Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome — ME/CFS) is one of the most disabling and least understood conditions in modern medicine. Conservative estimates indicate a prevalence of 0.2–2.5% in the adult population — representing tens of millions of people globally. CFS is characterized by debilitating fatigue not relieved by rest, persisting for more than 6 months, exacerbated by physical or mental exertion (post-exertional malaise — PEM), and frequently accompanied by cognitive dysfunction, sleep disturbances, musculoskeletal pain, and dysautonomia. The absence of established and effective pharmacologic therapy makes CFS a field where adjuvant therapies such as acupuncture have relevant potential. A Bayesian network meta-analysis published in the European Journal of Integrative Medicine in September 2025, pooling 35 RCTs with 2,383 patients, is the most comprehensive synthesis on the topic — and identifies moxibustion as the modality of greatest efficacy.
The study was conducted by Rong Li, Yu Zhang, and YuHang Xie, of the Chengdu University of Traditional Chinese Medicine, with searches across multiple databases covering studies through May 2024. The Bayesian network approach (Bayesian NMA) has methodological advantages over conventional meta-analysis: it allows ranking interventions by probability of efficacy (SUCRA — Surface Under the Cumulative Ranking Curve) and simultaneous comparison of all 9 modalities evaluated, even when they have not been directly compared in the same RCT. The modalities analyzed included: acupuncture, moxibustion, electroacupuncture, combined acupuncture + moxibustion, Western medicine (WM), and conservative treatments.
RESULTS OF THE BAYESIAN NMA OF ACUPUNCTURE FOR CHRONIC FATIGUE SYNDROME (EJIM, SEP 2025)
The FS-14 Scale and What a 12-Point Difference Means
The Fatigue Scale FS-14 is a 14-item questionnaire divided into two subscales: physical fatigue (8 items) and mental fatigue (6 items). Each item is scored as 0 or 1, with total score ranging from 0 to 14 — higher score indicates less fatigue. The 12.43-point difference favoring moxibustion vs. Western medicine is clinically expressive considering that the total range of the scale is 14 points. This means that patients treated with moxibustion present, on average, improvement of nearly the full possible range of the scale compared to the Western medicine group — a magnitude of effect rarely seen in conditions such as CFS, where pharmacologic treatments generally produce modest effects.
The difference between moxibustion (MD 12.43) and acupuncture alone (MD 11.15) suggests that the heat component of moxibustion adds a specific benefit beyond the mechanical stimulus of the needle. This datum is coherent with TCM theory: CFS, in many patients, presents the diagnostic pattern of yang deficiency (cold, lethargy, deep fatigue that worsens with exertion) — exactly the pattern for which moxibustion is indicated as primary therapy. The combination of acupuncture + moxibustion also demonstrated results superior to Western medicine, with magnitude similar to moxibustion alone.
Implications for Long COVID: A Relevant Parallel
The COVID-19 pandemic created a new dimension for interest in CFS: long COVID presents symptoms overlapping with ME/CFS — debilitating post-exertional fatigue, brain fog, sleep disturbances, and dysautonomia — and some researchers propose that both conditions share pathophysiologic mechanisms (mitochondrial dysfunction, neuroinflammation, viral reactivation). The data from this NMA on CFS are therefore clinically relevant also for the management of fatigue in patients with long COVID — especially considering that no pharmacologic therapy is approved for that condition.
The acupoint protocol most used in the included RCTs centered on GV-4 (Mingmen), CV-4 (Guanyuan), CV-6 (Qihai), BL-23 (Shenshu), and ST-36 (Zusanli) for moxibustion — acupoints traditionally used in chronic fatigue protocols and investigated for their potential effects on the HPA axis, immune function, and energy metabolism in experimental studies.
Frequently Asked Questions
Moxibustion is generally well tolerated, but requires individual adaptations. In CFS patients with increased sensitivities (multiple chemical sensitivity, heat intolerance), the smoke from traditional moxibustion may be a problem — in these cases, smokeless moxa sticks or infrared heat are alternatives. Patients with "excess heat" in the TCM diagnostic pattern (fever, night sweats, restlessness) may have a relative contraindication to moxibustion, which would be replaced by acupuncture alone. Individual evaluation by the medical acupuncturist is indispensable.
Post-exertional malaise is the most specific symptom of ME/CFS — any stimulus that exceeds the patient’s energy threshold may trigger it. In patients with severe CFS, the first sessions should be short (15–20 minutes), of low intensity (few needles, mild stimulation), to assess individual tolerance. If the patient reports worsening of fatigue in the 24–48 hours after the session, the protocol needs to be reduced in intensity — not necessarily discontinued. Gradual progression, similar to the "pacing" that CFS specialists recommend for physical activity, is the safest approach.
The RCTs in this meta-analysis used protocols of 8–12 weeks with 3 weekly sessions. CFS is a chronic condition and the response tends to be gradual: subjective improvement of energy usually appears in the first 4 weeks, with objective improvement on functional scales from week 8. Maintenance of benefit probably requires support sessions after the intensive phase — the ideal frequency is individualized, but 1–2 sessions per month as maintenance is a reasonable starting point.
Fonte Original
European Journal of Integrative Medicine(em inglês)Estudo Científico
DOI: 10.1016/j.eujim.2025.102556Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).