Comparative effectiveness of acupuncture-related therapies for frozen shoulder: a systematic review and network meta-analysis.

Background: Frozen shoulder is a common condition that limits shoulder mobility and causes pain, significantly affecting daily function. Acupuncture and related therapies are increasingly used as treatment options and may offer potential benefits, but their overall effectiveness remains uncertain. This study aims to systematically evaluate the clinical efficacy of acupuncture and related therapies for frozen shoulder through a network meta-analysis. Methods: We searched Chinese and international databases, including PubMed, Cochrane Library, EMbase, Web of Science, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biomedical Literature Database, for randomized controlled trials (RCTs) published from database inception to September 2025 on acupuncture and related therapies for Frozen Shoulder. Eligible studies were screened, and two independent reviewers assessed the quality and risk of bias using the ROB 2 tool from the Cochrane Handbook. Data were analyzed using Stata 18.0 software for network meta-analysis. The relative efficacy of each intervention was ranked using the surface under the cumulative ranking curve (SUCRA). Results: A total of 84 RCTs involving 7,125 patients and 17 interventions were included. For the overall effectiveness rate, small needle knife therapy showed the greatest improvement over both physical therapy [relative risk (RR) = 1.39, 95% confidence interval (CI) 1.21-1.60] and Western medicine (RR = 1.39, 95% CI 1.22-1.58). In terms of the apparent healing rate, joint mobilization combined with warm acupuncture-moxibustion achieved the most pronounced benefit compared with physical therapy (RR = 1.83, 95% CI 1.19-2.83) and Western medicine (RR = 2.19, 95% CI 1.36-3.54). For shoulder function, measured by the Constant-Murley Shoulder (CMS) score, floating needle therapy yielded the largest functional gain relative to physical therapy [standardized mean difference (SMD) = 3.12, 95% CI 1.91-4.33] and Western medicine (SMD = 4.87, 95% CI 3.47-6.26). Concerning pain intensity, assessed by the Visual Analogue Scale (VAS), Western medicine provided slightly greater pain reduction than acupuncture-based interventions, though the differences were not statistically significant. Adverse events were infrequent and generally mild, occurring less often in acupuncture-related therapies than in control groups. Across outcomes, the certainty of evidence ranged from low to moderate. Conclusion: Small needle knife therapy, joint mobilization plus warm acupuncture-moxibustion, and massage combined with acupuncture appear most effective for improving outcomes in frozen shoulder. Floating needle and moxibustion show advantages in restoring shoulder function. Acupuncture-based therapies are generally safe, but the overall evidence is of moderate-to-low certainty, warranting further high-quality, multicenter trials. Systematic review registration: CRD42024610867.