We have carefully reviewed the article by Yan et al entitled “Effect of Acupuncture Intervention on Chronic Musculoskeletal Pain in Hemodialysis-Dependent Kidney Failure Patients: Study Protocol for a Randomized Controlled Clinical Trial”.1 We applaud the authors for focusing on the efficacy of acupuncture as an intervention for chronic musculoskeletal pain in patients with hemodialysis-dependent kidney failure (HDKF). Exploring non-pharmacologic treatments has been around for a long time in the midst of the opioid crisis,2 and this study is expected to provide new ideas and approaches to improve pain management in this particular patient population with HDKF. At the same time, we would like to make some suggestions and comments on the study protocol, which we hope will help to further improve the study.

Firstly, we found that the same acupoints were selected for the sham acupuncture group as for the acupuncture group in the study design, and patients would feel a slight touch on the skin surface of the acupoints. It has been shown that touching acupoints can indirectly produce therapeutic effects by activating unmyelinated low-threshold mechanoreceptors, which trigger a series of affective and hormonal responses.3 Could the sham acupuncture group be considered to select non-acupoints? Better to exclude the interference of the above factors. And to ensure that both needling and sham needling operations are performed by acupuncturists who have undergone uniform and standardized training, clarifying this point can help improve the scientific validity of the study.

Secondly, subjects were allowed to continue taking prescription medications, including pain relievers. However factors such as the amount, frequency, and duration of pain-relieving medication use may interfere with the results of the study. For example, if a subject used a large amount of pain-relieving medication during the course of the study, the Numeric Rating Scale (NRS) score for the primary outcome may be lower even if the acupuncture treatment did not have an effect, thus masking the true effect of the acupuncture treatment. It is recommended that medication regimens for patients taking medications be further described, that strict monitoring of medication use be established, and that subject shedding be taken into account when appropriate.

Finally, the study set a follow-up period of only 12 weeks, which is insufficient for assessing the long-term effects of acupuncture for chronic musculoskeletal pain. Referring to relevant high-quality studies,4 chronic skeletal muscle pain is usually long-lasting and may continue to progress or fluctuate repeatedly, and it is recommended to extend the follow-up period or increase the follow-up time points to observe the duration and stability of the effects of acupuncture treatment.

In conclusion, we express great concern about the study protocol of Yan et al and look forward to the important research results and their potential impact on the treatment of chronic musculoskeletal pain in HDKF patients by acupuncture.

The authors would like to thank Huiting Liu, Xiaohan Huang, Liao Chen, and Hantong Hu for their participation in the scholarly discussions that shed light on the ideas of the article, as well as for providing relevant literature.

The authors report no conflicts of interest in this communication.

1. Yan C, Liu HR, Kong Q, et al. Effect of acupuncture intervention on chronic musculoskeletal pain in hemodialysis-dependent kidney failure patients: study protocol for a randomized controlled clinical trial. J Pain Res. 2024;17:4289–4300. doi:10.2147/JPR.S492158

2. Urits I, Schwartz RH, Orhurhu V, et al. A comprehensive review of alternative therapies for the management of chronic pain patients: acupuncture, tai chi, osteopathic manipulative medicine, and chiropractic care. Adv Ther. 2021;38(1):76–89. doi:10.1007/s12325-020-01554-0

3. Chae Y, Olausson H. The role of touch in acupuncture treatment. Acupunct Med. 2017;35(2):148–152. doi:10.1136/acupmed-2016-011178

4. Mao JJ, Liou KT, Baser RE, et al. Effectiveness of electroacupuncture or auricular acupuncture vs usual care for chronic musculoskeletal pain among cancer survivors. JAMA Oncol. 2021;7(5):1–8. doi:10.1001/jamaoncol.2021.0310