From tradition to healing: the promise of acupuncture in managing chronic fatigue syndrome

Chronic fatigue syndrome (CFS) represents a global public-health problem that affects more than 65 million people worldwide, with a pooled prevalence of 45.2% at 4 weeks in post–COVID-19 patients. This complex condition significantly affects the immune, nervous, and endocrine systems, disproportionately affecting women, people over 40, and low-income populations. This narrative review offers a comprehensive analysis of the application of acupuncture and moxibustion in the treatment of CFS, from its historical foundations in traditional Chinese medicine to contemporary clinical evidence. The epidemiology of CFS reveals a heterogeneous global distribution, with prevalences ranging from 0.2% to 1.4% across different populations.

Risk factors include genetic predisposition, prior infections (especially Epstein-Barr virus), and childhood trauma. The diagnosis remains challenging and is based on the evolution of clinical criteria from the 1994 CDC criteria to the 2015 SEID criteria, complemented by emerging biomarkers including immunologic dysfunction, metabolic alterations, and neuroimaging findings on magnetic resonance imaging. The pathophysiology of CFS involves multiple systems, including NK-cell dysfunction in the immune system, dysregulation of the hypothalamic-pituitary-adrenal axis in the neuroendocrine system, and alterations in energy and lipid metabolism. Genetic studies have identified variations in genes related to the immune system, hormones, and metabolism, with evidence of familial aggregation.

From a therapeutic standpoint, acupuncture and moxibustion are based on the holistic principles of traditional Chinese medicine, including the theory of meridians and the balance between qi and blood. Clinical evidence from multiple randomized controlled trials demonstrates significant efficacy, with rates of clinical improvement ranging from 72.2% to 97.7% depending on the technique used. A multicenter study of 150 patients showed a significant reduction in Fatigue Severity Scale (FSS) scores in the body acupuncture group compared with the control. Innovative techniques such as electroacupuncture and catgut embedding at acupoints have shown promising results, regulating cortical excitability and immune function.

The individualized approach based on traditional Chinese medicine syndrome differentiation allows treatment personalization, selecting specific points such as Pishu and Zusanli for spleen deficiency or Shenshu and Guanyuan for kidney deficiency. Combination with other therapies, including Chinese herbal medicine and psychotherapy, has demonstrated synergistic effects superior to single-treatment approaches. Despite encouraging results, methodologic limitations persist, including heterogeneity in diagnostic criteria, small sample sizes, and difficulties in achieving adequate blinding. Safety considerations are generally favorable, with mild local adverse events being the most common.

Future directions include high-quality multicenter clinical trials, mechanistic studies integrating neuroimaging and biomarker analysis, and exploration of the role of the gut microbiota. International collaboration emerges as a crucial opportunity for protocol harmonization and strengthening of the evidence base. The potential of precision medicine, incorporating genetic analysis and individual constitutional characterization, represents a promising frontier for therapeutic optimization.