This is a multicenter, randomized, patient and assessor-blinded trial. A target sample of 312 participants will be recruited from the acupuncture clinic at Yunnan Provincial hospital of Traditional Chinese Medicine , Kunming Minicipal Hospital of Traditional Chinese Medicine , Yuxi Minicipal Hospital of Traditional Chinese Medicine. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist(Additional file 1). The flow chart is shown in Fig.1. The protocol is in line with the principles of the Declaration of Helsinki and has been approved by Institution review board (IRB) of Yunnan Provincial hospital and Traditional Chinese Medicine (approval no.2018-003-01). This trial was registered at the Chinese Clinical Trial Registry (ChiCTR1800017581). Any changes which need to be made in the trial protocol will be communicated to all researchers, the ethics committees, and the trial registry. Each participant will sign an informed consent. Participants will be recruited into the study only once and will not receive any monetary compensation for their participation.
In the early stage, we will make the inclusion and exclusion criteria known to target population through posters, WeChat and Internet. The team leader will give lectures on osteoporosis in three hospitals, interact with osteoporosis patients, and improve the enthusiasm of patients to participate in the study. In the meantime, we will explain the eligibility criteria to interested patients, and the participants will sign an informed consent form when they have a clear and comprehensive understanding of the trials they will participate in, such as the benefits they may gain, the potential risks they may encounter, the settings of the acupuncture group and the interventions that will be conducted on them, and so on. The participants will be randomly assigned to the acupuncture group or drug group. We will pay particular attention to baseline characteristics such as age, sex, menopause time, bone density, time of first detection of fractures, level of risk for falls, exercise habits, ethnic distribution, smoking and drinking history.
This study will be performed over a period of 16 months: 1 month of preparition, 3 months of treatment, and 12 months of post-treatment follow-up. All eligible patients will be randomly divided to either an acupuncture group or a control group receiving standard western medicine treatment. Outcomes will be assessed at baseline, after 3-months treatment and at the 6-month and 12-month of the follow-up.Table 1 illustrate the time schedule of enrollment, interventions, assessments, and participant visits.
Randomization and blinding
The researchers are unable to predict the allocation of patients, and no changes in allocation are allowed after randomization. The "computer pseudo-random number generation method" will be used to generate pseudo-random numbers, and the patients numbered from 1 to 312 will be given the pseudo-random numbers each. Participants with their pseudo-random numbers ranked in the even-numbered position will be included in the acupuncture group, and the rest will be included in the control group. Randomized allocations of acupuncture or control groups will be generated by independent researchers using computer software. Computer-generated treatment codes are placed in sealed, opaque envelopes and distributed by dedicated study nurses, who will be trained before the trial and will not participate in treatment or care.
Participants in this study will be informed that they will receive acupuncture with medication or medication only. The acupuncturists in the acupuncture group and the physicians in the control group will receive a pre-experimental training session, and we are unable to apply the principle of blindness to them. However, acupuncturists and physicians are not involved in the measurement of results or statistical analysis, and the specific details of their treatment cannot be disclosed to the assessor or participant. Before the statistical analysis is completed, the statisticians know nothing about the group allocation which may cause biases.
Participants who meet all the following requirements will be allowed for enrollment:
- Meet the diagnostic criteria of traditional Chinese medicine: "Diagnosis and Treatment Program for Osteoporosis in the Key Specialty Cooperation Group of the State Administration of Traditional Chinese Medicine", the dialectical classification conforms to spleen and kidney yang deficiency, liver and kidney yin deficiency, qi stagnation and blood stasis;
- Meet the diagnostic criteria of western medicine: refer to the 2017 guidelines for diagnosis and treatment of primary osteoporosis compiled by the Chinese Medical Association, patients with primary osteoporosis aged 60-80 years;
- Willing to receive acupuncture treatment for 3 months;
- Sign the informed consent and agree to accept the research treatment plan and obey the research arrangement.
Participants meeting any of the following criteria will be excluded:
- report to have participated in other clinical trials in the past three months at the beginning of the study;
- report to have taken osteoporosis drugs or received acupuncture treatment in the past three months;
- report to have secondary osteoporosis;
- report to have serious heart, liver and kidney diseases;
- report to have hematological system diseases;
- report to have hemiplegia, physical disability, prolonged confinement to bed;
- report to have other serious chronic, consumptive diseases;
- report to have severe mental or cognitive impairment.
Criteria for case exclusion and dropout
Participants would be excluded or dropped out if they meet any of the criteria below:
- do not follow medical advice in treatment;
- quit by themselves during the test;
- become ineligible for the trial because of physical reasons.
Acupuncture and the control group
Patients in the acupuncture group will receive standard pharmacological treatment same as the control group, and receive acupuncture two times a week for 12 weeks for a total of 24 treatment sessions. Patients will receive treatment in supine position for 20 min per session. The treatment will be provided by licensed acupuncturists holding acupuncture physician certifications in China with at least 3 years of clinical experience. Disposable, sterile needles with a diameter of 0.25 mm and a body length of 40 mm (Huatuo, Suzhou, China) will be used. Based on TCM theory and our clinical experience, acupoints used here are unilateral BL11 (Dayu), BL23 (Shenshu), and St36 (Zusanli). In addition, for participants with kidney deficiency GV4 (Ming Men) and KI (Taixi) are inserted; for those with spleen-deficiency SP6 (Sanyinjiao) and BL20 (Pi Shu) are punctured; for those with blood stagnation BL17 (Geyu) and SP6 (Sanyinjiao) are used. (Table 2). The exact location and depth of needling for each point will be determined based on the 2006 People’s Republic of China National Standard (GB/T 12346–2006) Acu-Points Name and Location . After insertion, all points will be manually stimulated by lifting and thrusting the needle every 10 min to elicit the “deqi” , warm acupuncture will be used, fix the 2 cm-long moxa-stick on the handle of the needle and light it at the root of the needle ,the needles will be retained for 20 min.
The parameters of the skin needle are set as follows: Qixing needle: tapping along the first side line of the urinary bladder meridian in the back; moderate stimulation will be applied for the blood stasis type, until redness of the skin and petechiae is observed in the tapping part; mild stimulation was used for the rest of the syndromes until redness in the skin is observed.
The parameters of the cupping are set as follows: moving cupping: smear the tapping spot evenly with Vaseline and move the cup along the first lateral line of urinary bladder meridian back and forth until red blood stasis appears on the skin, according to the patient’s tolerance (feeling comfortable, without an obvious pain). Retaining cupping: Leave the cup for 8 to 10 minutes in Dazhui, Shenshu, and a severely painful area.
The patients in the control group will receive standard pharmacological treatment. Patients with osteoporosis will take Alendronate Sodium Tablets 10mg ( once per day, taken with a glass of warm water before breakfast) for 12 weeks. However, no acupuncture treatment was given during the study period. They will be evaluated at each visit.
Patients will be carefully examined before the treatment and after the last treatment (three months after the first acupuncture treatment). Evaluation and follow-up will be conducted at the timepoints of 3 months, 6 months and 1 year after acupuncture treatments.
The primary outcome measure of this trial is the bone mineral density (BMD). BMD was measured by a dual energy X-ray absorptiometry (manufacturer: DMS, France; model: CHALLENGER C 313). BMD of the lumbar vertebrae (L1-L4) in the two groups will be measured before and after treatment. Mean value of BMD will be collected, and the rate of its change will be used to assess the effectiveness. BMD change rate (Δ) = (BMD after treatment - BMD before treatment) /BMD before treatment × 100%.
The secondary outcome measures include Bone-derived alkaline phosphatase(BALP), bone glaprotein(BGP), visual pain scale score(VAS),Traditional Chinese Medicine (TCM) syndrome scores, quality of daily life score(QOL) and adverse events.
Bone metabolism markers: serum bone-derived alkaline phosphatase (BALP) levels, serum osteocalcin levels (BGP). The fasting venous blood was collected before treatment, one course of treatment and at the end of treatment respectively. The enzyme-linked immunosorbent assay (ELISA) (biocell enzyme standard instrument) was used to determine BGP and BALP .
Pain score. The pain score will be assessed for the lower back. A Visual Analogue Scale (VAS) will be used to measure each group before and after treatment (see Attached table 2). VAS is a 10 cm line with a scale of 0-10, with 0 being no pain and 10 being the worst pain. The subject will be asked to mark their current pain level on the line. The examiner scores the VAS by measuring the distance from the zero point to the point the subject marks. The unit is centimeter (CM).
Quality of life: Based on Quality of Life (QOL) and 36-Item Short Form Survey (SF-36), combined with the specificity of osteoporosis and clinical situations, a self-rating scale in line with Chinese ethnicity was developed (see Attached table 1). Previous studies have shown that it has good applicability[15-16]. The scale is answered by the patient without the physician be involved. The total score of 54 points or less is defined as a normal quality of life, >54-70 points as decreased quality of life, 71 -80 points as the quality of life decreased obviously, and > 80 points as a serious decline in quality of life. Self-control design will be conducted before and after treatment. A decrease in the score of ≥ 20 points is defined as an improvement in the quality of life.
Clinical symptoms of TCM: symptom quantitative score will be used, which is based on "Guidelines for Clinical Research of New Drugs of Traditional Chinese Medicine" . Four levels are used to assess the severity of symptoms, which include no, mild, moderate and severe. a specific score will be given to each level (see attached Table 3). Effectiveness assessment: clinical recovery: TCM symptoms disappear, symptom score decreases by ≥95%; remarkable effectiveness: TCM symptoms and signs are improved significantly, symptom score decreases by ≥70%; effectiveness: TCM symptoms and signs improve, symptom score decreases by ≥30%; No effectiveness: TCM symptoms and signs are not improved or aggravated, and the symptom score reduces by <30%.
During the study, adverse events (AEs) are defined as any unexpected or undesired harmful effect resulting from acupuncture or pharmacological treatment. A research assistant (GL) will be required to record all the AEs, including information on the time of occurrence, severity, duration, measurement, management, and its outcome, in a case report form (CRF). Any serious adverse events (SAEs) will be immediately reported to the principal investigator (JHS) and the Medical Ethics Committee within 24 h. The Acupuncture Department of Yunnan Province Hospital of TCM will be responsible for the treatment of all the AEs.
Sample size calculation and statistical analysis
According to our previous research results , which showed that, among 36 patients with primary osteoporosis in each group 28 cases gained an increase in their quality of life in the acupuncture group after a course of treatment (2 times a week, 3 months for a course of treatment), and 18 cases gained an increase in their quality of life in the drug group. In this proposal, two groups are set up, set α=0.05, 1-β= 0.90. According to the literature estimation, the effective rate of the drug group was 50%, that of the acupuncture group was 78%, and the expected loss to follow up was less than 10%. According to the formula for sample size of each groupn= 1/1-f*[2*（Za+Zb）2*p*(1-p)/（p0-p1）2]，in which p0=50%, p1=78%, p=(p0+p1)/2=64%, Zα=1.65(one-sided), Zβ=1.28. After calculation, the sample size of acupuncture group or drug group is 155.7 (), so 312 cases of osteoporosis patients are needed in this study, with 156 cases in each group.
Statistical analysis of all data in this study will be per- formed by a specialized statistician, who is blinded to the treatment allocation. All data will be analyzed by blinded statisticians using SPSS20.0 (SPSS Inc., Chicago, IL, USA). First, collect and compare baseline data. All participants randomly assigned to each group will be included in the analysis, and the intention to treat analysis (ITT) will be used. The randomly assigned patients, regardless of whether they complete the treatment or not, should be finally included in the assigned group for statistical analysis of efficacy. For the data of classified variables, "count n (percentage, %)" or "percentage (numerator/denominator, n/ n)" will be used for the statistics, and the Chi-square test will be used to compare rates between groups. For the data of numerical variables, the one-sample Kolmogorov-Smirnov Test will be used to verify whether the data is normally distributed. The data that is normally distributed will be expressed as "Mean±SD", and the Mean comparison between the two groups will be tested using the t-test. Data that is not normally distributed will be described as Median [lower quartile, upper quartile] (Median [Q1, Q3])of Tukey's Hinges ; Comparison of distributions between two groups will be performed using the Mann-Whitney U Test from Nonparametric Test. A two-sided p value of less than 0.05 will be considered statistically significant for all analyses.
Data management and monitoring
All the researchers will focus on and sign to protect the individual privacy of the participants. The raw data will be collected and cross-checked by two researchers (Huang M and Lai MX). The database software EpiData (version 3.1) will be used for the data management. All the management will be performed in compliance with the study Standard Operation Process (SOP).
The Department of Science and Technology in Yunanan University of TCM, which is not taking part in the study, will be responsible for the monitoring. The CRFs, protocol compliance, data management, treatment administration and AEs will be monitored independently during the study.