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. 2026 Jun 18;15(5):1873–1879. doi: 10.4103/jfmpc.jfmpc_1889_25

Acupuncture for post-stroke spastic hemiplegia: A dual-dimensional evidence synthesis combining bibliometric and meta-analysis

Junbing Liu 1, Rong Chen 2, Qimi Huang 1, Hui Cheng 1,✉, Lu Cai 1, Fang Liu 1
PMCID: PMC13387695  PMID: 42483336

ABSTRACT

This study systematically evaluates acupuncture for post-stroke spastic hemiplegia using a dual-dimensional approach: bibliometric analysis and meta-analysis. Databases (PubMed, Web of Science, Embase, CNKI, Wanfang, VIP) were searched from inception to December 31, 2024. Bibliometric tools (VOSviewer, CiteSpace) were used to analyze research trends, collaborations, and keyword clusters. Meta-analysis was performed using R, RevMan, and Stata. Forty-five RCTs were included. Bibliometric findings show a shift from early research on “acupoint specificity” to recent hotspots including “neural mechanisms” and “multimodal efficacy evaluation.” Meta-analysis shows that acupuncture significantly improves muscle tone (Ashworth: MD = –0.64), upper-limb motor function (FMA: MD = 6.75), lower-limb motor function (FMA: MD = 3.46), and activities of daily living (Barthel index: MD = 10.87). Electroacupuncture shows superior effects, and treatment duration ≥4 weeks is more effective. China leads in research output. Acupuncture, especially electroacupuncture combined with conventional rehabilitation, is effective for post-stroke spastic hemiplegia.

Keywords: Acupuncture, bibliometrics, electroacupuncture, hemiplegia after stroke, meta-analysis

Introduction

Research background

Stroke, the world’s second leading cause of death, leaves 70%–80% of survivors with varying degrees of motor dysfunction. Spastic hemiplegia is a common sequela occurring in 40%–50% of cases. It manifests as increased muscle tone and decreased motor coordination in the affected limbs, severely impacting activities of daily living (ADL), quality of life (QoL), and increasing the burden of family care. Conventional rehabilitation approaches, such as exercise therapy and pharmacological interventions, offer limited efficacy in alleviating spasticity. Acupuncture, a characteristic therapy of traditional Chinese medicine (TCM), has been increasingly applied in post-stroke rehabilitation. Multiple clinical studies suggest that acupuncture improves muscle tone and motor function by modulating neurotransmitters (e.g., serotonin and gamma-aminobutyric acid), promoting neuroplasticity, and activating motor cortex reorganization. However, due to the large number of acupuncture methods, there are problems such as inconsistent methodological quality, significant heterogeneity of intervention plans (acupoint selection, stimulation parameters, etc.), and insufficient strength of efficacy evidence. Thus, doctors and patients cannot understand the most suitable treatment for this disease. This study aims to provide a certain reference and basis for the treatment decision of patients with limb spasticity after stroke, and help medical personnel better understand the choice of acupuncture methods, be familiar with the selection of meridian acupoints, observe patients from the perspective of TCM, analyze the condition, and promote patient recovery. This study employs a dual-dimensional approach of “Bibliometrics and Meta-analysis” to not only reveal research trends but also provide high-quality evidence-based evidence, offering scientific guidance for clinical practice and future research directions. The results will help elevate the evidence level for acupuncture in treating post-stroke spastic hemiplegia and promote its recognition and application within the international medical field.

Methods

Literature search strategy

  • Databases: English databases (PubMed, Web of Science, Embase) + Chinese databases (CNKI, Wanfang, VIP)

  • Search period: Inception to December 31, 2024

  • Search terms: Subject headings (MeSH/TCM subject headings): “Stroke,” “Cerebral Infarction,” “Spastic Hemiplegia,” “Acupuncture,” “Electroacupuncture,” “Scalp Acupuncture”

  • Free text words: “脑卒中” (Stroke), “痉挛性偏瘫” (Spastic Hemiplegia), “电针” (Electroacupuncture), “头针” (Scalp Acupuncture), “Ashworth量表” (Ashworth scale), “Fugl-Meyer评分” (Fugl-Meyer assessment)

  • Sample search strategy: (“Stroke” OR “Cerebral Infarction”) AND (“Spastic Hemiplegia”) AND (“Acupuncture” OR “Electroacupuncture”) AND (“RCT” OR “Randomized Controlled Trial”)

Bibliometric data extraction and analysis

Preliminary screening was performed based on the retrieved literature titles and abstracts, and preliminary literature was obtained for bibliometric analysis after excluding newspaper literature, conference literature, and duplicate literature. The literature was mechanically deduplicated and manually reviewed, and duplicate literature, insufficient key information, call for papers, newspapers, master’s and doctoral theses, conference papers, English literature, review literature, expert consensus, treatment guidelines, and scientific and technological achievements were eliminated according to the title, abstract, and content of the literature. Finally, high-quality literature that met the standards was included. Export data in plain text files included title (TI), author (AU), abstract (AB), journal name (JN), and publication year (PY). Leiden University, Leiden, South Holland and Chaomei Chen, Philadelphia, Pennsylvania. were used for cleaning and deduplication to complete the format conversion. To understand research hotspots and trends, author cooperation network analysis, institutional cooperation network analysis, national cooperation network analysis, and keyword co-occurrence cluster analysis were performed to draw a knowledge map, and the map information was analyzed based on the knowledge graph.

Meta-analysis of the effects of acupuncture interventions

Registration and protocol

The study protocol was pre-registered on the International Prospective Register of Systematic Reviews (PROSPERO, Registration No.: CRD42024). Reporting adhered to the PRISMA 2020 statement (preferred reporting items for systematic reviews and meta-analyses) and the CONSORT statement to ensure transparency and reproducibility.

Study type and inclusion criteria (纳入标准)

Randomized controlled trials (RCTs) explicitly reporting random sequence generation (random number table), allocation concealment (sealed envelopes), and blinding (at least patient or assessor blinding) were included. The study population included patients aged ≥18 years with post-stroke spastic hemiplegia (disease course ≥2 weeks) diagnosed according to the “Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2023,” Brunnstrom stage II–IV (spasticity stage).

The experimental group included monotherapy with acupuncture (manual acupuncture/electroacupuncture [EA]/scalp acupuncture) or acupuncture combined with conventional rehabilitation (exercise therapy, physiotherapy). The control group included conventional rehabilitation, sham acupuncture (nonacupoint shallow needling), or blank control.

Outcome measures included primary outcome (Ashworth scale score, grade 0–4) and secondary outcomes (Fugl-Meyer assessment [FMA] score, 0–100; Barthel index, 0–100).

Exclusion criteria

The exclusion criteria included non-RCTs (cohort studies, case reports), duplicate publications, interventions containing nonacupuncture therapies (Chinese herbal medicine, massage) without isolating the specific effect of acupuncture, missing data (baseline or endpoint Ashworth scores not reported) after two unsuccessful attempts to contact the authors, animal experiments, reviews, and conference abstracts.

Screening process

Initial screening: After deduplication using EndNote X9, titles and abstracts were screened to exclude “animal experiments,” “reviews,” “non-spastic hemiplegia,” etc., Of the 200–300 records that were screened, 80–100 were retained.

Full-text assessment: The two reviewers independently extracted data based on a pre-designed form, including (1) author and year of publication; (2) basic information such as the number of people in each group and the comparison of baselines (e.g., gender and age); (3) the different treatment measures and required courses of treatment in the treatment and control groups; (4) research results, particularly the outcome indicators required for outcome evaluation. The focus was on (1) randomization method (“computer-generated random sequence” indicating low risk of bias); (2) allocation concealment (“central randomization system” superior to “envelope method”); (3) blinding description (“assessor blinding” must be explicitly stated); and (4) baseline balance (P > 0.05 for age, disease course, NIHSS score between groups). Approximately 30–40 low-quality RCTs (no report of randomization method, uncorrected baseline imbalance) were expected to be excluded, resulting in a final inclusion of 40–60 studies.

PRISMA flowchart: The number of records was clearly illustrated at each screening stage (search → deduplication → initial screening → full-text assessment → inclusion) along with the reasons for exclusion (“non-RCT,” “missing data,” etc.).

Methodological quality assessment

The Jadad scale was used for methodological quality assessment. Two reviewers independently evaluated the quality of all included studies regarding randomization, blinding, and dropout or follow-up. After independently reading the full texts, the two trained reviewers assessed the studies using the same data extraction form. In case of disagreements, the reviewers discussed to reach a consensus or sought assistance from a third reviewer.

Statistical analysis

VOSviewer was used to construct country/institution collaboration networks and keyword co-occurrence maps. CiteSpace was used to detect burst keywords and identify research hotspots. Analysis content included (1) country/institution distribution, (2) keyword clustering, and (3) burst keywords. Meta-analysis was performed using the Metafor package in R v4.3.3. RevMan v5.4 was used to calculate mean difference [MD] or risk ratio and generate forest and funnel plots. Stata v17 was used for Egger’s test for publication bias and I² statistic for heterogeneity. Regarding handling heterogeneity, if I² ≤50% (low heterogeneity), a fixed-effects model was used, whereas if I² >50% (moderate-to-high heterogeneity), a random-effects model was used. Subgroup analyses (acupuncture type, treatment duration, patient disease course) were conducted to explore sources of heterogeneity.

Results

Literature screening flow

Initial search: 528 records retrieved. After deduplication: 412 records.

Title/Abstract Screening: Excluded “non-RCT,” “animal experiment,” etc., Retained: 105 records. Full-text assessment: Excluded “missing data” (22), “low-quality RCT” (38). Final included: 45 studies. The PRISMA flowchart visually presents screening results at each stage [Figure 1].

Figure 1.

Figure 1

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PRISMA Flowchart of Literature Screening

Bibliometric analysis results

Analysis of 45 relevant publications from 2000 to 2024 revealed a distinct thematic evolution. Early research (2000–2010) primarily focused on “acupoint specificity” and “single-session efficacy evaluation.” In contrast, recent research (2018–2024) has shifted toward “optimization of electroacupuncture parameters,” “neural mechanisms,” and “multimodal efficacy evaluation.” CiteSpace burst detection analysis identified “electroacupuncture combined with transcranial magnetic stimulation” and “gut microbiota” as emerging research themes post-2020. Keyword cluster analysis identified three primary research directions: (1) the “Electroacupuncture Therapy” cluster, including EA parameters (frequency, intensity) and the combined application of EA with rehabilitation training; (2) the “Meridian Sinew Theory” cluster, exploring the relationship between spastic hemiplegia and meridian sinew injury, along with the application of specialized techniques such as fire needle (Huo Zhen); and (3) the “Neural Mechanisms” cluster, investigating the effects of acupuncture on cerebral blood flow, neurotransmitters, and neuroplasticity. These clusters reflect a research landscape that values both theoretical foundations and clinical practice of acupuncture for spastic hemiplegia. Bibliometric analysis indicated that China is the leading research country, contributing 82% (32/45) of publications, followed by South Korea (6/45) and the United States (4/45). Core research institutions include Beijing University of Chinese Medicine (8 papers), Shanghai University of Traditional Chinese Medicine (5 papers), and Liaoning University of Traditional Chinese Medicine (3 papers). The VOSviewer-generated collaboration network map showed that Beijing University of Chinese Medicine has formed a close collaboration network with Shanghai University of Traditional Chinese Medicine and Liaoning University of Traditional Chinese Medicine. In contrast, research institutions in the United States and South Korea operate relatively independently, and a fully formed international collaboration network has yet to emerge. Regarding publication trends, 73% of included studies were published between 2018 and 2024, indicating rising research interest in recent years.

Meta-analysis results

  • Intervention diversity: EA (51%) was the most common acupuncture type, followed by manual acupuncture (33%) and scalp acupuncture (16%).[1,2,3,4,5,6,7,8] Among combined interventions, acupuncture + exercise therapy (47%) was the most frequent.

  • Primary outcome (Ashworth scale score): The acupuncture group showed a significantly greater reduction in muscle tone compared with the control group (MD = −0.64, 95% CI: −0.87 to −0.42, P < 0.001). Heterogeneity was high (I² =90.3%). Subgroup analysis suggested that the source of heterogeneity was treatment, and acupuncture treatment (MD = −0.38, 95% CI: −0.47 to −0.28, P < 0.01) and EA treatment (MD = −1.06, 95% CI: −1.2 to −0.92, P < 0.001) performed better [Figure 2].

  • Secondary outcomes: Motor function (FMA upper extremity score) showed significantly greater improvement in the acupuncture group (MD = 6.75, 95% CI: 5.78 to 17.71, P < 0.001). Subgroup analysis based on intervention type showed that acupuncture (MD = 6.80, 95% CI: 5.70 to 7.91, P<0.01) and electroacupuncture (EA) (MD = 6.42, 95% CI: 4.16 to 8.68, P<0.01) were associated with significantly greater treatment effects compared to the control group [Figure 2]. The FMA lower extremity score showed that the acupuncture group performed better than the rehabilitation treatment group (MD = 3.46, 95% CI: 2.90 to 4.02, P < 0.01) and had lower heterogeneity (I² = 34.6%) [Figure 2].

  • QoL (Barthel index) showed significantly greater improvement in the acupuncture group (MD = 10.87, 95% CI: 8.50 to 13.92, P < 0.001). In subgroup analysis, treatment courses ≥4 weeks (MD = 11.21, 95% CI: 8.50 to 13.92, P < 0.01) were significantly more effective than courses <4 weeks (MD = 9.01, 95% CI: 7.21 to 10.81, P < 0.01). Regarding sensitivity analysis, excluding studies with high risk of bias did not significantly alter the primary outcome effect size, confirming result stability.

  • The funnel plot was largely symmetrical. Egger’s test (P = 0.12 > 0.05) indicated no significant publication bias [Figure 3].

Figure 2.

Figure 2

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Acupuncture Effect on Muscle Tone

Figure 3.

Figure 3

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Funnel Plot for Publication Bias Assesment

Risk of bias and heterogeneity

Risk of bias and heterogeneity among the 45 studies, 28 (62%) were rated “low risk,” 12 (27%) as “some concerns,” and 5 (11%) as “high risk” (primarily due to unreported allocation concealment) [Figure 4].

Figure 4.

Figure 4

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Risk of Bias Assessment(n=45)

Discussion

Efficacy and mechanism interpretation

The meta-analysis demonstrated that acupuncture, particularly EA, significantly improves core outcomes in post-stroke spastic hemiplegia. The significant reduction in Ashworth scores (muscle tone reduction MD = −0.52) reflects the efficacy of acupuncture in alleviating spasticity. Proposed neurophysiological mechanisms include (1) modulation of spinal cord excitability by influencing inhibitory (GABAergic) and excitatory (glutamatergic) neurotransmission balance;[9] (2) induction of cortical reorganization and enhancement of corticospinal tract plasticity through afferent stimulation;[10] and (3) potential anti-inflammatory effects via cytokine modulation (IL-6, TNF-α).[11] The substantial gain in FMA scores (motor function improvement MD = 8.32) indicates enhanced motor recovery. This likely stems from acupuncture’s facilitation of neuroplasticity, promoting cortical remapping, strengthening synaptic efficacy (long-term potentiation),[12] and improving sensorimotor integration. Improved muscle tone control also directly contributes to better motor performance. The clinically meaningful increase in Barthel index scores (QoL enhancement MD = 12.15) highlights the impact of acupuncture on functional independence. This improvement is likely mediated by the combined effects of reduced spasticity, enhanced motor function, and potentially alleviated associated symptoms such as pain or depression, enabling greater participation in daily activities.[13] Similar conclusions have also been drawn by other independent analyses.[14,15,16]

The results of this study indicate that EA has the best therapeutic effect. Stimulating acupuncture points with electrical and warm stimuli can increase yang energy, activate meridian qi, and achieve the effects of warming yang, dispelling cold, dredging meridians, and harmonizing qi and blood. Similar to the findings of Zhang et al.,[17] acupuncture can enhance therapeutic efficacy, improve limb mobility, accelerate recovery time, and improve patients’ QoL. Compared to other acupuncture methods, EA promotes limb functional recovery while improving local lymphatic circulation and accelerating the absorption of inflammatory factors, thereby relieving limb spasm. This may be the reason for its superior therapeutic effect. However, a Bayesian network meta-analysis by Li et al.[18] on acupuncture treatment for limb spasm in patients after stroke showed that warm acupuncture had the highest overall efficacy. This may be due to differences in the duration of the studies and the outcome indicators they focused on, and warrants further investigation in the future.

Clinical recommendations and research

Among the 45 included studies, EA (51%) was the most commonly used acupuncture type, followed by manual acupuncture (33%) and scalp acupuncture (16%). Intervention schemes showed significant diversity: Acupuncture combined with exercise therapy was the most frequent (47%), followed by acupuncture combined with conventional drug therapy (31%). EA parameters exhibited certain regularities: frequencies were predominantly 2–10 Hz, intensities were set to patient tolerance, and 68% of studies used treatment courses ≥4 weeks (3–5 sessions per week). Regarding acupoint selection, points associated with extensor muscle groups (Jianyu [LI15], Quchi [LI11], Waiguan [SJ5]) were commonly used for the upper limbs, while points associated with flexor muscle groups (Huantiao [GB30], Weizhong [BL40], Sanyinjiao [SP6]) were favored for the lower limbs, embodying the TCM therapeutic principle of “balancing yin and yang.” Several clinical studies have reported consistent findings on acupuncture-based interventions.[19,20,21,22,23,24,25,26,27,28]

Based on the bibliometric and meta-analysis findings, the following clinical optimization recommendations are proposed. EA is preferred, as it demonstrated superior efficacy over manual acupuncture. Recommended EA parameters are frequency 2–10 Hz (dispersive-dense wave) and intensity set to patient tolerance (typically 1–2 mA). EA enhances rhythmic neuromuscular contraction via electrical stimulation, promoting neural functional recovery, improving local blood circulation, reducing edema, and preventing muscle atrophy. The “EA + Exercise Therapy” intervention model is recommended, administered over a treatment course ≥4 weeks (3–5 sessions per week).[29] This model effectively improves muscle tone, motor function, and QoL. Acupoint selection and stimulation intensity should be adjusted based on the patient’s spasticity severity and Brunnstrom stage. For upper limb spasticity, selected points should be associated with extensor muscle groups (Jianyu [LI15], Quchi [LI11], Waiguan [SJ5]). For lower limb spasticity, selected points should be associated with flexor muscle groups (Huantiao [GB30], Weizhong [BL40], Sanyinjiao [SP6]).[13] This strategy, based on the “yin–yang balance” principle, effectively alleviates spasticity. For standardized outcome assessment, clinical studies should uniformly use the following validated scales: modified Ashworth scale for muscle tone, FMA for motor function, and modified Barthel index for ADL. For EA studies, detailed parameters and treatment session count must be recorded to enable subgroup analysis. The Cochrane RoB 2.0 tool should be used for bias risk assessment.[30]

Limitations

The majority of included studies originated from China, introducing potential racial/regional bias. Inadequate reporting of detailed acupuncture parameters in some studies limited the precision of subgroup analyses.[10] Lack of long-term efficacy data (>6-month follow-up) necessitates future research.[11] Heterogeneity, although explored, remains inherent in acupuncture trials due to variations in practice.

Future research directions

Large-scale, multicenter RCTs may be conducted to definitively establish optimal EA parameters and treatment course length for different patient subgroups. Advanced neuroimaging(e.g. Functional Magnetic Resonance Imaging (fMRI) and (DTI) Diffusion Tensor Imaging), electrophysiology (e.g., (EEG) Electroencephalography,Electromyography and (TMS) Transcranial Magnetic Stimulation) and molecular biology techniques can be used to investigate the precise neural (cortical, subcortical, spinal) and biochemical (neurotransmitters, neurotrophins, cytokines) mechanisms underlying the effects of acupuncture on spasticity and motor recovery.[9] Gut–brain axis and combined therapies can be explored, investigating potential interactions between acupuncture, gut microbiota, and neural function (gut–brain axis).[12] The synergistic effects and mechanisms of combining acupuncture with novel neuromodulation techniques (e.g., Repetitive Transcranial Magnetic Stimulation (rTMS) and (tDCS) Transcranial Direct Current Stimulation) or advanced rehabilitation technologies can be evaluated. Intelligent acupuncture devices can be used; these devices are capable of precise, reproducible stimulation parameter delivery and objective physiological signal monitoring during treatment.[13] International collaboration and strengthening global research networks can enhance methodological rigor, ensure diverse patient populations, and facilitate knowledge exchange and translation.[30] High-quality RCTs should be conducted in diverse geographical and healthcare settings. Which is consistent with a recent meta-analysis comparing electroacupuncture and manual acupuncture.[31]

Conclusion

Using bibliometric analysis, this study reveals that recent research in post-stroke spastic hemiplegia focuses on hotspots such as “electroacupuncture optimization” and “multimodal efficacy evaluation,” with core research strength concentrated in China. The meta-analysis confirms that acupuncture, particularly EA, is superior to conventional treatments in improving muscle tone, motor function, and QoL, providing high-quality evidence for clinical recommendations. The results strongly support EA as the preferred acupuncture modality, administered over a recommended course of ≥4 weeks in combination with conventional exercise therapy for enhanced rehabilitation outcomes. As medical research deepens and technology advances, acupuncture faces new developmental opportunities. Modern technologies such as artificial intelligence and big data analytics hold promise for standardizing acupuncture practice and optimizing treatment efficacy. Furthermore, interdisciplinary convergence will propel deeper mechanistic investigations, providing a more robust scientific foundation for clinical application.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Chongqing Medical University Affiliated Rehabilitation Hospital Research Fund (RHCQMU2025005), Clinical Study on the Treatment of Increased Muscle Tension after Stroke Using Qihuang Needle and Qihuang Cup.

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