Commentary: Use of acupuncture in stroke and stroke complications: a systematic review and meta-analysis based on sham-controlled trials

Abstract

510496772@qq.com 13 Lihua Xuan 14 xlh1083@163.com 15 16 We have read with interest the paper by Wang et al., titled "Use of acupuncture in 18 stroke and stroke complications: a systematic review and meta-analysis based on 19 sham-controlled trials", recently published in Frontiers in Neurology (1). This study, 20 based on 24 randomized controlled trials (RCTs) involving 2310 patients, suggested 21 that acupuncture was a promising treatment for stroke and stroke complications, as it 22 was shown to significantly improve the life quality, neurological function, and 23 depressive symptoms in patients compared with sham acupuncture. We appreciate the 24 author's contributions to this field; however, we have some suggestions for 25 First, the literature search, which covered seven electronic databases, yielded 24 27 included trials, 23 of which originated from China and only one from Korea, resulting 28 in notable geographic bias. According to Jüni et al., the evidence based on single-29 country trials shows a higher risk of bias toward exaggerated benefits and has limited 30 external validity (2). In addition, most of the included trials were single-center with 31 total sample sizes below 100, suggesting that the pooled outcomes are more likely to 32 be overestimated by small study effects (SSE), which may result from publication 2 bias (3). Consequently, the above risk of bias represents a major limitation, casting 34 doubt on the validity of the overall findings. 35Second, the included studies covered different stroke types, such as cerebral infarction 36 and intracerebral hemorrhage, acupuncture therapies, and disease courses, which 37 introduced considerable heterogeneity into the pooled outcomes (4). According to 38 employing lower frequency of electroacupuncture can more effectively improve the 46 motor function after focal cerebral infarction in rats, as evidenced by the shortened 47 latent period and increased wave amplitude of motor evoked potentials (8). The 48 limitations above constitute a major source of heterogeneity, urging caution in 49 interpreting the pooled results and diminishing the confidence in the findings. 50Finally, the majority of included trials lacked follow-up after treatment. Stroke is a 51 common serious disease that can lead to long-term disability, hence the long-term 52 follow-up is essential for evaluating the efficacy of acupuncture (9). However, among 53 the 24 included RCTs, only 3 trials conducted follow-up over 6 months after 54 treatment and reported the clinical outcomes. Therefore, the evidence based on these 55 studies was insufficient to evaluate the long-term efficacy of acupuncture in stroke 56 and its complications. 57In summary, although limited by some methodological issues, the author's work 58 nonetheless offers a comprehensive evaluation to date of the efficacy and safety of 59 acupuncture treatment in stroke and stroke complications. We hope that future studies 60 will build upon this foundational work by employing more rigorous methodologies to 61 validate and extend these findings. 62