Effect of Acupuncture Cooperated with Low-frequency Repetitive Transcranial Magnetic Stimulation on Chronic Insomnia: A Randomized Clinical Trial

Effect of combined treatment with transcranial direct current stimulation and repetitive transcranial magnetic stimulation compared to monotherapy for the treatment of chronic insomnia: a randomised, double-blind, parallel-group, controlled trial

BACKGROUND

Chronic insomnia increases the risk of various health problems and mental illness. Existing research suggests promise for both transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in treating chronic insomnia individually. However, the combined effects of tDCS and rTMS on this condition remain unclear. This study aimed to verify the efficacy and safety of tDCS combined with rTMS for the treatment of adult patients with chronic insomnia.

METHODS

This was a randomised double-blind parallel-group controlled study. Overall, 157 participants with chronic insomnia were randomly assigned to one of three neurotherapy regimens: tDCS + rTMS, sham tDCS + rTMS, or tDCS + sham rTMS. All groups received 20 treatment sessions over 4 consecutive weeks. The primary outcome was the change in patients' sleep as assessed by the Pittsburgh Sleep Quality Index (PSQI) at 2 weeks, 4 weeks, and 3 months of follow-up. The secondary outcome was the assessment of different dimensions of depression and anxiety in patients through the Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA), as well as the occurrence of adverse events.

RESULTS

Throughout the intervention and after the 3-month follow-up, the tDCS + rTMS group had significantly reduced total PSQI scores compared with the other two groups [tDCS + rTMS, 9.21 vs. sham tDCS + rTMS, 10.03; difference - 1.10; 95% confidence interval (CI), - 1.82 to - 0.38; p = 0.003; tDCS + rTMS, 9.21 vs. tDCS + sham rTMS, 10.76; difference - 2.14; 95% CI, - 2.90 to - 1.38; p < 0.001; sham tDCS + rTMS, 10.03 vs. tDCS + sham rTMS, 10.76; difference - 1.04; 95% CI, - 1.82 to - 0.26; p = 0.010), indicating improved overall sleep quality. Total HAMD and insomnia factor scores were significantly lower in the tDCS + rTMS group than in the other two groups after treatment (p < 0.05). Notably, no adverse events or serious adverse reactions were observed during the study period.

CONCLUSIONS

Combining tDCS with rTMS effectively relieved insomnia symptoms, achieving a significant therapeutic effect after 2-week of intervention, and demonstrating the persistence of treatment effects in later follow-up, emphasising the advantages of combination therapy in improving treatment stability and long-term benefits, reflecting the rapid and effective augmentation of combination therapy. This combined therapy may serve as a safe and effective treatment for adults with chronic insomnia.

TRIAL REGISTRATION

This study was registered as a clinical trial with the China Clinical Trial Registration Center (ChiCTR2100052681).

Catgut embedding in acupoints combined with repetitive transcranial magnetic stimulation for the treatment of postmenopausal osteoporosis: study protocol for a randomized clinical trial

Background

To date, the clinical modulation for bone metabolism based on the neuro-bone mass regulation theory is still not popular. The stimulation of nerve systems to explore novel treatments for Postmenopausal osteoporosis (PMOP) is urgent and significant. Preliminary research results suggested that changes brain function and structure may play a crucial role in bone metabolism with PMOP. Thus, we set up a clinical trial to investigate the effect of the combination of repetitive transcranial magnetic stimulation (rTMS) and catgut embedding in acupoints (CEA) for PMOP and to elucidate the central mechanism of this neural stimulation in regulating bone metabolism.

Method

This trial is a prospective and randomized controlled trial. 96 PMOP participants will be randomized in a 1:1:1 ratio into a CEA group, an rTMS group, or a combined one. Participants will receive CEA, rTMS, or combined therapy for 3 months with 8 weeks of follow-up. The primary outcomes will be the changes in Bone Mineral Density scores, total efficiency of Chinese Medicine Symptoms before and after treatment. Secondary outcomes include the McGill Pain Questionnaire Short-Form, Osteoporosis Symptom Score, Mini-Mental State Examination, and Beck Depression Inventory-II. The leptin, leptin receptor, and norepinephrine levels of peripheral blood must be measured before and after treatment. Adverse events that occur during the trial will be recorded.

Discussion

CEA achieves brain-bone mass regulation through the bottom-up way of peripheral-central while rTMS achieves it through the top-down stimulation of central-peripheral. CEA combined with rTMS can stimulate the peripheral-central at the same time and promote peripheral bone mass formation. The combination of CEA and rTMS may play a coordinating, synergistic, and side-effect-reducing role, which is of great clinical significance in exploring better treatment options for PMOP.Clinical trial registration: https://www.chictr.org.cn/, identifier ChiCTR2300073863.

Electroencephalography microstates as novel functional biomarkers for insomnia disorder

Background

Insomnia disorder (ID) is one of the most common mental disorders. Research on ID focuses on exploring its mechanism of disease, novel treatments and treatment outcome prediction. An emerging technique in this field is the use of electroencephalography (EEG) microstates, which offer a new method of EEG feature extraction that incorporates information from both temporal and spatial dimensions.

Aims

To explore the electrophysiological mechanisms of repetitive transcranial magnetic stimulation (rTMS) for ID treatment and use baseline microstate metrics for the prediction of its efficacy.

Methods

This study included 60 patients with ID and 40 age-matched and gender-matched good sleep controls (GSC). Their resting-state EEG microstates were analysed, and the Pittsburgh Sleep Quality Index (PSQI) and polysomnography (PSG) were collected to assess sleep quality. The 60 patients with ID were equally divided into active and sham groups to receive rTMS for 20 days to test whether rTMS had a moderating effect on abnormal microstates in patients with ID. Furthermore, in an independent group of 90 patients with ID who received rTMS treatment, patients were divided into optimal and suboptimal groups based on their median PSQI reduction rate. Baseline EEG microstates were used to build a machine-learning predictive model for the effects of rTMS treatment.

Results

The class D microstate was less frequent and contribute in patients with ID, and these abnormalities were associated with sleep onset latency as measured by PSG. Additionally, the abnormalities were partially reversed to the levels observed in the GSC group following rTMS treatment. The baseline microstate characteristics could predict the therapeutic effect of ID after 20 days of rTMS, with an accuracy of 80.13%.

Conclusions

Our study highlights the value of EEG microstates as functional biomarkers of ID and provides a new perspective for studying the neurophysiological mechanisms of ID. In addition, we predicted the therapeutic effect of rTMS on ID based on the baseline microstates of patients with ID. This finding carries great practical significance for the selection of therapeutic options for patients with ID.

Brain stimulation techniques as novel treatment options for insomnia: A systematic review

Despite the success of cognitive behavioural therapy for insomnia and recent advances in pharmacotherapy, many patients with insomnia do not sufficiently respond to available treatments. This systematic review aims to present the state of science regarding the use of brain stimulation approaches in treating insomnia. To this end, we searched MEDLINE, Embase and PsycINFO from inception to 24 March 2023. We evaluated studies that compared conditions of active stimulation with a control condition or group. Outcome measures included standardized insomnia questionnaires and/or polysomnography in adults with a clinical diagnosis of insomnia. Our search identified 17 controlled trials that met inclusion criteria, and assessed a total of 967 participants using repetitive transcranial magnetic stimulation, transcranial electric stimulation, transcutaneous auricular vagus nerve stimulation or forehead cooling. No trials using other techniques such as deep brain stimulation, vestibular stimulation or auditory stimulation met the inclusion criteria. While several studies report improvements of subjective and objective sleep parameters for different repetitive transcranial magnetic stimulation and transcranial electric stimulation protocols, important methodological limitations and risk of bias limit their interpretability. A forehead cooling study found no significant group differences in the primary endpoints, but better sleep initiation in the active condition. Two transcutaneous auricular vagus nerve stimulation trials found no superiority of active stimulation for most outcome measures. Although modulating sleep through brain stimulation appears feasible, gaps in the prevailing models of sleep physiology and insomnia pathophysiology remain to be filled. Optimized stimulation protocols and proof of superiority over reliable sham conditions are indispensable before brain stimulation becomes a viable treatment option for insomnia.

Effects of different interventions on insomnia in adults: Systematic review and network meta-analysis

OBJECTIVE

Insomnia is a common sleep disorder. There are many clinical-intervention methods for treating this condition, but thus far, the most effective method has not been determined.

METHODS

We conducted a network meta-analysis by including random evidence of insomnia improvement in people over 18 years old, without other physical diseases. From January 1, 1990 to June 15, 2022, we searched multiple electronic databases for randomized controlled trials of different insomnia-related, clinical-intervention methods. R software was used to analyze 10 indices, in order to evaluate the effect of sleep improvement. Primary outcomes comprised Pittsburgh sleep quality-index (PSQI) scores and insomnia severity-index (ISI) scores.

RESULTS

Finally, 122 randomized controlled trials were included in our study. For the PSQI scores, we found the sequence of intervention measures by effect to be as follows: electroacupuncture, acupuncture, repetitive transcranial magnetic stimulation (rTMS), essential oils, herbal medicine, traditional Western medicine, Tai Chi and Baduanjin, music, supplements, cognitive behavioral therapy for insomnia (CBT-I), and exercise. The results for ISI were similar to those for PSQI, but with slight differences.

CONCLUSION

Our research results indicate that various measures have a certain effect on improving sleep, among which the effect of instruments is more prominent. The curative effect of placebo groups was better than that of blank control groups. There is essentially no statistical difference in detailed classification within the same intervention category.

Effects on resting-state EEG phase-amplitude coupling in insomnia disorder patients following 1 Hz left dorsolateral prefrontal cortex rTMS

Despite burgeoning evidence for cortical hyperarousal in insomnia disorder, the existing results on electroencephalography spectral features are highly heterogeneous. Phase-amplitude coupling, which refers to the modulation of the low-frequency phase to a high-frequency amplitude, is probably a more sensitive quantitative measure for characterizing abnormal neural oscillations and explaining the therapeutic effect of repetitive transcranial magnetic stimulation in the treatment of patients with insomnia disorder. Sixty insomnia disorder patients were randomly divided into the active and sham treatment groups to receive 4 weeks of repetitive transcranial magnetic stimulation treatment. Behavioral assessments, resting-state electroencephalography recordings, and sleep polysomnography recordings were performed before and after repetitive transcranial magnetic stimulation treatment. Forty good sleeper controls underwent the same assessment. We demonstrated that phase-amplitude coupling values in the frontal and temporal lobes were weaker in Insomnia disorder patients than in those with good sleeper controls at baseline and that phase-amplitude coupling values near the intervention area were significantly enhanced after active repetitive transcranial magnetic stimulation treatment. Furthermore, the enhancement of phase-amplitude coupling values was significantly correlated with the improvement of sleep quality. This study revealed the potential of phase-amplitude coupling in assessing the severity of insomnia disorder and the efficacy of repetitive transcranial magnetic stimulation treatment, providing new insights on the abnormal physiological mechanisms and future treatments for insomnia disorder.

Repetitive transcranial magnetic stimulation in primary sleep disorders

Repetitive transcranial magnetic stimulation (rTMS) is a widely used non-invasive neuromodulatory technique. When applied in sleep medicine, the main hypothesis explaining its effects concerns the modulation of synaptic plasticity and the strength of connections between the brain areas involved in sleep disorders. Recently, there has been a significant increase in the publication of rTMS studies in primary sleep disorders. A multi-database-based search converges on the evidence that rTMS is safe and feasible in chronic insomnia, obstructive sleep apnea syndrome (OSAS), restless legs syndrome (RLS), and sleep deprivation-related cognitive deficits, whereas limited or no data are available for narcolepsy, sleep bruxism, and REM sleep behavior disorder. Regarding efficacy, the stimulation of the dorsolateral prefrontal cortex bilaterally, right parietal cortex, and dominant primary motor cortex (M1) in insomnia, as well as the stimulation of M1 leg area bilaterally, left primary somatosensory cortex, and left M1 in RLS reduced subjective symptoms and severity scale scores, with effects lasting for up to weeks; conversely, no relevant effect was observed in OSAS and narcolepsy. Nevertheless, several limitations especially regarding the stimulation protocols need to be considered. This review should be viewed as a step towards the further contribution of individually tailored neuromodulatory techniques for sleep disorders.

The evolving role of quantitative actigraphy in clinical sleep medicine

Actigraphy has a consolidated role in Insomnia and Circadian Rhythm Sleep-Wake Disorders (CRSWD) and recent studies have highlighted the use of actigraphy for narcolepsy and REM sleep behaviour disorder (RBD). This review aims at summarising the results of studies published over the last decade regarding the use of actigraphy. Thirty-five studies proved eligible, and results were analysed separately for insomnia, narcolepsy and RBD. Actigraphy showed to consistently differentiate insomnia patients from healthy controls. Furthermore, the application of advanced analytical techniques has been shown to provide both unique insights into the physiology of insomnia and sleep misperception and to improve the specificity of actigraphy in detecting wakefulness within sleep periods. Regarding narcolepsy, several studies showed that actigraphy can detect peculiar sleep/wake disruption and the effects of pharmacological treatments. Finally, although the number of studies in RBD patients is still limited, the available evidence indicates a reduced amplitude of the activity pattern, sleep-wake rhythm dysregulation and daytime sleepiness. Therefore, the potential use of these markers as predictors of phenoconversion should be further explored. In conclusion, quantitative actigraphy presents a renewed interest when considering the possibility of using actigraphy in clinical sleep medicine to diagnose, monitor, and follow sleep disorders other than CRSWD.

Improved Functional Organization in Patients With Primary Insomnia After Individually-Targeted Transcranial Magnetic Stimulation

Primary insomnia (PI) is among the most prevalent sleep-related disorders and has a far-reaching impact on daytime functioning. Repetitive transcranial magnetic stimulation (rTMS) has drawn attention because of its effectiveness and safety. The purpose of the current study was to detect changes in the topological organization of whole-brain functional networks and to determine their associations with the clinical treatment effects of rTMS. Resting-state functional magnetic resonance imaging (rsfMRI) data from 32 patients with PI were collected and compared with findings from 32 age- and gender-matched healthy controls (HCs). The patients were treated with Stanford accelerated intelligent neuromodulation therapy, which is a recently validated neuroscience-informed accelerated intermittent theta-burst stimulation protocol. Graph theoretical analysis was used to construct functional connectivity matrices and to extract the attribute features of small-world networks in insomnia. Scores on the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Self-Rating Anxiety Scale, Self-Rating Depression Scale, and the associations between these clinical characteristics and functional metrics, were the primary outcomes. At baseline, the patients with PI showed inefficient small-world property and aberrant functional segregation and functional integration compared with the HCs. These properties showed renormalization after individualized rTMS treatment. Furthermore, low functional connectivity between the right insula and left medial frontal gyrus correlated with improvement in ISI scores. We highlight functional network dysfunctions in PI patients and provide evidence into the pathophysiological mechanisms involved and the possible mode of action of rTMS.

Electroencephalographic connectivity predicts clinical response to repetitive transcranial magnetic stimulation in patients with insomnia disorder

BACKGROUND

Accumulating evidence suggests that low frequency repetitive transcranial magnetic stimulation (rTMS), which generally decreases cortical excitability and remodels plastic connectivity, improves sleep quality in patients with insomnia disorder. However, the effects of rTMS vary substantially across individuals and treatment is sometimes unsatisfactory, calling for biomarkers for predicting clinical outcomes.

OBJECTIVE

This study aimed to investigate whether functional connectivity of the target network in electroencephalography is associated with the clinical response to low frequency rTMS in patients with insomnia disorder.

METHODS

Twenty-five patients with insomnia disorder were subjected to 10 sessions of treatment with 1 Hz rTMS over the right dorsolateral prefrontal cortex. Resting-state electroencephalography was collected before rTMS. Pittsburgh Sleep Quality Index, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Mini-Mental State Exam were performed before and after rTMS treatment, with a follow-up after one month. Electroencephalographic connectivity was measured by the power envelope connectivity at the source level. Partial least squares regression identified models of connectivity that maximally accounted for the rTMS response.

RESULTS

Scores of Pittsburgh Sleep Quality Index, Hamilton Depression Rating Scale, and Hamilton Anxiety Rating Scale were decreased after rTMS and one-month later. Baseline weaker connectivity of a network in the beta and alpha bands between a brain region approximating the stimulated right dorsolateral prefrontal cortex and areas located in the frontal, insular, and limbic cortices was associated with a greater change in Pittsburgh Sleep Quality Index and Hamilton Depression Rating Scale following rTMS.

CONCLUSIONS

Low frequency rTMS could improve sleep quality and depressive moods in patients with insomnia disorder. Moreover, electroencephalographic functional connectivity would potentially be a robust biomarker for predicting the therapeutic effects.

Effectiveness of TES and rTMS for the Treatment of Insomnia: Meta-Analysis and Meta-Regression of Randomized Sham-Controlled Trials

Objectives: Transcranial electric stimulation (TES) and repetitive transcranial magnetic stimulation (rTMS) have experienced significant development in treating insomnia. This review aims to examine the effectiveness of randomized sham-controlled trials of TES and rTMS in improving insomnia and examine potential moderators associated with the effect of the treatment. Methods: Nine electronic databases were searched for studies comparing the effects of TES/rTMS with sham group on insomnia from the inception of these databases to June 25, 2021, namely, Medline, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science, PubMed, ProQuest Dissertation and Thesis, and CNKI. Meta-analyses were conducted to examine the effect of TES and rTMS in treating insomnia. Univariate meta-regression was performed to explore potential treatment moderators that may influence the pooled results. Risk of bias was assessed by using the Cochrane Risk of Bias Tool. Results: A total of 16 TES studies and 27 rTMS studies were included in this review. The pooled results indicated that there was no significant difference between the TES group and the sham group in improving objective measures of sleep. rTMS was superior to its sham group in improving sleep efficiency, total sleep time, sleep onset latency, wake up after sleep onset, and number of awakenings (all p < 0.05). Both TES and rTMS were superior to their sham counterparts in improving sleep quality as measured by the Pittsburgh Sleep Quality Index at post-intervention. The weighted mean difference for TES and rTMS were -1.17 (95% CI: -1.98, -0.36) and -4.08 (95% CI: -4.86, -3.30), respectively. Gender, total treatment sessions, number of pulses per session, and length of treatment per session were associated with rTMS efficacy. No significant relationship was observed between TES efficacy and the stimulation parameters. Conclusions: It seems that TES and rTMS have a chance to play a decisive role in the therapy of insomnia. Possible dose-dependent and gender difference effects of rTMS are suggested.

Transcranial magnetic stimulation therapeutic applications on sleep and insomnia: a review

Repetitive transcranial magnetic stimulation (rTMS) is a neuromodulatory technique approved by the US Food and Drug Administration for use in treatment-resistant major depressive disorder. It works by generating localized magnetic fields that create depolarizing electrical currents in neurons a few centimeters below the scalp. This localized effect is believed to stimulate neural plasticity, activate compensatory processes, and influence cortical excitability. Additionally, rTMS has been used in a variety of clinical trials for neurological and psychiatric conditions such as anxiety, post-traumatic stress disorder and epilepsy. Beneficial effects in sleep parameters have been documented in these trials, as well as in major depressive disorder, and have led to an interest in using rTMS in the field of sleep medicine for specific disorders such as insomnia, hypersomnia, and restless legs syndrome. It is unknown whether rTMS has intrinsically beneficial properties when applied to primary sleep disorders, or if it only acts on sleep through mood disorders. This narrative review sought to examine available literature regarding the application of rTMS for sleep disorder to identify knowledge gaps and inform future study design. The literature in this area remains scarce, with few randomized clinical trials on rTMS and insomnia. Available studies have found mixed results, with some studies reporting subjective sleep improvement while objective improvement is less consistent. Due to the heterogeneity of results and the variations in rTMS protocols, no definitive conclusions have been reached, signaling the need for further research.

The fMRI study for acupuncture on shift work sleep disorder: Study protocol for a randomized controlled neuroimaging trial

INTRODUCTION

Nearly 20% of night shift nurses will cause shift work disorder (SWD) due to the disruption of sleep-wake cycle, which not only affects the daily work efficiency, but also brings a huge burden on physical and mental health. Acupuncture is a safe and effective intervention on SWD. This trial will combine with functional magnetic resonance imaging (fMRI) to study the clinical effects and potential mechanism of acupuncture in the treatment of SWD.

METHODS AND ANALYSIS

This is a randomized controlled neuroimaging trial, with enrolled participants, outcome assessors, and data statisticians blinded. 60 patients with SWD and 30 healthy controls who sleep regularly will be recruited and divided into divided into a control group, a true acupoints treatment group (TATG) and a sham acupoints treatment group (SATG) by the ratio of 1:1:1. The TATG and SATG will receive 8 sessions of acupuncture treatment in 4 weeks. Cognitive function scales and MRI scanning will be performed before and after 4-week acupuncture treatment. The control group will receive no intervention. Functional connectivity of intra-network and inter-network will be the primary outcome and effect indicator. The secondary outcomes included Repeatable Battery for the Assessment of Neuropsychological Status, Attentional Network Test, Pittsburgh Sleep Quality Index scale and needle sensation assessment scale. Neuroimage indicators will be correlated with clinical data and scores of cognitive function assessment to explore the possible mechanisms underlying the changes of brain activity caused by acupuncture treatment.

DISCUSSION

The results of this study will enable us to verify the therapeutic effect of acupuncture on SWD and explore the potential central mechanism of acupuncture on SWD from the change of brain activity.

New potential stimulation targets for noninvasive brain stimulation treatment of chronic insomnia

BACKGROUND

Noninvasive brain stimulation (NIBS) was recently used as a therapeutic application in patients with insomnia. Most of the previous NIBS treatments for insomnia directly selected the dorsolateral prefrontal cortex (DLPFC) as the stimulation site. As the NIBS target is an important factor in the efficacy of NIBS, it is necessary to detect more potential cortical sites for NIBS in insomnia.

METHODS

A neuroimaging study-based meta-analysis was used to examine sleep-related brain regions. A sleep-associated brain region-based functional connectivity (FC) map was constructed in 50 patients with chronic insomnia disorder (CID) without any comorbidity. We also combined the meta-analysis and FC results to examine the potential surface targets for NIBS for CID.

RESULTS

The results identified the bilateral supplementary motor area (SMA), left superior temporal gyrus (STG), bilateral DLPFC, precentral lobule, supramarginal gyrus, angular gyrus, superior frontal gyrus, middle temporal gyrus and middle occipital gyrus as potential brain stimulation targets for insomnia treatment. Notably, the bilateral SMA, right DLPFC and left STG were identified in the FC and meta-analyses. In addition, the SMA and DLPFC were positively and STG was negatively connected with other sleep related brain regions, which indicated inhibitory and excitatory stimulation for NIBS treatment for CID, respectively.

CONCLUSION

Our study suggests the SMA, DLPFC and STG as preferentially selected brain targets of NIBS for CID treatment. We recommend an inhibitory stimulation over SMA and DLPFC, and an excitatory stimulation over STG for NIBS treatment. Future studies should test these new targets using NIBS treatment for insomnia.

Altered response to repetitive transcranial magnetic stimulation in patients with chronic primary insomnia

BACKGROUND

We aimed at evaluating the amplitude changes of the motor evoked potentials (MEPs) induced by of low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the primary motor cortex (M1) in10 patients with primary insomnia (PI) and in 10 age-matched healthy controls.

METHODS

Median peak-to-peak MEP amplitudes were assessed in all subjects at three times: at baseline (T₀), after the first train of a single rTMS session (T₁), and after the whole rTMS procedure (T₂). This consists of 20 trains of 1 Hz stimulation with 50 stimuli per train and an intertrain interval of 30 s.

RESULTS

Resting motor threshold (RMT) and MEPs amplitude did not differ between the two groups at T₀. A reduction of MEP size was observed at both T₁ and T₂ in all subjects, but this was significantly less pronounced in patients than in control subjects.

CONCLUSIONS

The lack of MEP inhibition reflects an altered response to LF rTMS in patients with PI. These rTMS findings are indicative of an altered cortical plasticity in inhibitory circuits within M1 in PI. Subjects with PI exhibited an impairment of the LTD-like mechanisms induced by inhibitory rTMS, thus providing further support to the involvement of GABA neurotransmission in the pathophysiology of PI.

The effect of repetitive transcranial magnetic stimulation for insomnia: a systematic review and meta-analysis

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) might be a promising technique in treating insomnia. A comprehensive meta-analysis of the available literature is conducted to offer evidence.

OBJECTIVE

To evaluate the efficacy and safety of rTMS for insomnia, either as monotherapy or as a complementary strategy.

METHODS

CENTRAL, PubMed, EMBASE, PsycINFO, CINAHL, PEDro, CBM, CNKI, WANFANG, and VIP were searched from earliest record to August 2019. Randomized control trials (RCTs) published in English and Chinese examining effects of rTMS on patients with insomnia were included. Two authors independently completed the article selection, data extraction and rating. Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies. The RevMan software was used for meta-analysis. The quality of the evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 36 trials from 28 eligible studies were included, involving a total of 2357 adult participants (mean age, 48.80 years; 45.33% males). Compared with sham rTMS, rTMS was associated with improved PSQI total score (SMD -2.31, 95% CI -2.95 to -1.66; Z = 7.01, P < 0.00001) and scores of seven subscales. Compared to other treatment, rTMS as an adjunct to other treatment was associated with improved PSQI total score (SMD -1.44, 95% CI -2.00 to -0.88; Z = 5.01, P < 0.00001), and may have effects on scores of seven subscales. Compared with other treatment, rTMS was associated with improved Pittsburgh sleep quality index (PSQI) total score (SMD -0.63, 95% CI -1.22 to -0.04; Z = 2.08, P = 0.04), and may have a better score in sleep latency, sleep disturbance and hypnotic using of seven subscales. In the three pair of comparisons, the results for polysomnography (PSG) outcomes were varied. In general, rTMS may improve sleep quality through increasing slow wave and rapid eye movement (REM) sleep. The rTMS group was more prone to headache than the sham or blank control group (RR 1.71, 95% CI 1.03 to 2.85; Z = 2.07, P = 0.04). No severe adverse events were reported. Reporting biases and low and very low grade of some evidences should be considered when interpreting the results of this meta-analysis.

CONCLUSIONS

Our findings indicate that rTMS may be a safe and effective option for insomnia. Further international, multicenter, high-quality RCTs with more objective, quality of life related and follow-up assessments are needed.

Restless legs syndrome: Clinical changes in nervous system excitability at the spinal cord level

Restless legs syndrome (RLS) is a complex multifactorial disorder whose aetiology has yet to be fully elucidated. Some of the features of RLS, such as processing of sensations and activation of movement, may result from a dysfunction in spinal processing giving rise to a state of spinal hyperexcitability. In the current article we review studies investigating spinal excitability in RLS patients looking specifically at electrophysiological studies of spinal activity, sensory evaluations, and spinal reflex studies. Increased spinal excitability has been shown in RLS patients based on the combined data from electrophysiological studies. Results from studies assessing sensory evaluations in RLS patients show enhanced spinal processing of nociceptive inputs possibly due to central sensitisation. However, not all sensory modalities demonstrate an increase in sensitivity. An increase in nervous system excitability would result in an increase in reflex responses in RLS patients however the data from reflex analyses in RLS patients has failed to consistently show this expected result. Overall changes to RLS spinal excitability have been demonstrated though these changes might be heterogeneous as not all afferent input appears to be affected in the same manner. There may be phase-dependent and modality-dependent alterations in spinal excitability suggesting that the theory of absolute spinal hyperexcitability in RLS patients' needs to be reconsidered.

Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature

BACKGROUND

Acupuncture is a common form of alternative medicine that is used for pain control among other modalities of treatment. It is a relatively safe procedure, but complications, including those of infectious etiology, may still occur.

CASE DESCRIPTION

A 47-year-old immunosuppressed woman presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass after acupuncture for headaches in the same area. Imaging demonstrated subgaleal and epidural collection localized in the left occipital region. She underwent urgent surgical evacuation of both collections. Cultures from intraoperative specimens grew Streptococcus anginosus. The patient started targeted antibiotic treatment leading to complete recovery.

CONCLUSIONS

To our knowledge, this is the first report of intracranial abscess after acupuncture. Given the worldwide application of this alternative treatment, physicians, acupuncturists, and the general public should be aware of the possibility of this rare but serious complication.