BACKGROUND: Post-stroke spasticity (PSS) is a prominent complication that severely hinders limb function recovery and diminishes quality of life in patients with stroke. Despite the widespread use of acupuncture-based adjunctive therapies, their efficacy in reducing spasticity severity, improving limb motor function, and enhancing quality of life among stroke survivors remains contentious. Therefore, a comprehensive synthesis of current evidence through evidence-based medical methodologies is essential to elucidate their clinical value. OBJECTIVE: This systematic review and network meta-analysis aimed to evaluate the efficacy of acupuncture-based adjunctive therapies in alleviating spasticity and improving motor function in individuals with PSS. METHODS: Randomized controlled trials (RCTs) investigating acupuncture for PSS were retrieved from domestic and international databases (PubMed, Web of Science, Cochrane Library, Embase, China National Knowledge Infrastructure, WanFang Data, Chinese Scientific Journal Database, and China Biomedical Literature) from inception to March 1, 2025. The risk of bias (ROB) in the included studies was assessed using the Cochrane ROB tool. Using the frequency method, relative risk (RR) was used for binary outcomes and mean difference (MD) for continuous variables, each reported with 95% confidence intervals (CIs). Meta-analysis was performed using Stata software (version 16.0). Probability rankings were estimated using the surface under the cumulative ranking area, and subgroup analyses were conducted to validate result consistency. RESULTS: A total of 66 RCTs involving 6180 patients evaluated 13 effective acupuncture-based interventions. Based on changes in the Modified Ashworth Scale (MAS), fire-needle acupuncture (FN) (MD -1.34, 95% CI -2.17 to -0.51), meridian-sinew acupuncture (MSA) (MD -1.19, 95% CI -1.84 to -0.55), and manual acupuncture (MA) combined with rehabilitation therapy (RT) (MD -0.63, 95% CI -0.82 to -0.43) were identified as the most effective interventions for reducing spasticity. Notably, FN also demonstrated the greatest improvements on the Clinical Spasticity Index (CSI) (MD -7.34, 95% CI -9.83 to -4.85) and total effectiveness rate (RR 2.02, 95% CI 1.45 to 2.81). The Fugl-Meyer Assessment (FMA) scores indicated that electroacupuncture (EA) (MD 32.92, 95% CI 20.83 to 45.02) yielded optimum efficacy in sensory and motor function recovery after stroke, followed by warm needle moxibustion and FN. Furthermore, subgroup analyses revealed that FN and MSA were most effective for MAS when the needle retention time was <= 30min and the treatment duration was <= 4 weeks. In contrast, EA achieved optimal outcomes on the FMA when administered at a frequency >= 5 times per week, with needle retention time <= 30min and treatment duration <= 4 weeks. Meanwhile, the SUCRA ranking results of interventions in the whole limb subgroup were largely consistent with those derived from the overall analysis. CONCLUSION: Acupuncture-based adjunctive therapies demonstrate efficacy in PSS management. FN and MSA are relatively effective, while EA is most suitable for motor function recovery. Clinical decisions should be guided by individualized treatment strategies based on patient-specific presentations and needs.

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