Five Critical Queries on Network Meta-Analysis: “Effective Yet Insignificant” Manipulative Therapy for Myofascial Pain Syndrome? [Response to Letter]

Dear editor

We sincerely thank the commentators for their rigorous scrutiny and constructive feedback on our work. We also appreciate the opportunity to respond to these comments. Below, we provide point-by-point responses to the critical queries raised. Our responses are outlined as follows:

Query 1: Statistical Power vs Clinical Assertion: A Paradox?

Response: Thank you for your valuable feedback. We have also identified the issues you raised during our research process. This study¹ is based on published clinical literature, and we must strictly adhere to the methodologies described in these publications. Our duty is to truthfully present the findings according to the data provided in the literature, which clearly indicate no significant difference in effectiveness compared to the control group. While theoretical research outcomes cannot fully align with clinical realities, we maintain an obligation to report the data objectively as revealed by the evidence.

Query 2: Methodological Flaws: Overlooked Biases?

Response: We sincerely appreciate your suggestions, which have helped us recognize the methodological limitations in this study. We will actively incorporate your recommendations to refine our methodologies in future research endeavors, thereby improving the robustness of our research outcomes.

Query 3: Heterogeneity Oversimplification: Technique Variability Ignored?

Response: We sincerely thank you for your valuable feedback. The clinical scenario you described does indeed exist in practice. However, due to the limited number of studies meeting our inclusion criteria, we were unable to adequately assess the specific clinical heterogeneity – this represents one of the inherent limitations of meta-analysis methodology. Moving forward, we will continue to monitor newly published literature and will conduct a more precise analysis once additional studies meeting the required standards become available.

Query 4: Publication Bias: Premature Certainty?

Response: We sincerely appreciate your valuable suggestions and fully concur with your observation that the limited number of included studies resulted in insufficient statistical power for our conclusions. As detailed in our manuscript, we conducted a comprehensive search across grey literature and clinical trial registries (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform), yet regrettably, the available studies remain inadequate to address this methodological constraint. We will maintain ongoing literature surveillance and conduct more precise analyses once additional qualified studies meeting the inclusion criteria are published.

Query 5: Clinical Recommendations: Evidence-Practice Discrepancy?

Response: We sincerely appreciate your constructive feedback. The current analysis did not incorporate evidence quality assessment due to the paucity of studies meeting predefined inclusion criteria—a limitation we explicitly acknowledge in our methodology section. We are committed to methodological refinement in subsequent investigations, including systematic implementation of evidence grading protocols when sufficient primary studies become available.