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Effect of acupuncture combined with Western medicine on vertebrobasilar artery hemodynamics and efficacy in patients with CV: a systematic review and meta-analysis

Systematic Reviews volume 14, Article number: 87 (2025) Cite this article

Abstract

Objective

To systematically evaluate the effect of acupuncture combined with Western medicine on vertebrobasilar artery hemodynamics and its clinical efficacy in patients with cervical vertigo. To provide a reliable evidence-based medical basis for the clinical treatment of CV.

Methods

This systematic review and meta-analysis will be reported in agreement with the Meta-Analyses (PRISMA2020) statement. MEDLINE, Embase, Web of Science, the Cochrane Library, CNKI, VIP, Wan Fang, and China Biology Medicine Disc (CBM) were searched until August 20, 2024. The quality of the included studies was assessed using the Cochrane Collaboration’s tool for assessing the risk of bias, and the data were analyzed using Revman5.4, StataMP 18, and TSA0.9.5.10Beta software.

Results

A total of 7 randomized controlled trials involving 714 patients were included. The meta-analysis results showed that acupuncture combined with Western medication was superior to simple Western medication in improving the blood flow velocity of the left vertebral artery, right vertebral artery, and basilar artery in patients with CV, improving the symptoms of cervical vertigo and improving its function and clinical efficacy. TSA analysis results again confirmed the robustness of the results of this meta-analysis.

Conclusion

Acupuncture combined with Western medicine has measurable benefits in improving vertebrobasilar hemodynamics and clinical efficacy in patients with CV, with certain safety. However, there are still methodological defects such as small sample size, different acupuncture treatment methods, and information on minimal clinically relevant differences is missing. In the future, RCTs with larger sample sizes and longer observations are still needed to further verify the efficacy of acupuncture combined with Western medicine, and an updated meta-analysis can be conducted to analyze the efficacy of acupuncture combined with Western medicine in the treatment of CV.

Systematic review registration

PROSPERO CRD42024592131.

Peer Review reports

Introduction

Cervical vertigo (CV) is caused by the degenerative changes of the cervical spine, spinal stenosis, and other causes of vertebrobasilar artery compression, which leads to cerebral blood supply limitation and ischemia and hypoxia, and stimulation and compression of peripheral blood vessels and nerves, leading to vertigo. At the same time, CV is accompanied by clinical symptoms such as neck, shoulder, and back pain and discomfort, palpating, dizziness, tinnitus, and so on [1, 2]. Vertigo is often the chief complaint of this disease, which has a high incidence in clinical practice. Some reports show that the incidence can reach 4.9% in foreign countries, 4.1% in China, and even 35.4% in some reports. With the change in lifestyle, electronic products gradually enter life, and the time spent at the desk has increased. In many young people, the dynamic balance of the cervical spine is disordered, leading to the disorder of the physiological function of the whole neck, which causes vertigo symptoms [3, 4]. In addition, studies have shown that 50% of patients with cervical spondylosis have vertigo symptoms [5]. CV seriously affects people’s lives, studies, and work [6].

Commonly used in Western medicine to relieve cerebral vasospasm and improve vertigo symptoms in patients with CV. Zeng Duoshou et al. [7] used Betastatin hydrochloride to treat cervical vertigo. The results showed that the clinical symptoms of the treatment group were significantly improved, and the total effective rate was 97.1%. Liang Dan et al. [8] treated cervical vertigo by intravenous infusion of betaustine hydrochloride 40 mg, with an atotal effective rate of 92.5%. Good results can be obtained in the short term, but their efficacy will be reduced in the long term, and they have strong drug dependence, and the recurrence rate is high after drug withdrawal. There is no specific drug treatment [9, 10]. Acupuncture, traditional Chinese medicine, Tuina, moxibustion, and other methods are commonly used in traditional Chinese medicine for treatment. Studies have shown that acupuncture therapy can change the blood supply of the vertebrobasilar artery and improve blood and oxygen supply to the brain by stimulating acupoints [11]. It can relieve the tension and spasms of neck muscles, ligaments, fascia, and other soft tissues and relieve the abnormal stimulation of sympathetic nerves to regulate nerves and improve cervical vertigo [12]. For example, Hou Zhuanzhuan et al. [13] used governor vessel-regulating conception acupuncture to treat cervical vertigo; the results showed that acupuncture could effectively improve the symptoms of cervical vertigo and vertebral artery hemodynamics. Compared with Western medicine treatment, the efficacy of acupuncture treatment lasts longer [14]. Therefore, when Western medicine is used to treat cervical vertigo, combined with acupuncture can alleviate its dependence [10], exert its combined effect, and improve the clinical symptoms of CV patients more significantly. However, there is still a lack of relevant systematic reviews and meta-analyses to confirm this. Therefore, this paper systematically evaluates the clinical efficacy of acupuncture combined with Western medicine in treating CV by Meta-analysis and trial sequential analysis (TSA) to provide an evidence-based basis for the clinical treatment of CV.

Material and methods

Inclusion/exclusion criteria

Inclusion criteria

The systematic review registration: PROSPERO (CRD42024592131). According to the PICOS (Population, Intervention, Control, Outcome, and Study Type) framework, the inclusion criteria for this review were as follows: (1) CV of study subjects; (2) acupuncture combined with western medication was used as the experimental group. The acupuncture methods included traditional acupuncture, electroacupuncture, press needling, three-point acupuncture for anti-halo, Tiaoshen Yizhi acupuncture, et al. The Western medication included flunarizine, betaustine mesylate tablets, betaustine hydrochloride, etc.; (3) The control group was treated with Western medicine; (4) RCT; (5) studies published in English or Chinese. No restrictions were placed on population characteristics and publication types, regardless of differences such as gender, age, country, time, and race.

Exclusion criteria

Studies using other forms of acupuncture, such as acupuncture needles and laser acupuncture, were excluded. Studies without clear diagnostic criteria and access to complete information and data were excluded.

Search strategy

This meta-analysis was performed according to the Cochrane Handbook for Systematic Reviews [15]. MEDLINE, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP database for Chinese Science and Technology Journals (VIP), Wanfang Database, and China Biology Medicine Disc (CBM) were searched by computer from the establishment of the database to August 20, 2024. Keywords: acupuncture (AT), cervical vertigo (CV), randomized controlled trial (RCT). Languages are limited to Chinese and English. Study screening was performed independently by two investigators. Detailed search strategies were referred to PubMed and CNKI. Specific search strategies are submitted in the form of words.

Study selection

Two investigators searched seven databases to obtain studies and imported them into EndNote X9 software for screening. Preliminary screening was performed by reading the title and abstract, and detailed screening was performed by reading the full text to identify the required studies.

Data extraction

Two investigators independently screened studies and collected data according to strict inclusion and exclusion criteria. The authors of the included literature, publication year, age, course of the disease, intervention measures, sample size, frequency (daily), course of treatment (week), and outcome indicators were recorded (Table 1). All studies were managed using EndNote X9. Disagreements were resolved through team discussion.

Table 1 Characteristics summary of included studies
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Quality of studies

Two assessors completed the risk of bias. The Cochrane Handbook for Systematic Reviews of Interventions 5.4 was followed. Items include randomization sequence generation (selection bias), assignment concealment (selection bias), blinding of participants and investigators (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other biases. The quality of the included studies was classified as low risk of bias (yes)/unclear/high risk of bias (no). For randomized sequence generation, assignment concealment, and use of blinding, the study was assessed as low risk if the method described was correct, unclear if not mentioned, and high risk if the method was incorrect. Completeness of outcome data and selectively reported results were assessed as low risk if there were no missing outcome data and all the expected results were reported, as unclear if there was not sufficient information to judge, and as not high risk if there were missing outcome measures or if the expected primary outcome measures were not reported. Other sources of bias were assessed as low risk if no other bias was evident, vice versa, and unclear if there was not enough information to judge. We assessed each study and made judgments about potential bias. GRADEpro was also used to assess the quality of evidence.

Data synthesis

Strict inclusion/exclusion criteria were established to screen the literature, and data extraction and quality evaluation were conducted. Review Manager 5.4 and StataMP 18 software was used for data analysis. For continuous data, mean difference (MD) was used, OR value was used for dichotomous variables, and a 95% confidence interval (CI) was used for each effect size. Inter-study heterogeneity was assessed using the I2 statistical test. When I2 < 50%, the fixed effect model was used for pooling, and when I2 > 50%, the random effect model was used for pooling. If I2 ≥ 50%, the heterogeneity was high. Meta-regression and subgroup analysis were performed to find the source of heterogeneity. The funnel plot and Egger’s test were used to analyze publication bias.

Trial sequential analysis

It has been reported that the probability of type I error (false positive) is between 10 and 30% when P < 0.05 is repeatedly considered to be statistically different with the continuous updating of meta-analysis [22, 23]. In order to minimize this risk, the Trial Sequential Analysis (TSA) method has been introduced into Meta-analysis, which overcomes the shortcomings of traditional meta-analysis and makes the statistical analysis results more robust. In addition, TSA can also estimate the Required Information Size (RIS) for a meta-analysis to obtain a stable conclusion, which provides a stopping criterion for clinical trials.

Therefore, this review used TSA.0.9.5.10 beta software for trial sequential analysis. If the Z-curve crosses the traditional boundary but not the TSA boundary, it suggests that there may be a false positive error in the meta-analysis results. If the cutoff value of TSA was crossed, the results of the meta-analysis were robust, even if RIS was not reached. If the Z-curve did not intersect with the traditional cut-off value or TSA cut-off value, no positive or negative conclusions could be drawn. The Z-curve intersects the null line, indicating that it is meaningless [24].

Results

Study selection

A total of 2702 articles were retrieved from 7 databases. By searching for duplicates and reading titles and abstracts, 2659 articles were excluded. After reading the remaining 43 studies, 35 studies were excluded. The reasons for exclusion included non-randomization (11 studies), inability to extract data (6 studies), non-Western medicine (3 studies), and Western medicine combined with traditional Chinese medicine (5 studies) as the control group, and inability to obtain full text (3 studies). Finally, 7 [10, 16,17,18,19,20,21] RCTs were included (Fig. 1). All were written by Chinese people in Chinese.

Fig. 1
figure 1

Flowchart of the selection process

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Study characteristics

The characteristics of the included RCTs are listed in Table 1. A total of 714 CV patients were enrolled. The treatment group was treated with acupuncture, electroacupuncture, thumbtack needling, three acupuncture for stopping the halo, and Tiaoshen Yizhi needling combined with Western medicine. The control group was treated with Western medicine intervention. The left vertebral artery (LVA) blood flow velocity, right vertebral artery (RVA) blood flow velocity, basilar artery (BA) blood flow velocity, cervical vertigo symptom and function assessment scale (ESCV), and efficacy were observed.

① Left vertebral artery (LVA) blood flow velocity; ② Right vertebral artery (RVA) blood flow velocity; ③ Basilar artery (BA) blood flow velocity; ④ Cervical vertigo symptom and function assessment scale (ESCV); ⑤ Efficacy rate.

Risk of bias

As shown in Fig. 2, the seven studies were overall at low risk. All studies reported specific methods for random sequence generation and were assessed as low-risk. In terms of allocation concealment, 5 [17,18,19,20,21] studies were not specifically described and were assessed as high risk, and 2 [10, 16] trials as low risk. In the blinded assessment of subjects, investigators, and study outcomes, seven studies were assessed as high risk because the use of blinding was not specifically described. However, because the original study protocol was not available, it was not possible to determine whether the included studies had other biases and were therefore assessed as unclear.

Fig. 2
figure 2

Risk of bias of included studies

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Outcomes

Left vertebral artery blood flow velocity (LVA)

A total of 5 studies [10, 16,17,18,19] compared the improvement of blood flow velocity of LVA in patients with CV by acupuncture combined with Western medicine and Western medicine. Using the random effects model, the results of the meta-analysis showed that acupuncture combined with Western medication was superior to Western medication alone in improving the blood flow velocity of the left vertebral artery (LVA) in patients with CV [MD = 6.87 (95%CI, 4.70, 9.04), P < 0.00001, I2 = 92%] (Fig. 3A).

Fig. 3
figure 3

Flow velocity results of the (LVA). A Meta-analysis. B Subgroup analysis

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Since the combined results of LVA data showed significant heterogeneity (I2 = 92% > 50%), we conducted meta-regression according to the intervention frequency, time, and sample of the included literature to find the source of heterogeneity. The results showed that the intervention time (P = 0.006 < 0.05) was the source of heterogeneity (Table 2).

Table 2 Meta-regression results of the intervention time
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Subgroup analysis was performed according to the above results. We used the fixed effect model; the results showed that whether the intervention time was < 4 weeks [16, 17, 19] or ≥ 4 weeks [10, 18], acupuncture combined with Western medicine was superior to the control group in improving the blood flow velocity of the LVA [MD < 4 weeks = 5.10 (95%CI, 4.44, 5.76); P = 0.75, I2 = 0%; MD ≥ 4 weeks = 9.84 (95%CI, 8.71, 10.96), P = 0.86, I2 = 0%], and the intervention effect was better in the intervention period of 4 weeks or more (Fig. 3B).

Right vertebral artery blood flow velocity (RVA)

A total of 6 studies [10, 16,17,18,19,20] compared acupuncture combined with western medicine with western medicine in improving the blood flow velocity of RVA in patients with CV. Using the random effects model, the results of the meta-analysis showed that acupuncture combined with Western medication was superior to Western medication alone in improving the blood flow velocity of the right vertebral artery (RVA) in patients with CV [MD = 5.55 (95%CI, 3.89, 7.22), P < 0.00001, I2 = 86%]. (Fig. 4A and Table 3).

Fig. 4
figure 4

Flow velocity results of the RVA. A Meta-analysis. B Subgroup analysis

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Table 3 Meta-regression results of the intervention time
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Since the combined results of RVA data showed significant heterogeneity (I2 = 86% > 50%), we conducted meta-regression according to the intervention frequency, time, and sample of the included literature to find the source of heterogeneity. The results showed that the intervention time (P = 0.013 < 0.05) was the source of heterogeneity (Tables 3).

Subgroup analysis was performed according to the above results. The patients were divided into 2 weeks, 3 weeks, and 4 weeks according to different intervention periods. Using the fixed effect model, the results showed that under different intervention cycles, acupuncture combined with western medicine was superior to the control group in improving the blood flow velocity of the RVA [MD2w = 5.78(95%CI, 4.98, 6.57), P = 0.57, I2 = 0%; MD3w = 2.43 (95%CI, 0.92, 3.94), P = 0.65, I2 = 0%; MD4w = 8.13 (95%CI, 6.59, 9.30), P = 0.87, I2 = 0%], and the intervention period of 4 weeks had a better intervention effect (Fig. 4B).

Basilar artery blood flow velocity (BA)

A total of 5 studies [10, 17,18,19, 21] compared the improvement of BA blood flow velocity in patients with CV by acupuncture combined with Western medicine and Western medicine. Using a fixed effect model, the results of the meta-analysis showed that acupuncture combined with Western medication was superior to Western medication alone in improving BA blood flow velocity in patients with CV [MD = 5.04(95%CI, 4.51, 5.58), P = 0.11, I2 = 46%] (Fig. 5).

Fig. 5
figure 5

The results of the basilar artery (BA)

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Cervical Vertigo Symptom and Function Assessment Scale (ESCV)

Two studies [17, 19] compared acupuncture combined with Western medicine in improving the symptoms and function of cervical vertigo in CV patients. Using a fixed effect model, the results of the meta-analysis showed that acupuncture combined with Western medication was superior to Western medication alone in improving the symptoms and function of cervical vertigo in CV patients [MD = 4.66(95%CI, 3.92, 5.40), P = 0.58, I2 = 0%] (Fig. 6).

Fig. 6
figure 6

Results of the Cervical Vertigo Symptom and Function Assessment (ESCV)

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Efficacy rate

A total of 7 studies compared the efficacy of acupuncture combined with Western medicine and Western medicine in improving CV patients. Using a fixed effect model, the results of the meta-analysis showed that acupuncture combined with Western medication was superior to Western medication alone in the treatment of CV patients [MD = 3.30(95%CI, 2.01, 5.40), P = 0.95, I2 = 0%] (Fig. 7).

Fig. 7
figure 7

Efficacy rate

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Publication bias

As can be seen from Fig. 8, all studies are not outside the funnel plot. However, according to the asymmetry of the funnel plot and Egger’s test results, publication bias can be suspected (P = 0.018 < 0.05) (Fig. 8 and Table 4).

Fig. 8
figure 8

Publication bias of included studies

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Table 4 Egger’s publication bias plot
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Assessment of evidence quality (GRADE)

GRADEpro was used to evaluate the quality of evidence for the outcome indicators. Due to methodological quality defects, high heterogeneity, and small sample size, the results showed that one outcome indicator was high grade, two were medium grade, and two were low quality (Fig. 9).

Fig. 9
figure 9

Evaluation of the evidence level of the included studies(GRADE)

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Trial sequential analysis

A total of 7 RCTS reported total clinical response rates and were analyzed sequentially, with a type I error of 5% and a statistical power of 80%. Sample size was taken as the expected information value (RIS). Figure 10 shows that the Z-curve crosses the traditional and TSA boundary values, indicating that the results obtained in this meta-analysis are robust and the efficacy of acupuncture combined with Western medicine in the treatment of CV is positive. At the same time, the penalty curve also exceeded the traditional boundary value, making the results of the meta-analysis more stable, but it did not reach the RIS value, which needs further research.

Fig. 10
figure 10

The result of TSA analysis

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Discussion

A total of seven studies involving 714 patients were included. Acupuncture is one of the traditional Chinese medicine (TCM) therapies. This meta-analysis classified ordinary acupuncture, electroacupuncture, three acupuncture for ZhiYun, and Tiaoshen Yizhi acupuncture as broad acupuncture therapy. All of them have been evaluated and compared with Western medicine.

The results of risk of bias showed that the included studies were at low risk. All studies reported randomized sequence generation and expected outcomes without missing trial data. However, blinding is underreported, and it is difficult to determine whether other biases exist because raw data are unavailable. Although there are methodological limitations, acupuncture combined with Western medication is superior to Western medication in improving the blood flow velocity of the left vertebral artery(LVA), right vertebral artery(RVA) and basilar artery (BA), ESCV score and curative effect in patients with CV. According to the funnel plot asymmetry and Egger’s test results, publication bias can be suspected (P = 0.018 < 0.05).

At the same time, trial sequential analysis (TSA) was performed to confirm the stability of the meta-analysis results. Figure 4 shows that the Z-curve crosses the traditional and TSA boundaries, indicating that the results obtained in this meta-analysis are robust. Compared with Western medicine, the CV effect of acupuncture combined with Western medicine is positive, and the penalty curve also exceeds the traditional boundary value, making the results of the Meta-analysis more stable. However, the Z-curve was within the RIS value, indicating that many high-quality studies are needed.

As the pathogenesis of CV is still unclear, it is currently reported that the occurrence of CV may be related to vertebrobasilar insufficiency [25], cervical sympathetic nerve stimulation [26], humoral factors [27], proprioceptive disorders [28], hemodynamic abnormalities [29] and migraine-related cervical vertigo [30]. At present, there is no definitive clinical treatment for CV. Western medicine treatment of CV [31] is mainly based on the use of drugs that dilate cerebral blood vessels and improve cerebral circulation blood supply to speed up blood circulation and improve metabolism. For example, betaustine hydrochloride tablets can effectively improve cardiovascular and cerebrovascular circulation, increase blood flow, inhibit sympathetic nerve excitability, and repair neurons [32]. However, its single-use has poor drug resistance, short duration of drug effect [33, 34], easy to relapse, and long-term use will lead to addiction, dependence, gastrointestinal discomfort, and other side effects [34, 35].

Therefore, patients turn to alternative therapies such as acupuncture, massage, and traction, especially acupuncture, which is recognized for its good efficacy, few adverse reactions, and high acceptance [36]. Studies have shown that acupuncture at the neck muscle group and the corresponding acupoints have dual effects on cerebral blood vessels, such as spasmodic relief, expansion, and contraction. It can improve the blood circulation of the brain, regulate the balance of vascular movement, stimulate the β receptors on the arterial wall cells, expand blood vessels, increase cerebral blood flow, improve cerebral ischemia and hypoxia, improve cerebral blood circulation function, and relieve muscle spasms. Reduce compression and stimulation of the vertebral artery [37, 38], and improve biomechanics, chemistry, and blood vessels [39]. Combining acupuncture and Western medicine in treating CV can have a combined effect.

This meta-analysis also has some limitations: (1) the lack of use of blinding: Researchers should pay more attention to the use of blinding in the future. (2) Seven studies were included, four of which were small-sample studies. In the future, more large-sample and high-quality studies are needed to confirm the effect of acupuncture combined with Western medicine on vertebrobasilar artery hemodynamics and its clinical efficacy in patients with CV. (3) This meta-analysis only compared the efficacy of acupuncture combined with Western medicine with Western medicine alone and did not include a control group with sham acupuncture, which may introduce some bias. An updated meta-analysis could be warranted in the future. (4) Missing information on minimal clinically relevant differences in outcomes is another limitation of this meta-analysis and should be addressed in updated meta-analyses.

Conclusion

Acupuncture combined with Western medicine has measurable benefits in improving vertebrobasilar hemodynamics and clinical efficacy in patients with CV, with specific safety. However, small sample sizes, different acupuncture treatment methods, and missing information on minimal clinically relevant differences could still be improved. In the future, RCTS with larger sample sizes and more extended observations are still needed to verify further the efficacy of acupuncture combined with Western medicine, and an updated meta-analysis can be conducted to analyze the efficacy of acupuncture combined with the treatment of CV.

Data availability

All relevant data are within the manuscript and its supporting information file.

Abbreviations

CV:

Cervical vertigo

RCT:

Randomized controlled trial

TSA:

Trial Sequential Analysis

LVA:

Mean blood flow velocity (Vm) of left vertebral artery (LVA)

RVA:

Mean flow velocity (Vm) of right vertebral artery (RVA)

BA:

Mean flow velocity (Vm) of basilar artery (BA)

ESCV:

Evaluation Scale For Cervical Vertigo

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Acknowledgements

This paper is supported by the Chongqing Sci-Health Joint Medical Research Project (Project No. 2022MSXM176) and supported by the TCM self-financing fund of Jiangbei District, Chongqing.

Funding

1. Chongqing Sci-Health Joint Medical Research Project (Project No. 2022MSXM176).

2. Supported by TCM self-financing fund of Jiangbei District, Chongqing.

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Author notes

  1. Ruiyong Yang and Meiting Liu contributed equally to this work and shared the first authorship.

Authors and Affiliations

  1. Chongqing Medical University, Chongqing Red Cross Hospital, Chongqing, 400016, China

    Ruiyong Yang

  2. Chongqing Jiangbei District Hospital of Traditional Chinese Medicine, Chongqing, 400020, China

    Meiting Liu

  3. Chongqing Medical University, Chongqing, 400016, China

    Chenglin Tang

  4. Chongqing Hospital of Traditional Chinese Medicine, Chongqing, 400021, China

    Shanshan Wang

Authors
  1. Ruiyong Yang
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  2. Meiting Liu
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  3. Chenglin Tang
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  4. Shanshan Wang
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Contributions

Ruiyong Yang and Meiting Liu contributed equally to this work. The study was conceived by Ruiyong Yang and Meiting Liu and Shanshan Wang and Chenglin Tang, who drafted the first framework of the manuscript. Ruiyong Yang and Meiting Liu were responsible for data collection and verification. Shanshan Wang and Chenglin Tang contributed greatly to the revision of the paper. All the authors contributed to the design, information collection, data analysis, writing, and final editing.

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Correspondence to Chenglin Tang.

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Yang, R., Liu, M., Tang, C. et al. Effect of acupuncture combined with Western medicine on vertebrobasilar artery hemodynamics and efficacy in patients with CV: a systematic review and meta-analysis. Syst Rev 14, 87 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-025-02810-6

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-025-02810-6

Keywords

Systematic Reviews

ISSN: 2046-4053