Objectives
Hypothesis
- We hypothesize that sleep quality will be significantly improved in the group receiving acupuncture treatment versus the sham group, as assessed by both subjective (PSQI) and objective (actigraphy) measurements.
- The hyperarousal state, measured by HAS, will be decreased more in the group receiving acupuncture versus the sham group.
- Based on fMRI examination, functional connectivity and ReHo, in the emotion-related areas, will be altered in the group receiving acupuncture versus the sham group.
Setting
The trial site will be the Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China. Sixty patients with insomnia disorder will be assigned to either a real acupuncture group or a sham group, using a digital randomization table in a 1:1 ratio.
Trial design
This study will be conducted as a single-center, prospective parallel-group, patient-assessor-blinded, randomized controlled trial (RCT). The trial will be conducted in accordance with the CONSORT (Consolidated Standards of Reporting Trials) [18] and STRICTA (Standards for Reporting Interventions in Clinical Trials of Acupuncture) principles [19], to fulfill adequate reporting standards for RCTs. Sixty patients, with insomnia disorder, will be assigned to either a real acupuncture group or a sham acupuncture group, using a digital randomization table in a 1:1 ratio. Participants will keep a sleep diary at baseline, during the 4th week of treatment, and during the 8th week of follow-up period. Both the neuropsychological measurements and fMRI scans will be performed at baseline, after completion of the acupuncture treatments, and at the conclusion of the follow-up period. Thirty age- and sex-matched healthy good sleepers will be recruited as controls for the fMRI data analysis. All outcome measures will be performed once for the healthy control patients. (Fig. 1)
Participants and recruitment
Posted notices in the hospital and recruitment information on the website of the Beijing Hospital of Traditional Chinese Medicine will be used to recruit study participants.
Participants will be informed about the benefits, as well as possible risks, of participation in the study, including poor clinical outcome and adverse events associated with acupuncture therapy. Completion of consent forms will be compulsory before trial participation and randomization. On the consent form, participants will be asked if they agree to use of their data should they choose to withdraw from the trial. Participants will also be asked for permission for the research team to share relevant data with people from the hospital taking part in the research or from regulatory authorities. This trial does not involve collecting biological specimens for storage. The model consent form and other related documentation given to participants can be are available from the corresponding author on request.
A neurologist will determine the PSQI, HAS, HAMD, HAMA scores to decide whether the participants meet the inclusion criteria. Patients whosatisfy the inclusion criteria will be randomized (1:1) into either a real acupuncture group or a sham acupuncture group. All participants will complete the baseline rs-fMRI, a 3-day actigraphy test, and the 1-week sleep diary. Participants will receive acupuncture treatment for 4 weeks. In addition, thirty age- and sex-matched Healthy good sleepers will be recruited as healthy controls for the fMRI data analysis. All personal information about the participants will be maintained confidentially by the research investigators and used for research purposes only.
Inclusion criteria for patients with insomnia disorder
Compliance with the criteria listed below will be required for participation in the study.
- Age between 20 and 60 years.
- Meet the diagnostic criteria for insomnia disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).
- A PSQI score >8 points; HAMD score <7; HAMA score <14; and HAS score >32.
- Signed informed consent form specific for this trial.
- Have not received medications for anxiety, depression, or insomnia within 1 month prior to enrollment in the study.
Exclusion criteria for patients with insomnia disorder
Patients will be excluded from enrollment in the trial if they meet one or more of the following:
- Diagnosis of anxiety, depression, or schizophrenia.
- Diagnosis of severe medical disorders, including cardiac, cerebral, renal, hepatic, or metabolic diseases, or benign prostatic hyperplasia.
- Diagnosis of other sleep disorders, such as sleep apnea and restless leg syndrome
- Women who are pregnant or breastfeeding.
- Difficulty completing the inspection and treatment.
- Contraindication for MRI including claustrophobia. Abnormal signal or obvious asymmetrical head structure by MRI.
- Acupuncture therapy for insomnia treatment in the past month.
- Addiction to drugs or alcohol.
Inclusion criteria for healthy good sleepers
- No complaints of sleep quality and quantity.
- Patients between 20 and 60 years of age.
- Signed informed consent form specific for this trial.
- Have not received medications for anxiety, depression, or insomnia within 1 month prior to enrollment in the study.
Exclusion criteria for healthy good sleepers
- Diagnosis of anxiety, depression, or schizophrenia.
- Diagnosis of severe medical disorders, including cardiac, cerebral, renal, hepatic, or metabolic diseases, or benign prostatic hyperplasia.
- Diagnosis of other sleep disorders, such as sleep apnea and restless leg syndrome
- Women who are pregnant or breastfeeding.
- Difficulty completing the inspection.
- Contraindications for MRI including claustrophobia. Abnormal signal or obvious asymmetrical head structure by MRI.
- Acupuncture therapy in the past month.
- Addiction to drugs or alcohol.
Sample size
This pilot study aims to determine the efficacy and central mechanism by which acupuncture affects insomnia disorder. Based on our previous pilot study [20], the PSQI score significantly decreased by 4.43 ± 3.60 in the group treated with acupuncture compared to 1.30 ± 2.58 in the control group. Based on a power analysis, 26 patients per group were required to detect a significant difference (power= 0.9, 𝛼 = 0.05, two-sided). Thus, we plan on recruiting 30 patients per group, to compensate for a 15% drop out rate. There is no known sample size calculation for fMRI research [21]. However, for the exploratory and pilot studies study, 10 15 to 30 patients are adequate to test the null hypothesis [21,22].
Ethics
Protocol approval was obtained by the Medical Ethical Committee of Beijing Hospital of Traditional Chinese Medicine on 12 March 2018 (2018BL-002-02). Written informed consent will be attained from each participant. This trial is funded by the National Natural Science Foundation of China (81774391, 81871507).
Randomization, allocation concealment, and blinding
After meeting the eligibility requirements, participants will be randomly assigned (1:1 ratio) to the real or the sham acupuncture group. The random allocation sequence will be generated by an independent statistician using Statistical Analysis Software (version 9.3, SAS Institute Inc., Cary, NC, USA). The randomization list will be closed in computer-made opaque envelopes with sequence numbers printed on the outside of the envelopes. After the patient has been screened, determined to be eligible, and has given informed consent, the envelopes will be opened by the researchers.
The acupuncturists cannot be blinded, and, therefore, will be excluded from assessments and data processing. In the trial, the participants, data analysts, and outcome assessors will be blinded. Assessors will not perform data analysis. Unblinding should only be performed in case of emergency, such as serious adverse events.
In addition, sterile steel needles of the same size and number for each treatment session will be used in both groups. Participants will be required to write down if they have received real acupuncture at the final treatment. The answer ‘Y’ or ‘N’ will be assessed to determine the confidence in the treatment.
Interventions
Real Acupuncture group (shown in table 1 and table 2)
The acupoints selection is based on the experience of experts and our previous clinical research [23]. All acupuncturists will receive training to assure consistent acupuncture technique in all participants. Acupoints on the vertex, including Baihui (GV-20), Shenting (GV-24), Benshen (GB-13), and Sishencong (EX-HN1), will be inserted horizontally for 10mm. Sanyinjiao (SP-6) will be inserted for 10 mm straight in, while Neiguan (PC-6) and Shenmen (HT-7) will be inserted perpendicularly for 5 mm. Needle manipulation, such as needling rotation, lifting, and inserting, will be employed to attain the ‘De Qi’ sensation (swelling, pain, numbness, distention, and heaviness). Needles will be kept in position for 30 min. Stainless steel needles used in the trial will be 0.32 mm×40 mm. The real acupuncture therapy will be performed three times per day at 2-day intervals for 4 weeks. The localization of the acupoints will be in accordance with the WHO Standard Acupuncture Locations [24].
Sham Acupuncture group (shown in table 1and table 2)
The sham acupuncture group will be given the sham therapy with the same treatment duration and frequency of sessions as the real acupuncture group. Based on previous clinical experience, we chose acupoints that are ineffective in treating insomnia for the sham acupuncture group. The following acupoints will be punctured in the sham group: Binao (LI-14), Shousanli (LI-10), Yangchi (TE-4), Waiguan (TE-5), Fengshi (GB-31), Liangqiu (ST-34), and Futu (ST-32). The same needle size as in the real acupuncture group will be used. Unlike the real acupuncture application, needles will be inserted superficially 1 mm without manual stimulation. The needles will be kept in place for 30 min. Meanwhile, creation of the De qi sensation will be prevented by not manipulating the needles.
Healthy Control group
No acupuncture intervention will be conducted in the healthy control group.
Functional MRI scanning procedure
The rs-fMRI data will be obtained with a Siemens TRio 3.0 Tesla MRI scanner in Beijing Hospital of Traditional Chinese Medicine. All rs-fMRI images will be taken from a contiguous echo planar imaging (EPI) template under the following conditions: 33 axial slices, repetition time (TR)=2,000 ms, echo time (TE)=30 ms, thickness/gap = 3.5/0.6 mm, field of view (FOV)= 220×220 mm2, flip angle (FA)= 90°, and matrix size 64mm x 64mm with 240 volumes. All participants will receive the following instructions: stay awake, do not move, close your eyes, and do not to think about anything. For an anatomic reference, T1 images will be obtained before resting state scans.
The real acupuncture and sham acupuncture groups will be examined three times (before treatment, after treatment, and in the follow-up period.) and the healthy controls will be examined only once.
Follow-up procedure
Eight weeks after the end of treatment, the PSQI, fMRI, FS-14, HAS, HAMD, actigraphy, and sleep diary records will be collected.
Outcome measurements
Table 1 and Figure 1 show all outcome parameters.
Primary outcome
Primary outcome is the mean change of PSQI scores from baseline to the end of the treatment period. The PSQI, a self-assessment to evaluate sleep quality, will be the primary outcome measurement [25]. The PSQI contains 19 items consisting of 7 component scores, including sleep quality, sleep latency, sleep duration, daytime dysfunction, sleep efficiency, sleep disturbances, and sleeping medication. Higher global scores reflect worse sleep quality [26].
Secondary outcomes
Sleep diaries
Sleep diaries will be assessed for sleep quality [27]. Participants with insomnia disorder will be required to record bedtime, sleep time, wake-up time, sleep latency, the state after morning awakening, and related factors in their sleep diaries. Recording of sleep diaries will be performed at baseline and at 4 and 12 weeks following entrance into the study.
Hyperarousal scale (HAS)
The HAS is a self-evaluation questionnaire containing 26 items. The questionnaire will be employed to evaluate the behaviors of cortical arousal, including information processing, strong response to unexpected stimuli, and introspective tendencies [28]. The scores correlate positively with a heightened arousal state. This questionnaire is usually applied to measure the change of cognitive and physical hyperarousal state increased cortical responsiveness [29].
Fatigue scale-14 (FS-14)
Fatigue is a dominant effect of insomnia [30]. The FS-14 is a self-rating scale to measure the severity of physical and mental fatigue. The FS-14 scores correlate positively with fatigue severity.
Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA)
Assessment of depressive status will be achieved with the HAMD. The HAMD is comprised of 17 variables with five- or three-point scales. Scores will be interpreted as follows: normal, less than 7; 8 to 17, mild depression; 17 to 24, moderate depression; and 24 or over, severe depression [31].
The 14-item HAMA will be used to determine anxiety. The HAMA is comprised of a 14 point self-assessment questionnaire, with a five-point scale for each item. A normal score is less than 7, scores between 7and 14 suggest mild anxiety, scores between 14 and 20 indicate moderate anxiety, scores between 21 and 28 indicate severe anxiety, and a score greater than or equal to 29 indicates extremely severe anxiety [32].
For insomnia disorder participants, the scores for HAMD and HAMA will be collected at baseline, week 4, and at the 8 week follow–up. The HAMD and HAMA will be collected only once at baseline for the healthy control group. Collection of the weeklong sleep diaries will be at baseline, at 4 weeks after treatment, and at the end of the 8 week follow–up.
Actigraph
To obtain objective data on sleep and activity, we will request that participants wear an actigraph (MTI Health Services Company, Pensacola, Florida, USA) on their non-dominant wrist for three one week periods before the intervention, at the end of the intervention period, and at the end of the follow-up period [33].
Safety monitoring
Potential acupuncture adverse events include fainting, needle sticking, infections at the puncture site, and subcutaneous hematoma. Participants will be asked to report adverse events and practitioners will report any adverse events at each patient visit. Vital signs and adverse events will be chronicled in the Case Report Form (CRF) at each visit. There is no anticipated harm and compensation for trial participation.Quality control
To ensure a standard operation procedure, acupuncturists will consistently apply acupuncture with the correct acupoints and manipulation. Investigators will attend training to properly apply the randomization number table, to make the diagnoses, to understand the inclusion and exclusion criteria, and to complete the case report forms. In addition, the fMRI scan will be performed with the same scanner and operator. Patients will be asked to close their eyes during the entire scanning procedure and stay still but do not sleep.
Additionally, the Scientific Research Supervision group of Beijing Hospital of Traditional Chinese Medicine trial will monitor the study regularly to ensure adequate recruitment rate, data accuracy, and data validity.Statistical analysis
Clinical data analysis
Statistical analyses will be performed with Statistical Package for the Social Sciences (SPSS, version 19.0) based on the intention-to-treat principle. Two-sided tests will be considered significant at 5%. We will investigate the reasons for any missing data and, if necessary, multiple imputations will be applied. Data will be evaluated in agreement with the intention-to-treat principle. Sociodemographic information will be shown as the mean ± standard deviation or the frequency (%) when appropriate. The baseline continuous, dependent variable data will be compared using independent-sample t-tests and chi-square tests will be performed for categorical data. Differences between group means will be analyzed with a repeated-measures analysis of variance (ANOVA). Multivariate analysis of variance (MANOVA) will be performed and Bonferroni correction will be applied for pairwise comparisons of changes in questionnaire scores with repeated measurement times for each group.
Functional MRI data analysis
The fMRI data will be analyzed with SPM12 software (SPM12, Wellcome Department of Imaging Neuroscience, London, UK), MATLAB_R2018a (Mathworks, Inc., Natick, MA, USA), DPARSF_V2.2 (http://www.rfmri.org/DPABI), and Freesurfer (http://surfer.nmr.mgh.harvard.edu/) software. Original data will be corrected; slice timing, affine head motion, and nonbrain extraction, spatial smoothing and temporal filtering will be applied.
Baseline ReHo and Amplitude of Low-Frequency Fluctuations (ALFF) values and FC maps from the real and sham acupuncture groups and the HC group will be compared using independent t- tests. Independent t-tests will be used for comparison of ReHo or ALFF values from the two groups after acupuncture. Paired t-tests will be utilized to compare the pre-acupuncture and post-acupuncture data within each group. Average time series data from significant areas will be extracted to test the regional relationship with the rest of the brain utilizing voxel-based general linear modeling (GLM). Fisher’s R-to-Z transformation will be applied to compare rs-FC using independent sample t-tests between groups [34].
Pearson's correlation analyses will be performed to evaluate the relationship of clinical symptoms with ReHo or ALFF values in regions demonstrating significant differences between groups.