A Commentary on “Effect of Acupuncture Intervention on Chronic Musculoskeletal Pain in Hemodialysis-Dependent Kidney Failure Patients: Study Protocol for a Randomized Controlled Clinical Trial” [Letter]

Dear editor

With great interest, we read the article titled “Effect of Acupuncture Intervention on Chronic Musculoskeletal Pain in Hemodialysis-Dependent Kidney Failure Patients: Study Protocol for a Randomized Controlled Clinical Trial” by Cuina Yan et al.¹ This is a study protocol for randomized controlled trial (RCT) with an expected total of 90 participants. This study aim to evaluate the effect of acupuncture on chronic musculoskeletal pain treatment outcomes in hemodialysis-dependent renal failure (HDKF) patients, with the goal of advancing the systematic management of chronic musculoskeletal pain in HDKF patients with through non-pharmacological interventions. We deeply appreciate the excellent contribution of this study is about to make. Concurrently, we will offer some constructive comments and express our desire to engage in an in-depth exchange with the authors.

Firstly, the theory of traditional Chinese medicine believes that the order of acupuncture and the therapist will affect its clinical effect. Different acupoint acupuncture sequences have different responses to body regulation, and even have opposite effects.² The strength and angle of acupuncture between different therapists can also cause deviations in efficacy. These may affect the consistency and repeatability of the trial. Moreover, the study protocol did not systematically analyze the therapeutic basis and clinical efficacy of the selected acupoints. These may affect the applicability of the findings.

Secondly, this study is a randomized clinical trial, and although the study plans to enroll 90 participants, this sample size may be sufficient to detect small effect sizes, but may not be sufficient to detect more subtle effects or perform subgroup analyses. At the same time, there are likely to be some potential biases in the process of the trial, such as the change of the patient’s condition and the patient’s drug use. Subjects falling off during the trial can also be a problem.

Thirdly, one of the main outcome measures is the Numerical Rating Scale (NRS), which is a subjective pain assessment tool. This assessment can be influenced by the patient’s mood, expectations, and other psychological factors. Placebo effect of sham acupuncture may complicate and confound study.³

Fourthly, chronic musculoskeletal pain in HDKF patients is a long-term, chronic developmental process. The study protocol included a 4-week follow-up period, which may not be sufficient to assess the long-term effects of acupuncture.

Finally, the study did not provide information on the feasibility and acceptability of acupuncture intervention in HDKF patients, which may affect the practical application of the intervention.

In conclusion, We sincerely appreciate Cuina Yan et al for their important research protocol on acupuncture intervention for chronic musculoskeletal pain in HDKF patients. Our proposal is only to further improve the already excellent study protocol. We look forward to more innovations in this area in the future.