Dear editor

We have read with great interest the study protocol 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” by Zuo et al.¹ While we appreciate the authors’ innovative approach in combining traditional therapy with modern assessment methods, we would like to offer several suggestions to enhance the clinical relevance of the findings.

Firstly, we noticed that the age range restriction (40–60 years) might limit the generalizability of the study results. Recent epidemiological data indicate that the prevalence of cervical spondylosis is rising among younger populations due to modern lifestyle factors.² Additionally, excluding older patients (>60 years) overlooks a critical group that often experiences concurrent degenerative conditions. Physiological responses to manual therapy and exercise interventions can vary across age groups, particularly considering age-related changes in muscle regeneration and tissue adaptability.

We also observed that a 6-month follow-up period may not be sufficient to evaluate the long-term efficacy of treatments for chronic degenerative conditions such as cervical spondylosis. Previous studies have demonstrated an association between cold environments and musculoskeletal issues, with individuals exposed to low temperatures showing a higher incidence of musculoskeletal symptoms.³ Therefore, it is essential to consider the potential impact of seasonal temperature changes on treatment outcomes. Additionally, given that cervical spondylosis is a chronic degenerative condition, a longer observation period would be valuable for assessing the durability of treatment effects.⁴

The single-center design raises concerns about external validity, as treatment protocols and levels of expertise may vary significantly between medical institutions. Findings from specialized hospital settings may not be directly applicable to primary care or community healthcare environments. Adopting a multicenter approach in future research could improve the generalizability of the results. Moreover, although musculoskeletal ultrasound has advantages in muscle assessment, its accuracy depends on the operator’s expertise. Integrating objective measurement methods, such as surface electromyography (sEMG) and quantitative analysis of cervical kinematics, would enhance the assessment of muscle function.

Another issue is the limited evaluation of psychosocial dimensions. Although the McGill Pain Questionnaire and the Neck Disability Index (NDI) have been validated as primary outcome measures, they mainly address pain intensity and functional impairment without adequately considering broader psychosocial contexts. Studies have shown that psychological factors, particularly symptoms of anxiety and depression, can influence pain perception and treatment outcomes in cervical spondylosis.⁵ Therefore, we recommend incorporating validated psychological assessment tools, such as the Hospital Anxiety and Depression Scale (HADS), the Pain Catastrophizing Scale (PCS), and the Pittsburgh Sleep Quality Index (PSQI), into the evaluation protocol.

In conclusion, we commend Zuo et al for their innovative integration of TCM with modern assessment methods in treating cervical spondylosis, marking an important step toward building evidence-based evaluation systems for complementary and alternative medicine. We look forward to future high-quality studies that further validate this therapy and support its evidence-based application and wider adoption.