Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
PEER REVIEW HISTORY
BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to
complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and
are provided with free text boxes to elaborate on their assessment. These free text comments are
reproduced below.
ARTICLE DETAILS
TITLE (PROVISIONAL)
AUTHORS
Acupuncture for chronic knee pain: A protocol for an updated
systematic review
Zhang, Qinhong; Yue, Jinhuan; Sun, Zhongren; Lu, Ying
VERSION 1 - REVIEW
REVIEWER
REVIEW RETURNED
Zhishun Liu
Guang An Men Hospital,China Academy of Chinese Medical
Sciences, PR China
02-Apr-2015
GENERAL COMMENTS
1.The author should give credible reason to do this meta-analysis
because several systematic review papers on acupuncture for knee
joint have been published.
2.The abstract should include possible results and conclution.
3.No ethics declared.
4.How about the unpublished papers?
5.I don't think the subanalysis for different acupuncture type is
possible because so many different acupuncture method included.
6.The author should describe the possible limitations in discussion.
REVIEWER
Ann Hopton
University of York
United Kingdom
14-Apr-2015
REVIEW RETURNED
GENERAL COMMENTS
Dear Authors
This review is timely and of interest to the research field. However
there are major revisions to be made before this publication could be
considered acceptable to a high profile journal. I have listed some
minor changes below and given directions to examples that would
show you how to improve the methods section. I hope you find them
helpful
Introduction section:_
There are several statements that require checking:
First paragraph line 5, please add the percentage
Paragraph one:- please provide a reference for psychological
impairment.
Paragraph three:- lines 38-39- Is acupuncture the most common
treatment for knee-pain? Or is acupuncture the most common
complementary therapy for knee pain please specify. In a Western
society more people take medication for knee-pain than attend
acupuncture.
Sentence 59:Typo significant should read significantly- also please
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
clarify whether this is statistically significant or clinically meaningful.
Statistical significance is not worth much if the difference is not
clinically meaningful.
Methods; The methods section is lacking in detail throughout. Rather
than provide a very lengthy list of suggested changes I think it would
be more helpful to you to look at an example of how much detail to
provide. Please refer to teh following paper as a good example:
Vickers et al. Trials 2010, 11:90
http://www.trialsjournal.com/content/11/1/90
Also consider using the STRICTA guidelines for reporting
acupuncture trials when assessing the quality of the studies to
include or exclude.
Revised STandards for Reporting Interventions in Clinical Trials of
Acupuncture (STRICTA): Extending the CONSORT Statement.
Hugh MacPherson1, Douglas G. Altman2, Richard Hammerschlag3,
Li Youping4, Wu Taixiang4, Adrian White5, David Moher6 andon
behalf of the STRICTA Revision Group1
DOI: 10.1111/j.1756-5391.2010.01086.x
I think with much more detail in the Methods section this would make
a very interesting study and I look forward to seeing it in publication
in the future.
REVIEWER
REVIEW RETURNED
Christos Mavrommatis
Rheumatologist, MD, PhD, Msc
General Hospital of Athens "Evangelismos"
17-Apr-2015
GENERAL COMMENTS
Generally, I believe that this is a properly structured protocol for a
systematic review of studies related to the effect of acupuncture on
chronic knee pain. In order to improve the article, I would like the
authors to better explain their objections about the design of the
study of Chinmann R.S. et al (15).
REVIEWER
Terje Alræk
National Research Center in Complementary and Alternative
Medicine (NAFKAM)
Department of Community Medicine, Faculty of Health Sciences
UiT The Arctic University of Norway, Tromsø, Norway
24-Apr-2015
REVIEW RETURNED
GENERAL COMMENTS
Systematic reviews are alway of importance, however sometimes
there are issues which make them dificult to interpret - as the case is
for acupuncture and OA of the knee. This leads on to several om my
questions:
When I read your Intoduction I get the impression that your review is
about older people (older adults, as you write is = 55+). However
page 4 under the heading Participants, you write that you will include
patients of any age, thats fine but this need to be reflected in the
Introduction as well. Will you discuss jumpers knee, patellofemoral
pain in you review?
Minor comments:
page 4, line 51; I'll think you should use ethnicity rather than race (?)
page 3, line 30, after the , you write, "including rare serious events
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
[8,9]" - as it reads now it dosen't make sense following the previous
sentence
page 3, line 36 You write that acupuncture is widly used, yhats true,
however I'm not familiar that it is widely used for pressure ulcers?
Your reference is also a case story. I would suggest that you use
other references to more widly use of acupuncture.
page 3, line 39-39. You write:" THe most common treatment for
chronic knee pain is acupuncture [13]" By reading your reference I
can't find that they say that; maybe you mean the most common
CAM treatment?
page 3, line 47 reads :"conventional measures for treating..." I'll
guess you mean conventional MEDICINE?
PAGE 5, LINE 28: you write: ", any unexpected events will be
recorded" is this viewed different than adverse events? For
consistency I suggest that you use adverse events in your paper
page 8, line 22 You write " ..health policy-makers in the us." It should
read US and I wonder why you only include healt policy-makers only
from US?
VERSION 1 – AUTHOR RESPONSE
1. Reviewer Name Zhishun Liu
Institution and Country Guang An Men Hospital,China Academy of Chinese Medical Sciences, PR
China
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
1.The author should give credible reason to do this meta-analysis because several systematic review
papers on acupuncture for knee joint have been published.
Answer: Thanks for the reviewer's excellent comment. We have responded it on the 4th paragraph,
introduction section.
2.The abstract should include possible results and conclusion.
Answer: We have added the possible results in the abstract section as this analysis “will provide the
latest analysis of the currently available evidence for acupuncture treating chronic knee pain.”
3.No ethics declared.
Answer: We have declared in the abstract section.
4.How about the unpublished papers?
Answer: We will retrieve unpublished protocols and summary results through a search of the clinical
trial registry at https://clinicaltrials.gov/.
5. I don't think the subanalysis for different acupuncture type is possible because so many different
acupuncture method included.
Answer: We will perform subanalysis for acupuncture type by comparing manual acupuncture or
electroacupuncture with control intervention.
6.The author should describe the possible limitations in discussion.
Answer: We have added the possible limitations in the discussion section. We also expand evaluation
of meta-biases.
2. Reviewer Name Ann Hopton
Institution and Country University of York
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
United Kingdom
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
Dear Authors
This review is timely and of interest to the research field. However there are major revisions to be
made before this publication could be considered acceptable to a high profile journal. I have listed
some minor changes below and given directions to examples that would show you how to improve the
methods section. I hope you find them helpful
Thank you.
Introduction section:_
There are several statements that require checking:
First paragraph line 5, please add the percentage
Answer: We have added the percentage to the sentence in line 5, first paragraph, introduction
section.
Paragraph one:- please provide a reference for psychological impairment.
Answer: Thanks. We have added a reference for psychological impairment.(See reference 5.)
Paragraph three:- lines 38-39- Is acupuncture the most common treatment for knee-pain? Or is
acupuncture the most common complementary therapy for knee pain please specify. In a Western
society more people take medication for knee-pain than attend acupuncture.
Answer: Thanks, we have rewritten this sentence to state it as one of the most common
complementary therapies.
Sentence 59:Typo significant should read significantly- also please clarify whether this is statistically
significant or clinically meaningful. Statistical significance is not worth much if the difference is not
clinically meaningful.
Answer: We have changed the "significant" to "significantly".
As a systematic review, this study drew the conclusion based on the results of meta-analysis. It
contained both statistics and estimations of effect size for people to determine the clinical
significance.
Methods; The methods section is lacking in detail throughout. Rather than provide a very lengthy list
of suggested changes I think it would be more helpful to you to look at an example of how much detail
to provide. Please refer to the following paper as a good example:
Vickers et al. Trials 2010, 11:90 http://www.trialsjournal.com/content/11/1/90
Answer: Thank you very much for your helpful suggestions. We have reorganized our method section
according to your recommendation. One big difference between the Vickers et al and this analysis is
that we will not obtain individual patient data and our analysis focuses on the aggregated study data.
Also consider using the STRICTA guidelines for reporting acupuncture trials when assessing the
quality of the studies to include or exclude.
Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA):
Extending the CONSORT Statement. Hugh MacPherson1, Douglas G. Altman2, Richard
Hammerschlag3, Li Youping4, Wu Taixiang4, Adrian White5, David Moher6 andon behalf of the
STRICTA Revision Group1
DOI: 10.1111/j.1756-5391.2010.01086.x
Answer: Thanks for the reviewer's excellent comment. We will conduct this systematic review
according to the STRICTA CONSORT Statement.
I think with much more detail in the Methods section this would make a very interesting study and I
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
look forward to seeing it in publication in the future.
3. Reviewer Name Christos Mavrommatis
Institution and Country Rheumatologist, MD, PhD, Msc
Until March of 2013 I was working in the Rheumatologygy Department of the General Hospital of
Athens "Evangelismos".
Since the summer of 2013 I'm working in private practice.
Greece
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
Generally, I believe that this is a properly structured protocol for a systematic review of studies related
to the effect of acupuncture on chronic knee pain. In order to improve the article, I would like the
authors to better explain their objections about the design of the study of Chinmann R.S. et al (15).
Answer: Thanks for the reviewer's excellent comment. We have stated this point and cited our
previous comment published in the Acupuncture in Medicine and 5 other letters to editors published in
JAMA. (See 2nd paragraph, Introduction section)
Reviewer: 4
Please leave your comments for the authors below
Dear authors
Systematic reviews are always of importance, however sometimes there are issues which make them
difficult to interpret - as the case is for acupuncture and OA of the knee. This leads on to several om
my questions:
When I read your Introduction I get the impression that your review is about older people (older
adults, as you write is = 55+). However page 4 under the heading Participants, you write that you will
include patients of any age, thats fine but this need to be reflected in the Introduction as well. Will you
discuss jumpers knee, patellofemoral pain in you review?
Answer: Thanks for the reviewer's great comment. In Introduction section, we have introduced the
prevalence of chronic knee pain in population. The previous study reported that "chronic knee pain
affects a large percentage of older adults, especially among people aged 50–69 years" However,
there are still a small portion of younger people under 50 years old, who still can suffer from chronic
knee pain. As for this systematic review, we try to research and include more wide range ages of this
kind of patients to evaluate the efficacy of acupuncture for chronic knee pain, not just the older
patients. Our meta-analysis is based on aggregated data and may not be able to address the efficacy
in different causes of knee pain, such as patellar-femoral/jumpers keen pain versus degenerative OA,
for example. We add a statement for possible limitation in the discussion section.
Minor comments:
page 4, line 51; I'll think you should use ethnicity rather than race (?)
Answer: We have revised it.
page 3, line 30, after the , you write, "including rare serious events [8,9]" - as it reads now it dosen't
make sense following the previous sentence
Answer: Thanks for the reviewer's great comment. We have rewritten these two sentences.
page 3, line 36 You write that acupuncture is widely used, yhats true, however I'm not familiar that it is
widely used for pressure ulcers? Your reference is also a case story. I would suggest that you use
other references to more widly use of acupuncture.
Answer: We have added an additional reference to the pressure ulcers.
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
page 3, line 39-39. You write:" THe most common treatment for chronic knee pain is acupuncture
[13]" By reading your reference I can't find that they say that; maybe you mean the most common
CAM treatment?
Answer: We have revised the sentence and responded this comment.
page 3, line 47 reads :"conventional measures for treating..." I'll guess you mean conventional
MEDICINE?
Answer: Yes, that's exactly right.
PAGE 5, LINE 28: you write: ", any unexpected events will be recorded" is this viewed different than
adverse events? For consistency I suggest that you use adverse events in your paper
Answer: Thanks for the reviewer's great suggestion. We have revised it.
page 8, line 22 You write " ..health policy-makers in the us." It should read US and I wonder why you
only include health policy-makers only from US?
Answer: Thanks for the reviewer's excellent comment. We have responded the comment and
removed the "US".
VERSION 2 - REVIEW
REVIEWER
REVIEW RETURNED
Zhishun Liu
Guang An Men Hospital, China Academy of Chinese Medicine
Sciences
15-May-2015
GENERAL COMMENTS
This protocol has been revised good enough.
REVIEWER
Ann HOpton
University of York
UK
20-May-2015
REVIEW RETURNED
GENERAL COMMENTS
the reporting standards of Chinese acupuncture interventions is
known to be poor. Given the extent of the timescale of papers that
you are to review I would prefer to see the STRICTA guidelines for
reporting used as part of the quality control for this review to ensure
tat the acupuncture interventions within the chosen papers are of
sufficient quality to replicate the study. I added this to my previous
review and it has not been addressed.
REVIEWER
Christos Mavrommatis
Rheumatologist, MD, PhD, MSc
28-May-2015
REVIEW RETURNED
GENERAL COMMENTS
I believe that the authors answered the questions and concerns of
the reviewers and that the protocol is ready for publication. I think it
will be a very interesting study and I look forward to see it published
in the future.
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
VERSION 2 – AUTHOR RESPONSE
Reviewer Name Zhishun Liu
Institution and Country Guang An Men Hospital, China Academy of Chinese Medicine Sciences
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
This protocol has been revised good enough.
Answer: Thanks for the Dr. Liu helpful comments.
Reviewer Name Ann HOpton
Institution and Country University of York
UK
Please state any competing interests or state ‘None declared’: None Declared
Please leave your comments for the authors below
the reporting standards of Chinese acupuncture interventions is known to be poor. Given the extent of
the timescale of papers that you are to review I would prefer to see the STRICTA guidelines for
reporting used as part of the quality control for this review to ensure tat the acupuncture interventions
within the chosen papers are of sufficient quality to replicate the study. I added this to my previous
review and it has not been addressed.
Answer: We appreciate reviewer’s comment on using the STRICTA guidelines in the evaluation of
quality of trials. We have added the use of STRICTA checklist as a quality control method in the
method section and also add a sensitivity studies by removing studies with incomplete reports
according to STRICTA checklist.
Reviewer Name Christos Mavrommatis
Institution and Country Rheumatologist, MD, PhD, MSc
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
I believe that the authors answered the questions and concerns of the reviewers and that the protocol
is ready for publication. I think it will be a very interesting study and I look forward to see it published
in the future.
Answer: Thanks for the Dr. Mavrommatis all helpful comments.
Downloaded from http://bmjopen.bmj.com/ on March 1, 2016 - Published by group.bmj.com
Acupuncture for chronic knee pain: a
protocol for an updated systematic review
Qinhong Zhang, Jinhuan Yue, Zhongren Sun and Ying Lu
BMJ Open 2016 6:
doi: 10.1136/bmjopen-2015-008027
Updated information and services can be found at:
http://bmjopen.bmj.com/content/6/2/e008027
These include:
References
This article cites 34 articles, 8 of which you can access for free at:
http://bmjopen.bmj.com/content/6/2/e008027#BIBL
Open Access
This is an Open Access article distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work
non-commercially, and license their derivative works on different terms,
provided the original work is properly cited and the use is
non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Email alerting
service
Receive free email alerts when new articles cite this article. Sign up in the
box at the top right corner of the online article.
Topic
Collections
Articles on similar topics can be found in the following collections
Evidence based practice (450)
Notes
To request permissions go to:
http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to:
http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to:
http://group.bmj.com/subscribe/