Dear editor

We want to extend our sincere gratitude for your careful review and valuable feedback on our recent study titled “Musculoskeletal Ultrasound Assessment of the Clinical Efficacy of the Combination of Acupressure and ‘Three Methods of Neck Movement (TCM)’ Therapy in the Treatment of Cervical Spondylosis: A Study Protocol for a Randomized Controlled Trial”. We appreciate your insights and would like to address your concerns and questions as follows:

1. Ultrasound Operator Skill and Experience:

Thank you for your insightful comments and for highlighting the importance of operator skill and experience in musculoskeletal ultrasound assessments. We appreciate your concern about the consistency and reliability of the ultrasound measurements in our study.

In response to your comments, we would like to clarify the following regarding our methodology:

Experienced Sonographers: The ultrasonographers involved in this study all had extensive clinical experience in the field of musculoskeletal ultrasound. Before the study, they underwent a comprehensive and systematic training program with standardized protocols covering the precise operation of the ultrasound equipment, standardized image acquisition techniques, accurate interpretation of various parameters, and detailed evaluation procedures for different tests. Training and Certification: At the end of the training, all ultrasonographers participated in a rigorous certification examination, which included a test of theoretical knowledge, a practical assessment, and an analysis and judgment of typical cases. Only those ultrasonographers who successfully passed the certification assessment were qualified to participate in the ultrasound evaluation in this study, thus ensuring that each participant had solid professional skills and uniform operational standards and providing highly reliable data support for the study. Quality Assurance: Throughout the study, a strict quality control system was established to further ensure the accuracy and consistency of the data. In addition to the assessment by three experienced sonographers, two of the sonographers will perform a cross-assessment, and if the results are in agreement, the result will be accepted. In case of disagreement, the third sonographer will conduct a review assessment. The final assessment result will be based on the consensus reached in the three assessments, thus minimizing human error and ensuring the reliability and scientific validity of the data. Protocol Adherence: We acknowledge the importance of mentioning the training and assessment process in the article. We will revise the manuscript to include details about the standardized training and certification process for the sonographers, as well as the quality assurance measures, we implemented to ensure the reliability of the ultrasound assessments.

We concur with your observation regarding the critical role of the operator’s skill and experience in ultrasound examinations. In our study, all measurements will be conducted by the same experienced sonographer to ensure consistency in image acquisition. We acknowledge the importance of this point and regret that it was not explicitly mentioned in the article. We will ensure that the sonographer undergoes specific training on the standardized protocol before the commencement of the study.

2. Patient Age Range:

Your query about the age range of patients included in our study is well taken. In Chinese national guidelines, there is no obvious standard for the age range of cervical spondylosis. According to the 2010 edition of the guidelines for the diagnosis, treatment, and rehabilitation of cervical spondylosis published by the Chinese Society of Rehabilitation Medicine, which is widely cited in China, cervical spondylosis usually occurs in women aged 30–40 years; neurogenic cervical spondylosis occurs in people aged 30–50 years and usually has a slow onset, but there are acute onset cases. Men are twice as likely as women to develop cervical radiculopathy. Cervical radiculopathy is typically slow-onset and is more common in middle-aged people between 40 and 60. According to a survey of the prevalence and correlates of symptomatic cervical spondylosis in Chinese adults: a community-based cross-sectional study that analyzed 3859 adults, the highest prevalence was found in the 45- to 60-year-old age group.1 According to the US Evidence-Based Diagnosis and Treatment of Cervical Spine Disease, it typically occurs between the ages of 40 and 60, with the highest prevalence between the ages of 50 and 54.2 Lastly, subjects over 60 years old often have more underlying diseases, complicating the enrollment process. Taken together, and with the recommendations of the editor-in-chief reviewers, we adopted the cervical spondylosis screening range of 40–60 years of age.3

While our current focus is on patients aged 40 to 60 years, we recognize the trend of cervical spondylosis affecting younger individuals.3 In future studies, we will consider expanding the age range to include younger patients, allowing for a more comprehensive validation of the intervention’s effectiveness and better alignment with current medical needs.

3. TCM Treatment Administration:

We clarify that administering TCM treatment twice a day is performed under the direct supervision of medical professionals.

Detailed description of the mode and frequency of supervision: Clarify that the physician is supervising through on-site observation, regular review of treatment records, and the specific number of times or time periods per day of supervision to ensure that the supervision is effective and actionable.

Describe specific methods for monitoring compliance: setting daily treatment reminders for patients, using patient self-reporting, setting up a treatment punch card record, and regular visits by study investigators to ensure authenticity and completeness of data and to focus on data from patients who may not be completing treatment as required.

4. Error in Time Points of Efficacy Evaluation:

We thank you for noting the minor error regarding the number of time points at which efficacy was evaluated. It was indeed an oversight, and we will correct it to ensure the accuracy and reliability of our study findings.

In conclusion, we eagerly anticipate the outcomes of this study and hope that it will provide significant insights into the role of TCM combined with acupressure in the treatment of neck-type cervical spondylopathy (NTCS). We are committed to contributing to the body of knowledge on traditional Chinese medicine treatments for cervical spondylosis.

We appreciate your interest in our work and look forward to any further discussions that may arise.

Disclosure

The authors report no conflicts of interest in this communication.

References

1. Lv Y, Tian W, Chen D, Liu Y, Wang L, Duan F. The prevalence and associated factors of symptomatic cervical spondylosis in Chinese adults: a community-based cross-sectional study. BMC Musculoskelet Disord. 2018;19(1):1–12. doi:10.1186/s12891-018-2234-0

2. Metzger RL. Evidence-based diagnosis and treatment of cervical spine disorders. Nurse Pract. 2019;44(8):30–37. doi:10.1097/01.Npr.0000574648.67659.09

3. Zuo J, Zeng X, Ma H, et al. Musculoskeletal ultrasound assessment of the clinical efficacy of the combination of acupressure and “three methods of neck movement (TCM)” therapy in the treatment of cervical spondylosis: a study protocol for a randomized controlled trial. J Pain Res. 2024;17:3651–3665. doi:10.2147/jpr.S469511