We have read with interest the paper by Wang et al., titled “Use of acupuncture in stroke and stroke complications: a systematic review and meta-analysis based on sham-controlled trials,” recently published in Frontiers in Neurology (1). This study, based on 24 randomized controlled trials (RCTs) involving 2,310 patients, suggested that acupuncture was a promising treatment for stroke and stroke complications, as it was shown to significantly improve the quality of life, neurological function, and depressive symptoms of patients in comparison to sham acupuncture. We appreciate the authors' contributions to this field; however, we have some suggestions for improvement.
First, the literature search, which covered seven electronic databases, identified 24 included trials, 23 of which originated from China and only one from the Republic of Korea, indicating a notable geographic bias. According to Jüni et al., evidence derived from single-country trials carries a higher risk of bias toward exaggerated benefits and has limited external validity (2). In addition, the majority of the included trials were single-center studies with total sample sizes below 100, suggesting that the pooled outcomes may be inflated due to small-study effects (SSE), which can result from publication bias (3). Consequently, the above risks of bias represent a major limitation that casts doubt on the validity of the overall findings.
Second, the included studies involved different stroke types, such as cerebral infarction and intracerebral hemorrhage, as well as various acupuncture therapies and disease courses, introducing considerable heterogeneity into the pooled outcomes (4). According to Okuda et al., researchers should consider different stroke types when developing clinical treatment strategies for stroke patients, as patients with intracerebral hemorrhage require a longer recovery period than those with cerebral infarction (5). Furthermore, the authors exhibited a critical oversight in the standardization of intervention dosage. A clear example of this is the difference between Boyang et al. (6), who employed a continuous wave of 2 Hz, and Ma et al. (7), who utilized a dilatational wave of 2/15 Hz. A study by Yao et al. found that using a lower frequency of electroacupuncture can more effectively improve motor function after focal cerebral infarction in rats, as evidenced by the shortened latent period and increased wave amplitude of motor evoked potentials (8). The limitations above constitute a major source of heterogeneity, urging caution in interpreting the pooled results and diminishing confidence in the findings.
Finally, the majority of the included trials lacked follow-up after treatment. Stroke is a common and serious disease that can lead to long-term disability; hence, long-term follow-up is essential for evaluating the efficacy of acupuncture (9). However, among the 24 included RCTs, only three trials conducted follow-up over 6 months after treatment and reported the clinical outcomes. Thus, the evidence based on these studies was insufficient to evaluate the long-term efficacy of acupuncture in stroke and its complications.
In summary, although limited by certain methodological issues, the authors' work nonetheless offers a comprehensive evaluation to date of the efficacy and safety of acupuncture treatment in stroke and stroke complications. We hope that future studies will build upon this foundational work by using more rigorous methodologies to validate and extend these findings.
Statements
Author contributions
RW: Conceptualization, Formal analysis, Methodology, Writing – original draft. YZ: Supervision, Writing – review & editing. LX: Supervision, Writing – review & editing.
Funding
The author(s) declared that financial support was not received for this work and/or its publication.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The author(s) declared that generative AI was not used in the creation of this manuscript.
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References
1.
Wang X Li J Yao K Cheng Z Jiang T Liu W et al . Use of acupuncture in stroke and stroke complications: a systematic review and meta-analysis based on sham-controlled trials. Front Neurol. (2025) 16:1668497. doi: 10.3389/fneur.2025.1668497
2.
Jüni P Holenstein F Sterne J Bartlett C Egger M . Direction and impact of language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol. (2002) 31:115–23. doi: 10.1093/ije/31.1.115
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Hong C Salanti G Morton SC Riley RD Chu H Kimmel SE et al . Testing small study effects in multivariate meta-analysis. Biometrics. (2020) 76:1240–50. doi: 10.1111/biom.13342
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Lillo-Albert G Boscà I Robledo A Pous-Serrano S . Assessment of heterogeneity in meta-analysis. Cir Esp (Engl Ed). (2024) 102:448–50. doi: 10.1016/j.cireng.2024.03.010
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Okuda Y Aoike F . Functional recovery of patients with intracerebral haemorrhage and cerebral infarction after rehabilitation. Int J Rehabil Res. (2021) 44:222–5. doi: 10.1097/MRR.0000000000000476
6.
Boyang Z Yang Z Liyuan F Dan S Lei HE Dan T et al . A neural regulation mechanism of head electroacupuncture on brain network of patients with stroke related sleep disorders. J Tradit Chin Med. (2024) 44:1268–76. doi: 10.19852/j.cnki.jtcm.2024.06.011
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Ma F Cao G Lu L Zhu Y Li W Chen L . Electroacupuncture versus escitalopram for mild to moderate post-stroke depression: a randomized non-inferiority trial. Front Psychiatry. (2024) 15:1332107. doi: 10.3389/fpsyt.2024.1332107
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Yao WP Wang S Han L Ma JQ Shen Y . Effects of different frequencies of electro-acupuncture at shuigou (GV 26) on recovery of motor function in rats with focal cerebral ischemic injury. J Tradit Chin Med. (2012) 32:99–104. doi: 10.1016/S0254-6272(12)60040-5
9.
Singh B Huang D . The role of circadian rhythms in stroke: a narrative review. Neurochem Res. (2024) 49:290–305. doi: 10.1007/s11064-023-04040-5
Summary
Keywords
acupuncture, commentary, meta-anaiysis, sham-controlled trial, stroke
Citation
Wang R, Zhao Y and Xuan L (2026) Commentary: Use of acupuncture in stroke and stroke complications: a systematic review and meta-analysis based on sham-controlled trials. Front. Neurol. 17:1750747. doi: 10.3389/fneur.2026.1750747
Received
20 November 2025
Revised
24 January 2026
Accepted
05 February 2026
Published
18 February 2026
Volume
17 - 2026
Edited by
Ahmed Negida, Virginia Commonwealth University, United States
Reviewed by
Yasmin Negeda, Virginia Commonwealth University, United States
Updates
Copyright
© 2026 Wang, Zhao and Xuan.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Yibin Zhao, 510496772@qq.com; Lihua Xuan, xlh1083@163.com
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.