Meta-analysis and acupoint selection patterns of acupuncture for post-stroke foot drop

Foot drop is a common complication of stroke, often causing difficulties in walking, restricted mobility, and reduced independence and quality of life. Timely systematic treatment for patients with foot drop after stroke is essential to restore foot function and improve quality of life. Acupuncture, as one of the traditional therapies in traditional Chinese medicine is widely used as an adjunctive rehabilitation intervention. However, the clinical efficacy and potential therapeutic prescriptions of acupuncture for foot drop after stroke remain unclear. Therefore, the purpose of this study was to evaluate the effects of acupuncture-based interventions for post-stroke foot drop and characterize acupoint selection patterns.

We searched eight databases, namely, Embase, PubMed, Web of Science, Cochrane Library, Wanfang Database, China National Knowledge Infrastructure, VIP Database, and China Biology Medicine Database, from inception to January 2025. Randomized controlled trials evaluating acupuncture-based interventions for post-stroke foot drop were included. Studies were included or excluded based on prespecified eligibility criteria. The included studies were assessed for quality using the Cochrane Risk of Bias tool, and certainty of evidence was assessed using GRADE. The primary outcome measure was the Fugl-Meyer Assessment (FMA). Secondary outcomes included clinical effective rate, active range of motion (AROM), tibialis anterior electromyography (EMG), Barthel Index (BI), Berg Balance Scale (BBS), Modified Ashworth Scale (MAS), triceps surae muscle tone (TSMT), Functional Ambulation Category (FAC), and co-contraction ratio during ankle dorsiflexion (CR). Meta-analysis was performed using RevMan V5.3 software, and acupoint selection patterns were analyzed using IBM SPSS Statistics 18.0 and 28.0. To address clinical differences among interventions, studies were analyzed separately as traditional acupuncture, electroacupuncture, and special acupuncture techniques.

A total of 59 relevant studies were included, with 4,596 participants; 2,290 received conventional treatment alone, and 2,306 received acupuncture-based interventions in addition to conventional treatment. To reduce clinical heterogeneity associated with different acupuncture modalities, studies were stratified into traditional acupuncture, electroacupuncture, and special acupuncture subgroups for quantitative synthesis. Traditional acupuncture and electroacupuncture were both associated with improved FMA scores compared with conventional treatment alone [mean difference (MD) = 6.25, 95% confidence interval (CI) 5.11-7.40, p < 0.00001; MD = 7.99, 95% CI 6.05-9.93, p < 0.00001, respectively]. Favorable effects were also observed for AROM, MAS, BBS, BI, and other functional outcomes in modality-specific analyses. Traditional acupuncture was associated with improved EMG and FAC scores and reduced TSMT and CR, whereas evidence for special acupuncture techniques was limited for most outcomes. The three most frequently used acupoints were Yanglingquan (GB34; 37 times, 9.37%), Zusanli (ST36; 37 times, 9.37%), and Jiexi (ST41; 31 times, 7.85%). Substantial heterogeneity was observed for several outcomes, and the certainty of evidence ranged from moderate to low. Exploratory publication bias assessments suggested possible small-study effects for selected outcomes; notably, the adjusted estimate for clinical effective rate crossed the line of no effect. Adverse events were insufficiently reported to permit a reliable assessment of safety.

Traditional acupuncture and electroacupuncture may provide additional functional benefits when used alongside conventional treatment for post-stroke foot drop. However, substantial heterogeneity, predominantly unclear or high risk of bias, possible small-study effects, and moderate-to-low certainty of evidence limit confidence in the precise magnitude of benefit and preclude conclusions regarding the superiority of specific acupuncture modalities or prescriptions. Larger, rigorously designed, and transparently reported randomized controlled trials are needed to confirm efficacy, clarify comparative effectiveness, and adequately assess safety.

The PROSPERO registration number is CRD42024520076.