Acupuncture is practiced as an accepted health care model in China, Korea and Japan. Traditionally, it involves the stimulation of specific points (acupoints) by inserting needles into the skin. Electro-acupuncture is similar in that the same points are stimulated with needles inserted on specific points along the body. It uses two needles attached to an electrical device that generates continuous electric pulses. These pass from one needle to the other with varying frequency and intensity dictated by the condition. Administration is usually for no more than 30 minutes at a time. Laser acupuncture is essentially the same except that a laser is used instead of needles. Moxibustion uses heat from burning a herb (artemisia vulgaris), or uses an electric source, to stimulate specific points or areas of the body.

One of the challenges in performing efficacy trials of acupuncture is that it is difficult to provide a control condition. Sham methods that have been used include needling the wrong points or with very superficial technique. Or using a simulation of laser acupuncture without full stimulation.

What is the evidence for the effectiveness of acupuncture in people with PTSD?

Moderate to low quality evidence found improvements in PTSD symptoms and some improvement in depression symptoms and functioning following needle acupuncture (30 to 60 minutes per session, 2 to 4 sessions per week over 3 to 12 weeks). There were no improvements in anxiety, sleep, or quality of life. Some participants experienced minor to moderate pain, superficial bleeding, and hematoma at needle insertion sites.

August 2021

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Biofeedback is a technique where information about the person’s body is fed back to them so that they can be trained to alter their body’s conditions. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Other specialists use biofeedback to help their patients cope with pain. It is also commonly used to reduce stress and anxiety, and to encourage relaxation.

Electromyographic biofeedback is used by psychologists to help anxious patients learn to relax. The electromyograph picks up electrical signals in the muscles and translates these signals into a flashing light or a beep every time muscles grow tense. If patients relax their tense muscles, they can slow down the flashing or beeping. Electroencephalographic biofeedback is used to teach self-regulation of brain function. It is usually provided using video or sound, with positive feedback for desirable brain activity and negative feedback for undesirable brain activity. Thermal biofeedback uses a temperature sensor to allow the patient to track his or her body temperature. During times of stress, the body will divert blood from the surface area of the body to the muscles and organs, allowing us to better respond to a nearby threat. When a patient is stressed, this will show as a drop-in temperature in the body’s surface areas. When a patient’s surface temperature is high, it typically means they are in a relaxed or sleepy state.

Dysregulation in autonomic nervous system activity is common in a variety of mental health disorders and presents targets for biofeedback. Hypoarousal patterns include slow, regular heart rate, increased heart rate variability, warm skin temperature, low sweat gland activity, and dominance of EEG frequencies in the theta to low alpha range (3.5–10 Hz). In contrast, hyperarousal is reflected by increased heart rate and decreased heart rate variability, high electrodermal activity, and higher frequency EEG bandwidth ranges in high-alpha or beta range (15–42 Hz).

What is the evidence for the effectiveness of biofeedback in people with PTSD?

The only review that met inclusion criteria assessed EEG neurofeedback. It contained moderate to low quality evidence and found a large improvement in PTSD symptoms with 4-12 weeks of neurofeedback compared to no treatment.

August 2021

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People with serious mental illnesses are more likely to be sedentary than the general population. This can lead to chronic medical conditions associated with inactivity. Physical activity reduces the risk of these medical conditions, and positive psychological effects have also been reported, including improved quality of life. Exercise also has the potential to alleviate secondary symptoms including depression, low self-esteem and social withdrawal.

What is the evidence for the effectiveness of exercise for people with PTSD?

Moderate to high quality evidence found a medium-sized effect of improved PTSD symptoms following physical activity (pre-post analysis). Compared to control conditions the effect was larger, but reduced over time (>1 month after the trial ended). The effect was largest in low quality studies, in military samples, with yoga rather than other exercise conditions, and when compared to passive rather than active control conditions.

August 2021

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Hyperbaric oxygen is used to treat traumatic brain injury and post-concussion symptoms. It increases the amount of oxygen dissolved in the blood and increases oxygen delivery to tissues. Oxygen is the active ingredient which is titrated in a manner similar to dosing a drug. The dose is dependent on the amount of oxygen in the gas being breathed multiplied by the absolute atmospheric pressure inside the hyperbaric chamber, and also the duration and frequency of the treatment. Hyperbaric oxygen may improve PTSD symptoms in people with both PTSD and traumatic brain injury.

What is the evidence for the effectiveness of hyperbaric oxygen for people with PTSD?

Moderate to low quality evidence found some improvement in PTSD symptoms following hyperbaric oxygen therapy in people with PTSD and a traumatic brain injury.

August 2021

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Repetitive TMS (rTMS) is a non-invasive method used to stimulate nerve cells in superficial layers of the brain. Control comparisons include ‘sham’ rTMS, which may involve tilting the stimulation coil against the scalp by 45 or 90 degrees, thus reducing the degree of brain stimulation, or use of a “placebo” coil of identical appearance. These placebo methods usually involve a ‘click’ noise but no magnetic field and no twitching sensation on the scalp. Comparison groups can also receive active rTMS applied to other brain regions.

What is the evidence for the effectiveness of rTMS for PTSD?

Moderate quality evidence found large improvements in PTSD and anxiety symptoms following rTMS compared to sham rTMS. This analysis included studies that mostly stimulated the right dorsolateral prefrontal cortex and used high frequency stimulation (>5 Hz) rather than low frequency stimulation (1 Hz). Deleting the low frequency stimulation studies resulted in improvements in PTSD symptoms only. There were no significant differences between active and sham groups for depression symptoms using the Hamilton Depression Scale or for overall symptoms using clinician assessment.

August 2021

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