, Cayton J. Complementary and alternative medicine for posttraumatic stress disorder symptoms: a systematic review. J Evid Based Complementary Altern Med. 2014. [170847].

ObjectivesTo (1) characterize complementary and alternative medicine studies for posttraumatic stress disorder symptoms, (2) evaluate the quality of these studies, and (3) systematically grade the scientific evidence for individual CAM modalities for posttraumatic stress disorder.
DesignSystematic review. Eight data sources were searched. Selection criteria included any study design assessing posttraumatic stress disorder outcomes and any complementary and alternative medicine intervention. The body of evidence for each modality was assessed with the Natural Standard evidence-based, validated grading rationale.
Results and Conclusions Thirty-three studies (n = 1329) were reviewed. Scientific evidence of benefit for posttraumatic stress disorder was strong for repetitive transcranial magnetic stimulation and good for acupuncture, hypnotherapy, meditation, and visualization. Evidence was unclear or conflicting for biofeedback, relaxation, Emotional Freedom and Thought Field therapies, yoga, and natural products. Considerations for clinical applications and future research recommendations are discussed.

1.1.5. Kim 2013

Kim YD, Heo I, Shin BC, Crawford C, Kang HW, Lim JH. Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. Evid Based Complement Alternat Med. 2013. [168779].

Objective- Methods To evaluate the current evidence for effectiveness of acupuncture for posttraumatic stress disorder (PTSD) in the form of a systematic review, a systematic literature search was conducted in 23 electronic databases. Grey literature was also searched. The key search terms were “acupuncture” and “PTSD.” No language restrictions were imposed. We included all randomized or prospective clinical trials that evaluated acupuncture and its variants against a waitlist, sham acupuncture, conventional therapy control for PTSD, or without control.
Results Four randomized controlled trials (RCTs) and 2 uncontrolled clinical trials (UCTs) out of 136 articles in total were systematically reviewed. One high-quality RCT reported that acupuncture was superior to waitlist control and therapeutic effects of acupuncture and cognitive-behavioral therapy (CBT) were similar based on the effect sizes. One RCT showed no statistical difference between acupuncture and selective serotonin reuptake inhibitors (SSRIs). One RCT reported a favorable effect of acupoint stimulation plus CBT against CBT alone. A meta-analysis of acupuncture plus moxibustion versus SSRI favored acupuncture plus moxibustion in three outcomes.
Conclusions This systematic review and meta-analysis suggest that the evidence of effectiveness of acupuncture for PTSD is encouraging but not cogent. Further qualified trials are needed to confirm whether acupuncture is effective for PTSD.

1.2. Special Acupuncture Techniques

1.2.1. Auricular Acupuncture

1.2.1.1. Kwon 2020

Kwon CY, Lee B, Kim SH. Effectiveness and safety of ear acupuncture for trauma-related mental disorders after large-scale disasters: A PRISMA-compliant systematic review. Medicine (Baltimore). 2020;99(8). [205648]. DOI

BackgroundLarge-scale disasters such as earthquakes cause mental health problems in individuals and lead to serious economic burdens on their communities and societies. Effective, simple, and safe intervention is needed to manage survivors of large-scale disasters. The purpose of this systematic review was to summarize and evaluate clinical studies using ear acupuncture for psychological trauma-related disorders after large-scale disasters, to determine its effectiveness, safety, and feasibility.
MethodsA comprehensive search of 15 electronic databases was conducted to collect relevant clinical studies up to November 2019. The methodological quality of the included studies was assessed using appropriate tools according to their study design.
ResultsIn total, 10 studies including 3 randomized controlled trials (RCTs), 3 before-after studies, 1 case report, 1 qualitative research, and 2 reports of public mental health services were analyzed. Ear acupuncture improved overall post-traumatic stress disorder (PTSD) related symptoms in patients with PTSD after disasters. For insomnia in patients with PTSD, although ear acupuncture improved a few subscales of the Pittsburgh sleep quality index in an RCT, other outcomes including sleep diary, actigraph, and the insomnia severity index were not improved. The methodological quality of RCTs was generally low. Serious adverse events related to ear acupuncture were not reported.
ConclusionIn conclusion, we found limited evidence suggesting the benefits of ear acupuncture in trauma-related mental disorders after large-scale disasters. Because of the small number of studies included and their heterogeneity, we could not draw conclusions about its effectiveness and safety. As 1 of the medical resources available after large-scale disasters, ear acupuncture still needs to be studied further. Registry studies aimed at investigating the results of ear acupuncture at disaster sites may be considered.

2. Overviews of Systematic Reviews

2.1. Lee 2012

Lee C, Crawford C, Wallerstedt D, York A, Duncan A, Smith J et al. The effectiveness of acupuncture research across components of the trauma spectrum response (TSR): a systematic review of reviews. Syst Rev 2012;:1-46. [167031

BackgroundCo-morbid symptoms (for example, chronic pain, depression, anxiety, and fatigue) are particularly common in military fighters returning from the current conflicts, who have experienced physical and/or psychological trauma. These overlapping conditions cut across the boundaries of mind, brain and body, resulting in a common symptomatic and functional spectrum of physical, cognitive, psychological and behavioral effects referred to as the 'Trauma Spectrum Response' (TSR). While acupuncture has been shown to treat some of these components effectively, the current literature is often difficult to interpret, inconsistent or of variable quality. Thus, to gauge comprehensively the effectiveness of acupuncture across TSR components, a systematic review of reviews was conducted using the Samueli Institute's Rapid Evidence Assessment of the Literature (REAL©) methodology.
Methods PubMed/MEDLINE, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, and PsycInfo were searched from inception to September 2011 for systematic reviews/meta-analyses. Quality assessment was rigorously performed using the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Adherence to the Standards for Reporting Interventions in Clinical Trials in Acupuncture (STRICTA) criteria was also assessed.
ResultsOf the 1,480 citations identified by our searches, 52 systematic reviews/meta-analyses, all high quality except for one, met inclusion criteria for each TSR component except post-traumatic stress disorder (PTSD) and sexual function. The majority of reviews addressed most STRICTA components, but did not describe safety.
ConclusionsBased on the results of our review, acupuncture appears to be effective for treating headaches and, although more research is needed, seems to be a promising treatment option for anxiety, sleep disturbances, depression and chronic pain. It does not, however, demonstrate any substantial treatment benefit for substance abuse. Because there were no reviews on PTSD or sexual function that met our pre-defined inclusion criteria, we cannot comment on acupuncture's effectiveness in treating these conditions. More quality data are also needed to determine whether acupuncture is appropriate for treating fatigue or cognitive difficulties. Further, while acupuncture has been shown to be generally safe, safety was not described in the majority of studies, making it difficult to provide any strong recommendations. Future research should address safety reporting in detail in order to increase our confidence in acupuncture's efficacy across the identified TSR components.

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

3.1. Department of Veterans Affairs Department of Defense (VA/DOD, USA) 2023 Ø

  • Schnurr PP, Hamblen JL, Wolf J, Coller R, Collie C, Fuller MA, Holtzheimer PE, Kelly U, Lang AJ, McGraw K, Morganstein JC, Norman SB, Papke K, Petrakis I, Riggs D, Sall JA, Shiner B, Wiechers I, Kelber MS. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2024 Feb 27. https://doi.org/10.7326/M23-2757
There is insufficient evidence to recommend for or against the following mind–body interventions for the treatment of PTSD: acupuncture, cognitively-based compassion training–veteran version, creative arts therapies (e.g., music, art, dance), guided imagery, hypnosis or self-hypnosis, loving kindness meditation, mantram repetition program, mindfulness-based cognitive therapy, other mindfulness trainings (e.g., integrative exercise, mindfulness-based exposure therapy, brief mindfulness training), relaxation training, somatic experiencing, tai chi or qigong, transcendental meditation, or yoga. Strength of Recommendation: Neither for nor against. Recommendation Category: Reviewed, new/replaced

3.2. Phoenix Australia 2021 ⊕

Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder, and Complex Posttraumatic Stress Disorder. https://files.magicapp.org/guideline/d4beae17-63d3-421f-a97a-941423f7a9cd/published_guideline_5359-6_0.pdf

For adults with PTSD we recommend offering TF-CBT, PE, CT, CPT or EMDR in preference to acupuncture. There is emerging evidence for acupuncture and this could be used in a research context.

3.3. Department of Veterans Affairs Department of Defense (VA/DOD, USA) 2017 ⊕

VA/DOD Clinical Practice Guideline for The Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Department of Veterans Affairs Department of Defense. 2017:200P. [198422].

There is insufficient evidence to recommend acupuncture as a primary treatment for PTSD. Strength: N/A . Category: Reviewed, New-replaced.
Acupuncture may be considered as treatment for patients with PTSD. Grade: [B].
Recommendation 33. CAM approaches that facilitate a relaxation response (e.g. mindfulness, yoga, acupuncture, massage, and others) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques. [I]
CAM approaches may be considered as adjunctive approaches to address some co-morbid conditions(e.g. acupuncture for pain). [C]
When appropriate,recommend use of non-pharmacological modalitiesfor pain control, such as biofeedback, massage, imaging therapy, physical therapy, and complementary alternative modalities (yoga,meditation, acupuncture).[C]

3.4. Accident Compensation Corporation (ACC, New-Zealand) 2014 Ø

Dara S. Effectiveness of acupuncture in selected mental health conditions , Accident Compensation Corporation (ACC, New-Zealand). 2014. [182119].

There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.

3.5. Australian Centre for Posttraumatic Mental Health (Australie) 2013

Australian Centre for Posttraumatic Mental Health. Australian guidelines for the treatment of acute stress disorder & posttraumatic stress disorder. Melbourne (Australia): Australian Centre for Posttraumatic Mental Health. 2013. 177P. [168135].

Recommendation R11.Acupuncture may be considered as a potential intervention for PTSD for people who have not responded to trauma-focussed psychological therapy or pharmacotherapy (grade D).