Efficacy of acupuncture in the management of ankylosing spondylitis: a systematic review and meta-analysis with insights

Background Ankylosing spondylitis (AS) is a chronic, progressive autoimmune disease characterized by inflammation of the axial skeleton. Although acupuncture has been investigated as a potential therapeutic option for symptom relief, its efficacy in AS remains inconclusive. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of acupuncture for patients with AS, aiming to generate evidence to inform clinical practice. Methods This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. A literature search was performed across 7 databases to identify articles published up to December 25, 2024. Only randomized controlled trials (RCTs) that met the eligibility criteria were included. The methodological quality of the included trials was assessed using the Cochrane Risk of Bias Tool (RoB 2.0), and meta-analyses were conducted with RevMan 5.4 software. If high heterogeneity was observed among the included studies, a random-effects model was used for data synthesis. Subgroup analyses and sensitivity analyses were performed when necessary. Results A total of 35 randomized controlled trials (RCTs) met the inclusion criteria of this study. We used 6 indicators to estimate the results of the meta-analysis, all outcomes showed statistically significant improvements, including BASDAI score, BASFI score, ASDAS, VAS score, CRP level, and ESR level. Specifically, the BASDAI score (MD = −1.55, 95% CI: −1.97 to −1.13, p < 0.0001), BASFI score (MD = −1.47, 95% CI: −1.76 to −1.19, p < 0.0001), and ASDAS (MD = −0.57, 95% CI: −0.82 to −0.33, p < 0.0001). VAS score (MD = −1.30, 95% CI: −1.54 to −1.06, p < 0.0001), CRP level (MD = −7.12, 95% CI: −8.68 to −5.56, p < 0.0001), and ESR level (MD = −7.22, 95% CI: −9.13 to −5.32, p < 0.0001) all decreased significantly. Moreover, no serious acupuncture-related adverse events were reported across the 35 RCTs (only mild, transient reactions in a few cases). Conclusion Acupuncture (including electroacupuncture, warm acupuncture, and fire acupuncture, etc.) is an effective and safe treatment for AS. However, the evidence base is limited by substantial heterogeneity and the lack of large-scale, high-quality clinical trials. Future research should focus on high-quality multicenter studies and comparative analyses of different acupuncture modalities to optimize the evidence for acupuncture in AS treatment. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/ , identifier CRD42025633263.