Authors: Jie Zhao, Janita Pak Chun Chau, Wenli Wang, Kai Chow Choi, Rong He, Yali Zhao, Suzanne Hoi Shan Lo
Categories: Article, Stroke, Complex regional pain syndromes, Shoulder pain, Pain management, Acupuncture
Source: International Journal of Nursing Studies Advances
Authors: Jie Zhao, Janita Pak Chun Chau, Wenli Wang, Kai Chow Choi, Rong He, Yali Zhao, Suzanne Hoi Shan Lo
Shoulder-hand syndrome is one of the most common post-stroke complications. It presents with a variety of symptoms, especially pain and a limited range of motion of the wrist and hand, which negatively affect an individual's quality of life and ability to complete daily tasks. Nurse-led complementary and alternative medicine approaches have been adopted in China to alleviate the pain and symptoms associated with shoulder-hand syndrome, and wrist-ankle acupuncture was reported to reduce pain by up to 96.2%.
We aimed to 1) evaluate the effectiveness of wrist-ankle acupuncture on post-stroke shoulder-hand syndrome, 2) identify the optimal dose of wrist-ankle acupuncture for post-stroke shoulder-hand syndrome.
Seventy-nine studies published in English or Chinese between 2001 and 2025 were retrieved from eight electronic databases. We also searched trials registries up to July 2025.
The Cochrane Risk of Bias 2.0 was used for quality assessment. The Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture was used to evaluate the reporting quality of included trials. The overall certainty of evidence and strength of the recommendation were assessed using the Grading of Recommendations Assessment, Development and Evaluation. Meta-analyses were conducted using RevMan 5.4.
Four studies, all conducted in China, were included in the meta-analysis. We found that, compared to usual care, wrist-ankle acupuncture may reduce shoulder pain (mean difference [MD] = -1.41, 95% confidence interval [CI] [-2.24, -0.58]), improve upper limb function (MD = 7.86, 95% CI [4.25, 11.46]) and improve activities of daily living (MD = 11.34, 95% CI [10.73, 11.94]).
Wrist-ankle acupuncture is a technique that nurses in China can perform independently and may effectively reduce shoulder pain associated with post-stroke shoulder-hand syndrome. For areas or countries where nurses are not allowed to perform this technique, we have offered insights into enabling nurses possibly to ensure patient safety and facilitate interprofessional collaboration in post-stroke rehabilitation. Although several acupuncture intervention parameters, including acupuncture point selection and needle retention time were consistently reported across the included studies, further high-quality, adequately powered randomised controlled trials are necessary to evaluate the acupuncture dose more thoroughly, as this information has broad clinical and research significance.
This study was registered in PROSPERO (CRD420251042530).
What is already known •One of the stroke-related upper limb function disorders with a high incidence rate is shoulder-hand syndrome.•Symptoms of post-stroke shoulder-hand syndrome include pain, swelling, limited range of motion of the wrist and hand, hyperalgesia, allodynia, and warmth and redness of the wrist and hand, all of which adversely affect stroke survivors’ re-integration into normal life and result in poor quality of life.•Wrist-ankle acupuncture is currently being promoted in clinical practice, especially in traditional Chinese medicine hospitals in China, as part of traditional Chinese medicine nursing. Alt-text: Unlabelled box dummy alt text What this paper adds •We found low‐certainty evidence that the use of wrist-ankle acupuncture was slightly more beneficial than conventional rehabilitation in relieving shoulder pain and improving upper limb function and activities of daily living.•In the limited trials we synthesised, the consistent dose for wrist-ankle acupuncture was 30 min per session, one session per day, and 5 days per week. Alt-text: Unlabelled box dummy alt text
According to the latest Global Burden of Disease report, stroke remains the third leading cause of death and disability combined (GBD Stroke Risk Factor Collaborators, 2024). The number of people who experience a stroke, die from it, or live with a disability after a stroke has increased significantly worldwide between 1990 and 2021. The estimated global cost of stroke exceeds US$ 890 billion (0.66% of the global gross domestic product) annually and is projected to nearly double by 2050 (Feigin et al., 2025). One of the stroke-related upper limb function disorders with a high incidence rate is shoulder-hand syndrome. It primarily results from the physical disability caused by stroke, which, in turn, causes the survivors to lose their ability to care for themselves and increases the economic burden on their families and society. Shoulder-hand syndrome is classified as complex regional pain syndrome type 1 (Pertoldi and Di Benedetto, 2005) and is one of the most common post-stroke complications. Previous researchers have reported that the prevalence of post-stroke shoulder-hand syndrome ranges from 12.5% to 50.0% (Katsura et al., 2022). Symptoms of post-stroke shoulder-hand syndrome include pain, swelling, limited range of motion of the wrist and hand, hyperalgesia, allodynia, and warmth and redness of the wrist and hand (Pertoldi and Di Benedetto, 2005), all of which adversely affect stroke survivors’ re-integration into normal life and result in poor quality of life. Pain has been regarded as the fifth vital sign of human beings, and pain management is a doctor-nurse collaboration programme that can be led by nurses. Wrist-ankle acupuncture is one of the emerging pain management programmes that nurses can lead in mainland China (The First Affiliated Hospital of Henan University of Chinese Medicine, 2025; Tongji Hospital, 2025). We acknowledge that acupuncture is not within the scope of nurses' practice in most countries, including China. However, wrist-ankle acupuncture is a special type of acupuncture. It solely employs acupuncture needles to perform shallow subcutaneous needling (Zhang et al., 2002). The procedure is similar to subcutaneous injections administered by nurses, for which nurses in China are approved to perform acupuncture independently upon meeting the educational and training requirements. We aimed to provide insight into promotion of the independent practice of wrist-ankle acupuncture by nurses, allowing more patients to benefit from this pain management technique. For areas where nurses are not currently permitted to perform wrist-ankle acupuncture independently, understanding these techniques may also help ensure safety of stroke patients with shoulder-hand syndrome receiving wrist-ankle acupuncture.
Wrist-ankle acupuncture is a new therapy that has been inspired by traditional meridian theory, acupoints, and acupuncture techniques. It is a distinctive acupuncture treatment that solely employs acupuncture needles to perform shallow subcutaneous needling at specific areas of the wrist and ankle along the longitudinal axis of the limb (Zhang et al., 2002). Essentially, each side of the body is divided into six longitudinal areas and six acupuncture points on the wrist and ankle are set on each side (Supplementary Material File 1). The areas and points are all labelled with the same number. The acupuncture points are selected based on the area where the symptoms manifest, and superficial subcutaneous needling is performed. During the wrist-ankle acupuncture implementation process, there is no need to cause negative sensations, such as soreness, numbness, swelling, or pain; however, the therapeutic effect can still be achieved (Wang and Zhou, 2017). According to the results of data mining and bibliometrics study, the overall effective rate of wrist-ankle acupuncture in pain relief reached 96.2%, and it was widely used in mainland China, primarily led by nurses (Hai et al., 2023; Yang et al., 2019). It is postulated that a potential difference signal in the skin receptors may be generated during wrist-ankle acupuncture, and this signal influences the neural centres at all levels during its transmission to the cerebral cortex (Li et al., 2011). Researchers have also found that wrist-ankle acupuncture can improve the ischaemia and hypoxia of nerve cells by reducing blood viscosity, and has a significant therapeutic effect on neurological diseases (Jiang et al., 2005).
Wrist-ankle acupuncture targets six stimulation points on each of the patient's wrists and ankles. The point selection is simple, and similar to a subcutaneous injection. There is no soreness, numbness, or tingling during the needling process. This makes this acupuncture technique suitable for most patients, especially those who are old and frail.
Although a meta-analysis exists on the treatment of post-stroke shoulder pain with wrist-ankle acupuncture (Yu et al., 2022), it synthesised the evidence related to the effectiveness of combined wrist-ankle acupuncture and other forms of acupuncture therapies. Wrist-ankle acupuncture has not been examined for its independent effectiveness in treating post-stroke shoulder pain. Furthermore, despite being practised independently in hospitals, there is insufficient evidence to support its use as a standalone management approach. In addition, our review differs from the previous one in that we not only focus on indicators of shoulder pain but also on other symptoms caused by shoulder-hand syndrome, including swelling of the hand, limited range of motion of the wrist and hand, hyperalgesia, allodynia, and warmth and redness of the wrist and hand. To the best of our knowledge, no systematic reviewers have assessed these outcomes, apart from shoulder pain. It is also important to determine if wrist-ankle acupuncture improves upper limb function and activities of daily living among stroke survivors with shoulder-hand syndrome. Therefore, we aimed to conduct a meta-analysis of wrist-ankle acupuncture alone in the treatment of shoulder-hand syndrome, with the goal of providing reliable evidence for its use in stroke survivors with this syndrome. We also aimed to inform the development of evidence-based guidelines for nurses, where permitted, to independently lead the operation of wrist-ankle acupuncture and promote its clinical application for post-stroke rehabilitation.
This review was reported in accordance with the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analysis and was registered in PROSPERO (CRD420251042530).
We included randomised controlled trials that recruited adult participants (aged ≥ 18 years) with a clinical diagnosis of ischaemic or haemorrhagic stroke who had shoulder-hand syndrome that developed following a stroke, regardless of the duration after stroke onset, severity of stroke, and level of physical function at the time wrist-ankle acupuncture was administered.
The participants in the intervention groups of these trials had to have received wrist-ankle acupuncture targeting stroke survivors with shoulder-hand syndrome on the basis of comparator interventions. We considered wrist-ankle acupuncture therapies that adopted any frequency and duration of needle retention and any number and location of acupoints.
The participants in the comparison group received other forms of acupuncture, usual stroke care, ranging from stroke rehabilitation programmes to promote lifestyle changes, rehabilitation exercises to improve physical function, positioning, and the use of herbal medicine to treat stroke.
We included all measurement time points examined in the included trials. The outcomes measured closest to 4 weeks were considered short-term follow-up, those measured closest to 6 months were considered intermediate-term follow-up, and those measured closest to 1 year were considered long-term follow-up.
•Shoulder measured by validated tools, such as the Visual Analog Scale.•Upper limb measured by validated tools, such as the Fugl-Meyer Upper Extremity index or Wolf Motor Function Test.
•Performance of activities of daily measured by validated tools, such as the modified Barthel Index, Barthel Index, or Functional Independence Measure.•Swelling of the assessed, for example, with a tape measure, a water volumeter, or imaging tests.•Range of motion (shoulder, wrist, hand): measured by joint range of motion measuring tools.•Hyperalgesia or assessed with subjective and objective measures or tests, such as the Visual Analog Scale, Pain Disability Index, or Pain Threshold Test.•Warmth of the wrist and measured by skin temperature measuring devices, such as infrared thermography or skin thermometers.•Redness of the wrist and measured by objective or subjective skin colour measuring tools, such as a spectrophotometer.•Adverse reported as the number of participants experiencing any adverse event, including dizziness, bleeding/bruising, infection, or death.
All randomised controlled trials published in English or Chinese were included.
Wrist-ankle acupuncture administered by healthcare providers in hospitals, community health centres, or nurse clinics was included.
We excluded studies that included stroke survivors with upper limb pain, oedema, or movement disorders caused by shoulder periarthritis, cervical spondylosis, upper limb trauma, soft tissue strain, or rheumatic diseases.
Interventional studies that combined wrist-ankle acupuncture with any other form of acupuncture (e.g., conventional acupuncture, fire needle acupuncture, electroacupuncture) were excluded.
Control groups that combined wrist-ankle acupuncture with other treatments and then compared them to wrist-ankle acupuncture alone were excluded.
Conference papers and animal experiment studies were excluded. Studies with unclear intervention descriptions and in which no response was obtained after attempts to contact all authors were also excluded.
Randomised controlled trials on wrist-ankle acupuncture for post-stroke shoulder-hand syndrome were retrieved from the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Embase via OvidSP, MEDLINE, PubMed, Scopus, Wanfang (Chinese) and China National Knowledge Infrastructure (Chinese). There were no restrictions on publication years, and the retrieval date was until 22 May 2025. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (www.clinicaltrials.gov) on 14 July 2025 for any ongoing trials.
Search terms used (Stroke) AND (Complex Regional Pain Syndrome Type 1 OR
Shoulder-hand Syndrome) AND (Wrist-ankle Acupuncture OR Wanhuai Acupuncture OR Wanhuai needles). The search strategy for MEDLINE is presented in Supplementary Material File 2.
The titles and abstracts of the selected articles were reviewed for relevance by two authors independently. Disagreements were resolved through discussion with the third author.
Data extraction was independently performed by two authors. A data extraction form was developed to extract information regarding the population and setting, interventions, treatment times, follow-up periods, potential sources of bias, outcomes and outcome measures, authors’ conclusions, and funding sources. Authors of the included studies were contacted for any missing data necessary for the analysis.
Assessment of study quality/risk of bias was conducted independently by two authors using Cochrane’s Risk of Bias 2.0 for randomised trials (Sterne et al., 2019). Five bias domains were assessed, including bias arising from the randomisation process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. An overall risk of bias was used to guide analysis and interpretation. A cross-check was conducted after completion, and, if a dispute occurred, a third author assisted in adjudication. The reporting quality of acupuncture interventions in the included trials was evaluated using the Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (Chau et al., 2018; MacPherson et al., 2010).
Meta-analysis was performed using RevMan 5.4. Quantitative analysis included only continuous variables. The measurement methods and units across the included trials for each continuous variable were the same, and, therefore, mean difference (MD) was selected as the effect estimate. Both point estimates and 95% confidence intervals (CIs) were given for each outcome. As frequency of acupuncture sessions and duration of treatment varied across trials, the meta-analyses were conducted by using the random-effects model. Heterogeneity was assessed based on I^2^ with values > 50% considered as considerable heterogeneity. When possible, we analysed data according to intention-to-treat on addressing missing data in clinical studies. We planned to perform sensitivity analyses, but, due to too few included trials for each outcome analysis, we did not carry them out.
We employed Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the findings and used GRADEpro GDT (2025) to create a summary of findings table (Guyatt et al., 2008). Two review authors performed assessments of the certainty of evidence, with any disagreements resolved through discussion. The summary of findings table provides outcome-specific information concerning the overall certainty of evidence from studies included in the comparisons, the magnitude of the intervention’s effect, and the sum of available data on the outcomes considered. When using GRADE, we downgraded the evidence from 'high certainty' by one level for serious (or by two for very serious) study limitations (risk of bias), indirectness of evidence, serious inconsistency, or imprecision of effect estimates. We generated a summary of findings table that presents the overall certainty of the body of evidence for each primary and secondary outcome (shoulder pain, upper limb function, activities of daily living), assessed using GRADE criteria. We described, documented, and considered judgements about the certainty of the evidence in our reporting of the results.
A total of 79 relevant articles were retrieved from the databases, including 26 from English databases and 53 from Chinese databases. After screening, four randomised controlled trials were included (Feng, 2013; Li et al., 2022; Shen and Wang, 2019; Zhang and Wu, 2023). Fig. 1 presents a flowchart of the review process.Fig. 1PRISMA flow chart of search process.Fig 1 dummy alt text
We included four randomised controlled trials, involving 256 Chinese stroke survivors with shoulder-hand syndrome. All of the included trials were conducted in China. The stroke survivors included were all in the subacute stage, that is, within 6 months after the stroke. All the trials reported that stroke survivors' shoulder-hand syndrome was at stage I (Feng, 2013; Li et al., 2022; Shen and Wang, 2019; Zhang and Wu, 2023). Stage I of shoulder-hand syndrome is characterised by pain and limited movement in the upper limbs (shoulders, wrists, and hands), which may be accompanied by swelling, redness, and increased skin temperature (Zhang, 2025). All the outcome measures included in the studies were considered short-term follow-up. Table 1 presents the characteristics of the included trials, including treatment regimens and the control or comparator interventions.Table 1Basic information of the included studies.Table 1 dummy alt textStudy (Year/Region)ParticipantsStroke statusInterventionsOutcome measuresDropout rateAdverse inventsAge, sex (male/ female)Stroke typePost-stroke durationStroke onsetsSHS severityIGCGFeng et al. (2013)/Chinaage 45–75, IG: 63.20±7.01CG:62.57±7.90(39/21)NIWithin 6 monthsNIStage IRoutine treatment/ rehabilitation +Wrist-ankle acupuncture (n = 30)Routine treatment/ rehabilitation + acupuncture (n = 30)Pain (VAS)↓, Upper limb motor function (FMA)↑, Hand edema↓, ADL(MBI)↑, Evaluation of curative effect↑/NIShen et al. (2019) /ChinaMean age 69.2 (29/17)NIWithin 6 monthsNIStage IRoutine rehabilitation +Wrist-ankle acupuncture (n = 23)Routine rehabilitation (n = 23)Pain (VAS)↓, ADL(MBI)↑/NILi et al. (2022)/ChinaIG: 49.00±2.00CG:54.00±1.00(33:31)Ischemic 27,hemorrhagic 37Within 6 monthsFirstStage IRoutine treatment/ rehabilitation +Wrist-ankle acupuncture (n = 32)Routine treatment/ rehabilitation + acupuncture (n = 32)Primary: Pain (VAS)↓, Hand edema↓, SHS (SHSS)↓; Secondary: Upper limb motor function (FMA)↑, ADL (MBI)↑, Evaluation of curative effect↑/noneZhang et al. (2023)/ChinaIG: 64.00±11.00CG:59.00±9.00(37:42)NIWithin 6 monthsNIStage IRoutine treatment/ rehabilitation +Wrist-ankle acupuncture (n = 40)Routine treatment/ rehabilitation (n = 40)Pain (VAS)↓, Upper limb motor function (FMA)↑, Shoulder range of motion↑, Evaluation of curative effect↑/noneADL: Activities of daily living; CG: Control group; FMA: Fugl-Meyer Assessment; IG: Intervention group; MBI: Modified Barthel Index; NI: No information; SHS: shoulder-hand syndrome; SHSS: shoulder-hand syndrome scale, VAS: Visual Analogous Scale,.
In all four trials, acupuncture was administered to the upper 4, upper 5, and upper 6 regions of the hemiplegic side (Supplementary Material File 1). Shen & Wang (2019) reported that the acupuncture was administered by a nurse, Li et al. (2022) reported that the intervention provider was an acupuncturist, while two of the remaining trials did not provide detailed information (Feng, 2013; Zhang and Wu, 2023). In all four trials, the needle retention time was 30 min with one session per day. There were variations in the frequency of acupuncture sessions, needle insertion depth, duration of treatment, and intervention doses. Acupuncture sessions took place 5 to 6 days a week, with needles inserted horizontally between 32 and 35 mm deep. All of the treatments lasted for 3 weeks, and the intervention doses ranged from 450 to 540 min. Details of the acupuncture interventions, including practitioner backgrounds, details of needling, and the number, frequency, duration of treatment sessions, and dose of the intervention used in the included trials are presented in Supplementary Material File 3
None of the four included trials implemented blinding for participants. Only one trial implemented blinding for outcome assessors and performed allocation concealment (Li et al., 2022). All the results of the trials were complete, and no evidence of selective reporting of research results or other sources of bias was found (Figs. 2 & 3).Fig. 2Risk of bias graph.Fig 2 dummy alt textFig. 3Bias risk assessment of the included studies.Fig 3 dummy alt text
The Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture checklist was employed to assess the quality of the reporting of acupuncture interventions in the included trials. As shown in Supplementary Material File 4, six items were well-reported, among which details of needling, the reasoning for treatment, and treatment regimen were fully reported (100%). One of the four studies did not report the setting and context of the treatment (Zhang et al., 2023). The practitioner background was under-reported, with only one study providing detailed information about the practitioner’s qualification and relevant experience (Li et al., 2022).
All four trials (256 participants) measuring the effect of wrist-ankle acupuncture on shoulder pain using the Visual Analogue Scale were pooled in the meta-analysis (Feng, 2013; Li et al., 2022; Shen and Wang, 2019; Zhang and Wu, 2023). The statistical heterogeneity was substantial (I^2^ = 90%, Chi^2^ test, p < 0.00001), which may be attributed to the varieties of needle retention frequency and duration, as well as acupoint location and number across trials. We nevertheless conducted meta-analysis, as the direction of the effect estimates were generally consistent. Our meta‐analysis showed between‐group difference in pain intensity in favour of wrist-ankle acupuncture (MD −1.41, 95% CI −2.24 to −0.58; low‐certainty evidence; Analysis 1.1) at short-term follow-up.
Three trials provided data on upper limb function measured by the Fugl-Meyer Upper Extremity index (203 participants) at short-term follow-up (Feng, 2013; Li et al., 2022; Zhang and Wu, 2023). There was a substantial degree of heterogeneity (I^2^ = 82%, Chi^2^ test p = 0.004). A between‐group difference in upper limb function in favour of wrist-ankle acupuncture was identified (MD 7.86, 95% CI 4.25 to 11.46; low‐certainty evidence; Analysis 1.2).
We include three trials that reported the change in activities of daily living after receiving the intervention (170 participants). The impact of wrist-ankle acupuncture on activities of daily living improvement was found to be beneficial when compared with the control group at short-term follow-up (MD 11.34, 95% CI 10.73 to 11.94; low‐certainty evidence; Analysis 1.3). There was no statistical heterogeneity (I^2^ = 0%).
One study used the water displacement method to measure the effect of the intervention on the degree of hand swelling and reported that wrist-ankle acupuncture was effective in reducing hand swelling (Li et al., 2022).
None of the included studies measured other symptoms, including joint range of motion, hyperalgesia or allodynia, warmth of the wrist and hand, or redness of the wrist and hand.
Two studies reported that the intervention did not cause any adverse events (Li et al., 2022; Zhang and Wu, 2023), while the remaining two studies did not provide the relevant information.
The evidence level for each outcome measure included in the meta-analysis was evaluated. We judged the certainty of evidence for the outcomes of shoulder pain, upper limb function and activities of daily living as low (Supplementary Material File 5).
We systematically synthesized the effects of wrist-ankle acupuncture for shoulder-hand syndrome after stroke. The included trials were all conducted in China. Wrist-ankle acupuncture may alleviate shoulder pain and improve activities of daily living more than conventional rehabilitation. There may not be any adverse events associated with the intervention; however, the certainty of current evidence is low.
There was consistency among the four trials in terms of acupoint selection; i.e., the upper 4, upper 5, and upper 6 regions of the hemiplegic side. The upper 4 points are located along the course of the Hand Yangming Large Intestine Meridian, the upper 5 points are along the course of the Hand Shaoyang Sanjiao Meridian, and the upper 6 points are located along the course of the Hand Taiyang Small Intestine Meridian (Zhang et al., 2002). Performing shallow subcutaneous needling at these acupoints can regulate the corresponding meridians, invigorate Qi (the flow of the energy though human body), and treat diseases (Zhang et al., 2002; Low and Ang, 2010). The depth of needle insertion must be strictly controlled and cannot be changed or altered at will. The same applies to wrist-ankle acupuncture. The needling depths in the four studies ranged from 32 to 35 mm, which is a reasonable range. The needles should be inserted shallowly into the skin without eliciting a pricking sensation. If the needles are inserted deeper into the muscles or cause the patient to experience soreness, numbness, distension, or pain, it is considered improper operation. As for subcutaneous shallow punctures, nurses in China are the most experienced and most likely to master the procedure (Wang and Zhou, 2017).
The duration and frequency of wrist-ankle acupuncture in three of the four included studies was 30 min per session, one session per day, 5 days per week, for 3 weeks, for a total dose of 450 min (Li et al., 2022; Shen and Wang, 2019; Zhang et al., 2002). This dose also accounted for the largest proportion in other published meta-analyses on wrist-ankle acupuncture for analgesia (Yu et al., 2022, 2024). The researchers in this review also indicated that wrist-ankle acupuncture can be administered effectively not only by nurses but also by acupuncturists or other licensed healthcare providers. These findings may offer educational insights for regions or countries where nursing practice regulations currently restrict the performance of this technique. Healthcare providers may be able to use this as a reference when conducting wrist-ankle acupuncture for stroke survivors with shoulder-hand syndrome. Understanding the evidence-based procedure for wrist-ankle acupuncture may enable nurses to ensure patient safety and facilitate interprofessional collaboration with the acupuncturist. However, owing to the low certainty of the evidence, more research is needed to investigate and compare the differences in efficacy among different doses. Since no trial has evaluated the intermediate-term and long-term efficacy of wrist-ankle acupuncture intervention, it is expected that subsequent trials will be able to address this gap.
The results of our review were consistent with the previous meta-analysis (Yu et al., 2022). The causes of shoulder-hand syndrome, as reported in the literature, include soft tissue injury, motor dysfunction, and damage to the peripheral and central nervous systems (Altas et al., 2020). However, according to traditional Chinese medicine theory, after a stroke, the communication and conduction functions of the meridians become impaired. When the meridians become blocked, pain occurs (Wang and Zhou, 2017). Wrist-ankle acupuncture has the functions of unblocking meridians and harmonising the functions of internal organs (Zhang et al., 2002). The sections of the wrist and ankle needling correspond to the twelve cutaneous zones, and the needling sites are roughly located along the paths of the twelve meridians. During the needling process, it helps to stimulate the Qi of the meridians, unblock the meridians, promote the circulation of Qi and blood, and achieve the effect of regulating Qi and relieving pain (Zhang et al., 2002).
From the perspective of Western medicine, the therapeutic effect may be achieved by inhibiting the neural centres in the cerebral cortex that process pain, thereby increasing the pain perception and pain tolerance thresholds of stroke survivors with shoulder-hand syndrome. Wrist-ankle acupuncture may influence the perception and conduction of shoulder pain by regulating the levels of neurotransmitters and neuropeptide substances, such as nitric oxide, prostaglandins, serotonin, endorphins, and substance P (Zhang and Zhou, 2018).
Wrist-ankle acupuncture is performed along the sympathetic nerve's sensitive line. When the needle is inserted into the subcutaneous tissue, it disrupts the original balanced state of the tissue, causing the subcutaneous tissue fluid to generate tissue hydraulic waves (mechanical waves) and the capillaries and small veins to generate elastic waves (chemical waves). These two types of waves rapidly transmitted along the sensitive line of the sympathetic nerve to the shoulder and readjust the internal environment of the shoulder to a balanced state. Acupuncture has an immediate analgesic effect. On this basis, the synergistic oscillation of mechanical waves and chemical waves increases the ion conductivity (K^+^, Ca^+^), which is conducive to improving the ischemic state of the shoulder and promoting rehabilitation (Xu and Zhou, 2015; Zhang and Zhou, 2018).
Meta-analysis results of this review suggest that wrist-ankle was beneficial in improving the upper limb function of stroke survivors with shoulder-hand syndrome compared to the control group, which is inconsistent with a previous review (Yu et al., 2022). It should be noted that the previous review included some trials that combined wrist-ankle acupuncture with other interventions and compared it with a control group. Therefore, the reason for the difference in our results might be the difference caused by the combined interventions in the studies that Yu et al. (2022) included. However, since the number of studies was limited, additional measurement tools could be included in future research to explore further the therapeutic effect of wrist-ankle acupuncture on upper limb function.
We found that, when compared with conventional rehabilitation, wrist-ankle acupuncture slightly improved activities of daily living performance, which is consistent with Yu et al’s (2022) review, further demonstrating that wrist-ankle acupuncture enhances the ability of stroke survivors with shoulder-hand syndrome to perform essential self-care tasks. activities of daily living is a comprehensive measurement of an individual's autonomous activities. When pain is alleviated, physical and mental pleasure may assist in enhancing overall activities of daily living assessment (Cremer et al., 2023). However, the certainty of the evidence remains low due to the presence of small sample sizes in the included trials.
We judged all four studies as having an unclear risk of bias, mainly because of a lack of blinding of participants and outcome assessors, and insufficient information on allocation concealment. Although blinding participants is difficult due to the nature of the intervention, blinding outcome assessors is achievable. We also downgraded the certainty of evidence because of considerable heterogeneity in the meta-analyses, risk of bias, or small sample sizes. Overall, the adequacy of acupuncture interventions was well-reported according to the Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture guidelines. However, strengthening the reporting of qualifications and experience of acupuncture practitioners is warranted in future research.
The number of randomised controlled trials included in this review was limited. The trials were all small sample randomised controlled trials conducted in China, and the certainty of evidence remains low. Considerable heterogeneity existed, which could affect the reliability of the conclusion. Furthermore, the risk of bias for all outcome measures was rated as unclear, which was related to the non-standard implementation of randomisation and blinding. Given the limitations in the quality of the included trials, we recommended enhancing the methodological rigour in subsequent randomised controlled trials in diverse cultural contexts.
The participants were all in the post-stroke subacute stage. The therapeutic effect for stroke survivors with shoulder-hand syndrome in the chronic stage remains unknown. Additionally, there was no report on the stroke severity of the participants. One of the primary symptoms of shoulder-hand syndrome is swelling. However, among the studies included in this review, only one measured its effect on swelling. None of the studies measured other symptoms. Therefore, the efficacy of wrist-ankle acupuncture in treating swelling, as well as other symptoms, in shoulder-hand syndrome remains unknown. Furthermore, the long-term effect of the intervention is still unknown, and its effectiveness on the upper limb function remains to be verified. Therefore, more multi-centre, large-scale, and well-designed randomised controlled trials are required to confirm the effectiveness of wrist-ankle acupuncture in treating shoulder-hand syndrome after stroke, as well as to provide a scientific basis for its promotion and use by nurses or other healthcare providers.
We found low‐certainty evidence that the use of wrist-ankle acupuncture was slightly more beneficial than conventional rehabilitation in relieving shoulder pain and improving upper limb function and activities of daily living. In the limited trials we synthesised, the consistent dose for wrist-ankle acupuncture was 30 min per session, one session per day, and 5 days per week. Wrist-ankle acupuncture is currently being promoted in clinical practice, especially in traditional Chinese medicine hospitals in China, as part of traditional Chinese medicine nursing (Guo, 2022). However, nurse-led studies are scarcely reported in the available research, indicating a gap between practice and research. Future nurse-led randomised controlled trials on wrist-ankle acupuncture should be conducted to evaluate its clinical effects on other symptoms of shoulder-hand syndrome, such as swelling and shoulder range of motion, employing more rigorous research designs, and providing explicit descriptions of the acupuncture regimens.
Analysis 1.1 Shoulder pain post intervention.Unlabelled image dummy alt text
Analysis 1.2 Upper limb function post intervention.Unlabelled image dummy alt text
Analysis 1.3 ADL post intervention
SD: standard deviation, CI: confidence intervals, ADL: activities of daily living.Unlabelled image dummy alt text
We confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. All authors have approved the manuscript and agree with submission to the International Journal of Nursing Studies.
This study received no external funding.
Jie Zhao: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Formal analysis. Janita Pak Chun Chau: Writing – original draft, Project administration, Methodology. Wenli Wang: Writing – review & editing, Supervision, Project administration, Methodology. Kai Chow Choi: Writing – review & editing, Writing – original draft, Project administration, Formal analysis. Rong He: Writing – review & editing, Supervision, Resources, Conceptualization. Yali Zhao: Writing – review & editing, Supervision, Project administration. Suzanne Hoi Shan Lo: Writing – review & editing, Writing – original draft, Supervision, Methodology.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.