Comparative effectiveness of non-pharmacological traditional Chinese medicine therapies for chronic fatigue syndrome: a systematic review and network meta-analysis

Background: Chronic fatigue syndrome (CFS) is a systemic disorder with symptoms, including persistent fatigue, unrefreshing sleep, anxiety, and depression, raising health concerns. The effectiveness of non-pharmacological Traditional Chinese Medicine (TCM) therapies for CFS has not been systematically investigated. Objective: This study was designed to investigate the comparative effectiveness of non-pharmacological TCM therapies for CFS. Methods: Searches of Web of Science, Embase, PubMed, Scopus, CINHAL, Cochrane Library, CNKI, WanFang, VIP database, and SinoMed were conducted on January 1, 2026. The Cochrane Risk of Bias Assessment Tool and CINeMA web application were used to assess the risk of bias. Pairwise meta-analysis and NMA were performed using Stata 18.0. Results: A total of 29 studies involving 2,234 participants were included in the analysis. Compared with the conventional care, moxibustion was associated with a reduction in overall fatigue (SMD, -1.84; 95% CI, -2.25 to -1.44). Massage was associated with reduced physical fatigue (SMD, -2.21; 95% CI, -2.65 to -1.77), mental fatigue (SMD, -2.05; 95% CI, -3.07 to -1.02), anxiety (SMD, -3.35; 95% CI, -6.64 to -0.05) and depression (SMD, -1.23; 95% CI, -1.76 to -0.69) vs. conventional care. Cupping therapy showed the greatest improvement in sleep quality (SMD, -4.60; 95% CI, -7.05 to -2.15) vs. conventional care. Conclusion: Current evidence suggests that within the non-pharmacological TCM clinical framework, moxibustion is more effective for overall fatigue. Massage better alleviated physical and mental fatigue, anxiety, and depression, while cupping improved sleep quality. These findings suggest that different non-pharmacological TCM therapies may have varying effects across multiple symptom areas. However, the results should be interpreted with caution, given the uncertainties in the available evidence and the limitations of the included studies. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, Identifier CRD420251113292.