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Flow diagram.
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Figure 1

Flow diagram.

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Funnel plot of comparison: 1 Acupuncture versus control, outcome: 1.1 Death or dependency at end of follow‐up.
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Figure 2

Funnel plot of comparison: 1 Acupuncture versus control, outcome: 1.1 Death or dependency at end of follow‐up.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Acupuncture versus control, Outcome 1 Death or dependency at end of follow‐up.
Figuras y tablas -
Analysis 1.1

Comparison 1 Acupuncture versus control, Outcome 1 Death or dependency at end of follow‐up.

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Comparison 1 Acupuncture versus control, Outcome 2 Death or dependency at end of follow‐up (> 3 months).
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Analysis 1.2

Comparison 1 Acupuncture versus control, Outcome 2 Death or dependency at end of follow‐up (> 3 months).

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Comparison 1 Acupuncture versus control, Outcome 3 Death or institutional care at end of follow‐up.
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Analysis 1.3

Comparison 1 Acupuncture versus control, Outcome 3 Death or institutional care at end of follow‐up.

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Comparison 1 Acupuncture versus control, Outcome 4 Change in global neurological deficit score at end of treatment period.
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Analysis 1.4

Comparison 1 Acupuncture versus control, Outcome 4 Change in global neurological deficit score at end of treatment period.

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Comparison 1 Acupuncture versus control, Outcome 5 Motor function at end of acupuncture treatment period.
Figuras y tablas -
Analysis 1.5

Comparison 1 Acupuncture versus control, Outcome 5 Motor function at end of acupuncture treatment period.

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Comparison 1 Acupuncture versus control, Outcome 6 Motor function at end of follow‐up (> 3 months).
Figuras y tablas -
Analysis 1.6

Comparison 1 Acupuncture versus control, Outcome 6 Motor function at end of follow‐up (> 3 months).

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Comparison 1 Acupuncture versus control, Outcome 7 Death within first 2 weeks.
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Analysis 1.7

Comparison 1 Acupuncture versus control, Outcome 7 Death within first 2 weeks.

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Comparison 1 Acupuncture versus control, Outcome 8 Death during whole follow‐up period.
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Analysis 1.8

Comparison 1 Acupuncture versus control, Outcome 8 Death during whole follow‐up period.

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Comparison 1 Acupuncture versus control, Outcome 9 Adverse events during treatment period.
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Analysis 1.9

Comparison 1 Acupuncture versus control, Outcome 9 Adverse events during treatment period.

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Comparison 2 Ischemic stroke versus hemorrhagic stroke, Outcome 1 Death or dependency at end of follow‐up.
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Analysis 2.1

Comparison 2 Ischemic stroke versus hemorrhagic stroke, Outcome 1 Death or dependency at end of follow‐up.

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Summary of findings for the main comparison. Acupuncture compared with all control (sham and open) for patients with acute stroke

Acupuncture compared with all control for patients with acute stroke

Patient or population: patients with acute stroke
Settings: rehabilitation after acute stroke for inpatients
Intervention: acupuncturea
Comparison: all control (sham and open)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Acupuncture

Death or dependency at end of follow‐up

Study population

OR 0.61
(0.46 to 0.79)

1582
(11 studies)

⊕⊝⊝⊝
very lowb,c

Dependency was defined as BI ≤ 60 (of a potential total of 100), BI ≤ 70 (of a potential total of 100), or BI ≤ 12 (of a potential total of 20). One trial used the trialists' own definition.

347 per 1000

245 per 1000
(196 to 296)

Death or dependency at end of follow‐up (> 3 months)

Study population

OR 0.67
(0.53 to 0.85)

1436
(8 studies)

⊕⊝⊝⊝
very lowb,d

Dependency was defined as BI ≤ 60 (of a potential total of 100), BI ≤ 70 (of a potential total of 100), or BI ≤ 12 (of a potential total of 20). One trial used the trialists' own definition.

325 per 1000

244 per 1000
(203 to 291)

Moderate

444 per 1000

349 per 1000
(297 to 404)

Death or institutional care at end of follow‐up

Study population

OR 0.78
(0.54 to 1.12)

1120
(5 studies)

⊕⊕⊝⊝
lowe

162 per 1000

131 per 1000
(94 to 178)

Changes in global neurological deficit score at end of treatment period

Mean change in global neurological deficit score at end of treatment period in intervention groups was
0.84 standard deviations higher
(0.36 to 1.32 higher).

1086
(12 studies)

⊕⊝⊝⊝
very lowf,g

Global neurological function was measured via modified Edinburgh‐Scandinavian Stroke Scale in 9 trials, NIHSS in 2, and SSS in 1.

Motor function at end of acupuncture treatment period

Mean motor function at end of acupuncture treatment period in intervention groups was
1.08 standard deviations higher
(0.45 to 1.71 higher).

895
(11 studies)

⊕⊝⊝⊝
very lowf,h

Motor function was measured via Fugl‐Meyer Assessment in 7 trials, Motricity Index in 1, motor function score in 1, Rivermead Mobility Index in 1, and mobility index in 1.

Death within first 2 weeks

Study population

OR 0.91
(0.33 to 2.55)

1612
(18 studies)

⊕⊕⊝⊝
lowi

10 per 1000

9 per 1000
(3 to 25)

Death during whole follow‐up period

Study population

OR 1.08
(0.74 to 1.58)

2865
(22 studies)

⊕⊕⊝⊝
lowj

45 per 1000

48 per 1000
(34 to 69)

Adverse events related to acupuncture

See comments.

See comments.

See comments.

(13 studies)

⊕⊕⊝⊝
lowk

The incidence of adverse events directly related to acupuncture (such as pain, dizziness, faint) was approximately 6.17% (64/1037 participants) in the acupuncture group, and 1.35% (14/1037 participants) discontinued acupuncture. AEs related to sham acupuncture occurred in 8.0% (24/298) of participants.

*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
AEs: adverse events; BI: Barthel Index; CI: confidence interval; NIHSS: National Institute of Health Stroke Scale; OR: odds ratio; RCTs: randomized controlled trials; SSS: Scandinavian Stroke Scale.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aOf the 33 included RCTs, the acupuncture treatment type and period were heterogeneous. The acupuncture treatment period ranged from one to three months. The acupoints varied across trials. The needling sensation could be provoked by manual stimulation or electrical stimulation.

bDowngraded one level for serious inconsistency: variation in the definition of dependency and acupuncture treatment type and duration.

cDowngraded two levels for very serious risk of bias: Among the 11 included trials, eight had risk of performance bias and seven had risk of detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

dDowngraded two levels for very serious risk of bias: Among the eight included trials, six had risk of performance bias and four had risk of detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

eDowngraded two levels for very serious risk of bias: Among the five included trials, four had risk of performance bias; the result was not consistent with the sensitivity analysis using only sham controls.

fDowngraded two levels for very serious inconsistency: considerable statistical heterogeneity (I2 > 50%) and variation in acupuncture treatment type and duration.

gDowngraded two levels for very serious risk of bias: Among the 13 included trials, at least eight trials had risk of allocation bias, performance bias, or detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

hDowngraded two levels for very serious risk of bias: Among the 11 included trials, at least six had risk of allocation bias, performance bias, or detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

iDowngraded two levels for very serious risk of bias: Among the 18 included trials, at least 10 trials had risk of allocation bias, performance bias, or detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

jDowngraded two levels for very serious risk of bias: Among the 22 included trials, at least 11 trials had risk of allocation bias, performance bias, or detection bias; the result was not consistent with the sensitivity analysis using only sham controls.

kDowngraded two levels for very serious inconsistency: variation between trials in reporting of adverse events and in acupuncture treatment type and duration.

Figuras y tablas -
Summary of findings for the main comparison. Acupuncture compared with all control (sham and open) for patients with acute stroke
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Summary of findings 2. Acupuncture compared with sham control for patients with acute stroke

Acupuncture compared with sham control for patients with acute stroke

Patient or population: patients with acute stroke
Settings: rehabilitation after acute stroke for inpatients
Intervention: acupuncture1
Comparison: sham control

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Acupuncture

Death or dependency at end of follow‐up

Study population

OR 0.71
(0.43 to 1.18)

262
(4 studies)

⊕⊕⊝⊝
low2,3

464 per 1000

384 per 1000
(264 to 404)

Death or dependency at end of follow‐up (> 3 months)

Study population

OR 0.67
(0.40 to 1.12)

244
(3 studies)

⊕⊕⊝⊝
low2,4

476 per 1000

376 per 1000
(256 to 496)

Death or institutional care at end of follow‐up

Study population

OR 0.47
(0.23 to 0.96)

145
(2 studies)

⊕⊕⊝⊝
low2,5

456 per 1000

286 per 1000
(126 to 476)

Changes in global neurological deficit score at end of treatment period

Mean change in global neurological deficit score at end of treatment period in intervention groups was
0.01 standard deviations higher
(0.55 lower to 0.57 higher).

53
(1 studies)

⊕⊕⊝⊝
low6

Motor function at end of acupuncture treatment period

Mean motor function at end of acupuncture treatment period in intervention groups was
0.10 standard deviations lower
(0.38 lower to 0.17 higher).

202
(3 studies)

⊕⊕⊝⊝
low2,7

Death within first 2 weeks

Study population

OR 1.20
(0.27 to 5.26)

378
(5 studies)

⊕⊕⊝⊝
low2,8

15 per 1000

4 per 1000
(0 to 45)

Death during whole follow‐up period

Study population

OR 0.90
(0.47 to 1.72)

668
(6 studies)

⊕⊕⊝⊝
low2,9

79 per 1000

79 per 1000
(59 to 99)

Adverse events related to acupuncture

See comments.

See comments.

OR 0.58 (0.29 to 1.16)

576

(5 studies)

⊕⊕⊝⊝
low2,10

The incidence of adverse events directly related to acupuncture (such as pain, dizziness, faint) was approximately 8.0% (24/298) in sham acupuncture patients.

*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio; RCTs: randomized controlled trials.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aOf the 33 included RCTs, the acupuncture treatment type and period were heterogeneous. The treatment period for acupuncture ranged from one to three months. Acupoints varied across trials. The needling sensation could be provoked by manual stimulation or electrical stimulation.

bDowngraded one level for serious imprecision: small number of studies and wide confidence intervals.

cDowngraded one level for serious risk of bias: Among the four included trials, two trials had risk of performance bias or attrition bias.

dDowngraded one level for serious risk of bias: Among the three included trials, one trial had risk of performance bias.

eDowngraded one level for serious risk of bias: Among the two included trials, one trial had risk of performance bias.

fDowngraded two levels for very serious imprecision: single study and very wide confidence intervals.

gDowngraded one level for serious risk of bias: Among the three included trials, at least two trials had risk of performance bias or attrition bias.

hDowngraded one level for serious risk of bias: Among the five included trials, at least two trials had risk of performance bias or attrition bias.

iDowngraded one level for serious risk of bias: Among the six included trials, at least two trials had risk of performance bias or attrition bias.

jDowngraded one level for serious inconsistency: Reporting of adverse events varied between trials.

Figuras y tablas -
Summary of findings 2. Acupuncture compared with sham control for patients with acute stroke
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Comparison 1. Acupuncture versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death or dependency at end of follow‐up Show forest plot

11

1582

Odds Ratio (M‐H, Random, 95% CI)

0.61 [0.46, 0.79]

1.1 Acupuncture vs sham acupuncture

4

262

Odds Ratio (M‐H, Random, 95% CI)

0.71 [0.43, 1.18]

1.2 Acupuncture vs open control

8

1320

Odds Ratio (M‐H, Random, 95% CI)

0.55 [0.37, 0.80]

2 Death or dependency at end of follow‐up (> 3 months) Show forest plot

8

1436

Odds Ratio (M‐H, Random, 95% CI)

0.67 [0.53, 0.85]

2.1 Acupuncture vs sham acupuncture

3

244

Odds Ratio (M‐H, Random, 95% CI)

0.67 [0.40, 1.12]

2.2 Acupuncture vs open control

6

1192

Odds Ratio (M‐H, Random, 95% CI)

0.62 [0.42, 0.93]

3 Death or institutional care at end of follow‐up Show forest plot

5

1120

Odds Ratio (M‐H, Random, 95% CI)

0.78 [0.54, 1.12]

3.1 Acupuncture vs sham acupuncture

2

145

Odds Ratio (M‐H, Random, 95% CI)

0.47 [0.23, 0.96]

3.2 Acupuncture vs open control

4

975

Odds Ratio (M‐H, Random, 95% CI)

0.93 [0.61, 1.42]

4 Change in global neurological deficit score at end of treatment period Show forest plot

12

1086

Std. Mean Difference (IV, Random, 95% CI)

0.84 [0.36, 1.32]

4.1 Acupuncture vs sham acupuncture

1

53

Std. Mean Difference (IV, Random, 95% CI)

0.01 [‐0.55, 0.57]

4.2 Acupuncture vs open control

12

1033

Std. Mean Difference (IV, Random, 95% CI)

0.91 [0.41, 1.41]

5 Motor function at end of acupuncture treatment period Show forest plot

11

895

Std. Mean Difference (IV, Random, 95% CI)

1.08 [0.45, 1.71]

5.1 Acupuncture vs sham acupuncture

3

202

Std. Mean Difference (IV, Random, 95% CI)

‐0.10 [‐0.38, 0.17]

5.2 Acupuncture vs open control

8

693

Std. Mean Difference (IV, Random, 95% CI)

1.52 [0.70, 2.34]

6 Motor function at end of follow‐up (> 3 months) Show forest plot

3

186

Std. Mean Difference (IV, Random, 95% CI)

0.08 [‐0.21, 0.37]

6.1 Acupuncture vs sham acupuncture

2

144

Std. Mean Difference (IV, Random, 95% CI)

‐0.02 [‐0.35, 0.31]

6.2 Acupuncture vs open control

1

42

Std. Mean Difference (IV, Random, 95% CI)

0.44 [‐0.18, 1.05]

7 Death within first 2 weeks Show forest plot

18

1612

Odds Ratio (M‐H, Random, 95% CI)

0.91 [0.33, 2.55]

7.1 Acupuncture vs sham acupuncture

5

378

Odds Ratio (M‐H, Random, 95% CI)

1.20 [0.27, 5.26]

7.2 Acupuncture vs open control

14

1234

Odds Ratio (M‐H, Random, 95% CI)

0.71 [0.17, 2.96]

8 Death during whole follow‐up period Show forest plot

22

2865

Odds Ratio (M‐H, Random, 95% CI)

1.08 [0.74, 1.58]

8.1 Acupuncture vs sham acupuncture

6

668

Odds Ratio (M‐H, Random, 95% CI)

0.90 [0.47, 1.72]

8.2 Acupuncture vs open control

17

2197

Odds Ratio (M‐H, Random, 95% CI)

1.19 [0.74, 1.91]

9 Adverse events during treatment period Show forest plot

5

576

Odds Ratio (M‐H, Random, 95% CI)

0.58 [0.29, 1.16]
Figuras y tablas -
Comparison 1. Acupuncture versus control
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Comparison 2. Ischemic stroke versus hemorrhagic stroke

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death or dependency at end of follow‐up Show forest plot

6

1094

Odds Ratio (M‐H, Random, 95% CI)

0.71 [0.54, 0.94]

1.1 Death or dependency in hemorrhagic stroke

1

60

Odds Ratio (M‐H, Random, 95% CI)

0.38 [0.13, 1.08]

1.2 Death or dependency in ischemic stroke

5

1034

Odds Ratio (M‐H, Random, 95% CI)

0.75 [0.56, 1.00]
Figuras y tablas -
Comparison 2. Ischemic stroke versus hemorrhagic stroke
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