Comparative effectiveness of acupuncture and Tuina for cervical vertigo: a systematic review and network meta-analysis of randomized controlled trials.

Objective: This study conducted a network meta-analysis to systematically evaluate and compare the effectiveness of acupoint-based stimulation and manual therapies for cervicogenic vertigo. We examined needling-based stimulation, including manual acupuncture and electroacupuncture; thermal stimulation through moxibustion, including warm-needle techniques; acupotomy; manual therapy including tuina and Chinese osteopathic manipulation; and prespecified combinations of these approaches. By synthesizing evidence from parallel-group randomized controlled trials, we aimed to provide an evidence-based foundation for clinical decision-making and practice. Methods: We systematically searched China National Knowledge Infrastructure, Wanfang Data, VIP Chinese Science and Technology Journal Database, PubMed, Embase, the Cochrane Library, Web of Science, and Ovid MEDLINE to identify eligible parallel-group randomized controlled trials. We performed a systematic review and network meta-analysis to evaluate the efficacy and safety of acupoint-based stimulation and manual therapy strategies, including manual acupuncture and electroacupuncture, moxibustion, acupotomy, Tuina and Chinese osteopathic manipulation, and prespecified combinations. We assessed outcomes using the Evaluation Scale for Cervical Vertigo, the Dizziness Handicap Inventory, and overall response measured as the total effectiveness rate. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251113507). Results: Sixty-six parallel-group randomized controlled trials involving 5,797 patients and 18 intervention combinations were included. A combination of electroacupuncture and Tuina showed the most significant overall clinical benefit compared with Tuina alone (OR = 1.53; 95% CI: 1.23-1.89). The following highest effects were observed for a combination of electroacupuncture and moxibustion (OR = 1.52; 95% CI: 1.23-1.87) and a combination of electroacupuncture and acupotomy (OR = 1.50; 95% CI: 1.17-1.92). Electroacupuncture alone also outperformed Tuina (OR = 1.36; 95% CI: 1.12-1.67). For the Evaluation Scale for Cervical Vertigo, a combination of manual acupuncture and Chinese osteopathic manipulation produced the most significant improvement compared with tuina (mean difference = 12.52; 95% confidence interval: 8.51-16.54). A combination of manual acupuncture and moxibustion also significantly improved the Evaluation Scale for Cervical Vertigo vs. tuina (mean difference = 12.34; 95% confidence interval: 8.77-15.90), although the effect was slightly smaller. Among monotherapies, manual needle acupuncture was superior to tuina in improving the Evaluation Scale for Cervical Vertigo (mean difference = 8.38; 95% confidence interval: 4.66-12.11). For the Dizziness Handicap Inventory, warm needle moxibustion showed the largest reduction in dizziness-related disability compared with tuina (standardized mean difference = 2.04; 95% confidence interval: 1.49-2.58). Conclusions: Acupuncture- and Tuina -based interventions may improve outcomes in cervicogenic vertigo; however, comparative rankings should be interpreted cautiously, given the predominance of low/very low certainty evidence. Combination regimens, particularly electroacupuncture plus tuina, tended to rank favorably for overall response, while manual acupuncture combined with Chinese osteopathic manipulation appeared promising for the Evaluation Scale for Cervical Vertigo; evidence for the Dizziness Handicap Inventory remains sparse. High-quality, internationally conducted head-to-head randomized controlled trials using validated outcomes and rigorous bias control are needed to confirm comparative effectiveness. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251113507, identifier: CRD420251113507.