Comparative Efficacy of Different Acupuncture-Related Therapies for Primary Tinnitus: A Systematic Review and Network Meta-Analysis Protocol
Yang et al. · Journal of Pain Research · 2023
Evidence Level
MODERATEOBJECTIVE
Compare the efficacy of different acupuncture-related therapies for primary tinnitus through network meta-analysis
WHO
Patients diagnosed with primary tinnitus, without age or sex restrictions
DURATION
Protocol for searching through March 2023 across 10 databases
POINTS
All modalities of invasive acupuncture involving needle insertion
🔬 Study Design
Protocol
n=0
Methodology for comparing multiple acupuncture therapies
📊 Results in numbers
Databases searched
Languages included
Primary outcome
PROSPERO registration
📊 Outcome Comparison
Methodological quality (RoB 2.0)
This is a research protocol that establishes how a large review of different types of acupuncture for ringing in the ears (tinnitus) will be conducted. The researchers will analyze all previously published studies to determine which type of acupuncture works best.
Article summary
Plain-language narrative summary
This protocol outlines a rigorous methodological approach to conducting a systematic review and network meta-analysis on the comparative efficacy of different acupuncture-related therapies for primary tinnitus. Tinnitus is a common medical condition affecting 10-15% of the general population, characterized by the perception of sound without an identifiable external source, and can significantly impact quality of life and contribute to psychological comorbidities such as anxiety, depression, and sleep disorders. Primary tinnitus is defined as tinnitus without an identifiable defined cause, differing from secondary tinnitus, which is explicitly associated with a specific medical condition. Conventional treatment options recommended by guidelines include medications, sound therapy, hearing aids, cognitive behavioral therapy, and dietary changes; however, efficacy varies among individuals and often offers only modest relief.
Acupuncture has gained popularity as an alternative therapy and is recognized as a potential treatment option in some clinical guidelines. The proposed methodology will include a comprehensive search across 10 representative databases (6 in English and 4 in Chinese), from the inception of each database through March 2023. Eligibility criteria follow the PICOS framework, including patients diagnosed with tinnitus without age or sex restrictions; invasive acupuncture interventions involving needle insertion (manual acupuncture, electroacupuncture, warm needling, fire acupuncture, bloodletting puncture, catgut embedding at acupoints, point injection, among others); comparators including active therapies recommended by guidelines or inactive controls; and primary outcomes of symptom severity measured by visual analog scales or validated standardized questionnaires such as the Tinnitus Functional Index, Tinnitus Handicap Inventory, and others. Only randomized clinical trials will be included.
Methodological quality assessment will use the Cochrane Risk of Bias 2.0 tool, analyzing the randomization process, deviations from intended treatments, missing outcome data, outcome measurement, and selection of reported outcomes. Statistical analysis will employ standard pairwise meta-analysis and Bayesian network meta-analysis, using WinBUGS V.1.4.3 and R 3.6.2 software. Network meta-analysis will allow indirect comparisons through a network of studies, overcoming limitations of conventional meta-analyses that only allow direct comparisons. Network graphs, contribution matrices, ranking probabilities, and SUCRA (Surface Under the Cumulative Ranking) values will be constructed to determine the optimal treatment.
Consistency will be evaluated using the node-splitting method, and subgroup analyses will be conducted according to different tinnitus durations, measurement time points, age groups, and geographic settings. Acknowledged limitations include restriction to Chinese and English languages, potential selection bias, and possible publication bias considering that the majority of Chinese acupuncture studies produce positive results. Certainty of evidence will be assessed using the GRADE system, and publication bias will be evaluated by funnel plots and Egger's tests when appropriate. This protocol represents a significant methodological advance in the field, being only the second network meta-analysis in this area, updating evidence since 2017 and employing more rigorous PICOS criteria than previous studies.
Strengths
- 1Rigorous methodology following PRISMA guidelines
- 2Comprehensive search across 10 databases
- 3Use of network meta-analysis for indirect comparisons
- 4Prospective registration in PROSPERO
Limitations
- 1Restriction to Chinese and English languages
- 2Possible publication bias in Chinese studies
- 3Most studies likely conducted in China
- 4Protocol only, no results available
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
Primary tinnitus remains one of the most frustrating challenges in pain and rehabilitation practice: patients arrive at the office after seeing otolaryngologists, neurologists, and audiologists without satisfactory response, and the conventional armamentarium — sound therapy, CBT, hearing aid adjustment — often offers only partial relief. In this context, a systematic review protocol with network meta-analysis has genuine clinical value because it proposes to answer not only whether acupuncture works, but which specific modality — manual, electroacupuncture, warm needling, point injection — performs best in direct and indirect comparison. For the physician caring for this population, the distinction between modalities is not trivial: each mobilizes distinct neurophysiologic mechanisms, with implications for patient selection and integration into the multidisciplinary treatment plan. The subgroup analyses by tinnitus duration and age group, planned in the protocol, will make future findings even more applicable to daily practice.
▸ Notable Findings
Being the second network meta-analysis study in the area, updating evidence since 2017 with more rigorous PICOS criteria than its predecessor, already confers methodological relevance to the work. The decision to include ten databases — six in English and four in Chinese — explicitly recognizes that the most substantial volume of acupuncture clinical trials in tinnitus comes from Sinophone literature, and the protocol incorporates formal mechanisms for publication bias assessment via funnel plots and Egger's test. The use of a Bayesian approach with SUCRA values for ranking interventions is particularly promising: it will allow clinicians to visualize a probabilistic hierarchy of efficacy among modalities that today are prescribed in a relatively arbitrary manner. The inclusion of modalities such as catgut embedding and acupoint injection extends the scope beyond conventional acupuncture, covering practices already in use at some specialized services.
▸ From My Experience
In my practice with refractory chronic tinnitus patients, I have combined electroacupuncture at auricular and cervical points with vestibular rehabilitation therapy and, when there is evident auditory hypervigilance, concurrent referral for auditory CBT. The response typically appears between the fourth and sixth session, generally as a reduction in perceived intensity or in the interference of tinnitus with sleep — which, in my experience, is the outcome patients value most. Patients with an associated cervical myofascial component — which I frequently see in post-whiplash cases or in musicians — respond particularly favorably to paravertebral electroacupuncture, something I expect to see reflected in the subgroups of the future review. The profile that benefits least, and which I am cautious about indicating, is the patient with severe sensorineural hearing loss and well-established high-frequency tinnitus of more than five years: expectations need to be calibrated from the start. A review that classifies modalities by relative efficacy will be a decision-making instrument that is missing in daily practice.
Full original article
Read the full scientific study
Journal of Pain Research · 2023
DOI: 10.2147/JPR.S414622
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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