Dear editor

We recently reviewed the meta-analysis published in the Journal of Pain Research titled “Cervical Rotation-Traction Manipulation for Cervical Radiculopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.”¹ This meta-analysis included nine randomized controlled trials (RCTs) and demonstrated the effectiveness of cervical rotation-traction manipulation (CRTM) in alleviating pain and improving cervical motion in patients with cervical radiculopathy (CR). These findings offer valuable insights for the clinical management of this condition. While we commend the authors for their important contributions, we would like to offer a few suggestions for further consideration.

First, the studies included in this meta-analysis span a wide range of publication years (2008 to 2023). Cervical rotation-traction manipulation, a traditional Chinese therapeutic maneuver, is often adapted over time in clinical practice, which may lead to variations in how clinicians perform the manipulation.^2,3 Such variations may contribute to inconsistencies and biases in the data, resulting in the high heterogeneity observed in the meta-analysis results.

Second, most of the included studies did not report safety evaluations as part of their methodology. Safety analysis is a crucial aspect of clinical trials, and meta-analyses are key sources of evidence in this regard.⁴ However, due to small sample sizes and low event rates, comprehensive safety assessments were difficult to conduct. Only four of the nine RCTs mentioned safety measures, so caution should be exercised when interpreting the findings as indicative of high safety.

Third, Feng et al did not provide specific details on how sensitivity analysis was conducted. Sensitivity analysis is essential in assessing the robustness of the results in a meta-analysis,⁵ which involves systematically excluding individual studies, modifying inclusion criteria, and addressing low-quality studies. Relying solely on the authors’ statements without a transparent sensitivity analysis may limit the readers’ ability to fully evaluate the reliability of the conclusions.

In conclusion, we highly appreciate the work of Feng et al for advancing the traditional Chinese technique in managing CR, and provides an evidence-based basis for the treatment of CR by CRTM. At the same time, we also look forward to future studies that can refine inclusion and exclusion criteria (eg, by focusing on studies with standardized cervical rotation-traction protocols) and incorporate larger multi-center clinical trials to enhance the robustness of safety evaluations.