Study setting {9}
This RCT will be performed at the First Affiliated Hospital of Changchun University of Chinese Medicine, China. It is a comprehensive tertiary-level Chinese medicine hospital with medical treatment, scientific research, prevention and health care. The hospital has a clinical research centre for acupuncture and moxibustion. This study will be conducted in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee of the First Affiliated Hospital of Changchun University of Chinese Medicine (CCZYFYLL2020-054), and has been registered in the Chinese Clinical Trial Registry (ChiCTR2000039713).
Eligibility criteria {10}
All participants will be subjected to a standardized interview and be given more information about this study. To minimize treatment bias, the acupuncturists who will be involved in this trial are specialists in acupuncture, with more than 5 years’ experience in acupuncture treatment. They have valid acupuncture licenses (Chinese medicine practitioner license) from the Ministry of Health of the People’s Republic of China. Before performing this trial, the acupuncturists will receive special training regarding the purpose and content of the trial, treatment strategies, and quality control.
Inclusion criteria
The inclusion criteria will be:
i. Healthy male volunteers aged 18 to 30 years at the screening visit.
ii. Participants must not have had any congenital defects or chronic diseases within the 3 years prior to the screening visit and should have no pathological or abnormal clinical findings on physical examination.
iii. Participants must not have any sleep disorders and must have Pittsburgh Sleep Quality Index (PSQI) scores of 7 points or lower.
iv. Participants must have Self-rating Anxiety Scale (SAS) scores of 50 points or lower,Self-rating Depression Scale (SDS) scores of 53 points or lower.
v. Participants must keep normal nocturnal sleeping hours (between 21:00 and 09:00) for a week before the first clinical trials.
vi. Participants must sleep for at least 7 hours per night for a week before the first clinical trials.
vii. Participants must be non-smokers or ex-smokers who stopped smoking at least 1 year before the screening visit.
viii. An agreement to participate in the study by signing the informed consent.
Exclusion criteria
Participants who experience, have, or have had one or more of the following will be excluded:
i. History of regular alcohol consumption (>210 g/week) within the 6 months before the screening visit, (Beer (5 % v/v): 250 mL = 10 g, soju (20 % v/v): 50 mL = 8 g, wine (12 % v/v): 125 mL = 12 g).
ii. Participation in another clinical study within 2 months before the screening visit.
iii. Intake of prescribed or over-the-counter drugs within 7 days before the first clinical trials.
iv. Participants who will have received acupuncture treatment during the 7 days before the first clinical trials.
v. Participants with a fear of acupuncture or infection related to the locations of Baihui (DU20), Shenmen (HT7) and Sanyinjiao (SP6).
Who will take informed consent? {26a}
Personal information will be collected after oral and written consents are obtained from each participant at the first visit. After potential participants voluntarily consent to the study, they will be screened using pre-determined inclusion/exclusion criteria at the first visit. Written informed consent will be obtained from all the participants by the principal investigator or sub-investigators prior to enrollment.
Additional consent provisions for collection and use of participant data and biological specimens {26b}
This will not be applicable as no biological specimens will be collected for research purposes.
Interventions
The two control interventions will be NAE and the blank control. The manipulation of NAE will be conducted as described below. To eliminate out placebo effects, the NAE control group will be used. The blank control group will be used to assess whether EA is effective. Intergroup comparisons will be done for the three groups.
Intervention description {11a}
Interventions will be according to records in ancient books and research results of modern papers about treating diseases related to sleep disorders with acupuncture in China or in the West. These interventions will be slightly modified by Chinese acupuncturists and acupuncture experts from the study team and non-study team in all regions where the study will be conducted. The project team has made SOPs for clinical research to ensure that the treatment is followed throughout the clinical research. Participants will be randomly allocated into one of three groups: the AE group; the NAE control group; or the blank control group.
The Acupoints electroacupuncture group
The acupoints to be used in the AE group are Baihui (GV-20), Shenmen (HT-7), and Sanyinjiao (SP-6), which are recommended points for the treatment of diseases related to sleep disorders [18-19]. HT-7 is the point with the highest frequency of use [20], SP-6 and GV-20 are often used with HT-7 as combination regimen according to the TCM theory and clinical experience of acupuncture therapists [21]. The acupuncture operation is based on the textbook of the 13th Five-Year Plan of the Ministry of Health. Participants will be required to take the supine position. Acupoints will be needled after disinfection. Baihui (GV-20) will be horizontally punctured 0.3–0.5 cun (The acupuncture needle tip travels in the opposite direction to the meridian circulation of Dumai meridians). Shenmen (HT-7) will be perpendicularly punctured 0.5–0.8 cun while Sanyinjiao (SP-6) will be perpendicularly punctured 1.0–1.5 cun. All acupoints will be localised according to the WHO Standard Acupuncture Locations as shown in Table 1 and Figure 2.
Non-acupoints electroacupuncture control group
In the NAE control group, we will select non-acupoints as reported in previous studies, including non-acupoint 1, non-acupoint 2, and non-acupoint 3. Non-acupoint 1, the edge of tibia 1 to 2 cm lateral to the Zusanli (ST36) horizontally [22], will be perpendicularly punctured 0.5–1 cun. Non-acupoint 2, Half between the tip of the elbow and the axilla [23], will be perpendicularly punctured 0.5–1 cun. Non-acupoint 3, Ulnar side, half between epicondylus medialis of the humerus and ulnar side of the wrist [23], will be perpendicularly punctured 0.5–1 cun. All non-acupoints are shown in Table 1 and Figure 2.
In each session all acupoints and non-acupoints will be bilaterally punctured by filiform needles. After the puncture of 3 acupoints or non-acupoints by needles, 6 auxiliary needles will be punctured at 2 mm lateral to every acupoint or non-acupoint and punctured to a depth of 2 mm without manual stimulation. Transcutaneous electric acupoint stimulation (Hwato SDZ-V Acupoint Nerve Stimulator, Suzhou Medical Co., Ltd.) will be used for electro-acupuncture stimulation at every acupoint or non-acupoint after needle insertion. Each acupuncture needle at the acupoints or non-acupoints and auxiliary needles will be connected to the electricity by Hwato SDZ-V for 30 minutes. The stimulation frequency will be 2/100 Hz. The stimulation intensity will vary from 0.1 mA to 1.0 mA until the patients feel comfortable. The Massachusetts General Hospital acupuncture sensation scales (MASS) will be used to determine whether the De-Qi sensations are produced during acupuncture. To screen for patients with the De-Qi sensation. The intensity of soreness, numbness, heaviness, warmth, cold, sharp pain and dull pain will be rated on a numerical scale of 1–10.
The filiform needles to be used in this trial are single use sterile acupuncture needles; namely Hwato Needles, made in Suzhou, China, 25–40 mm in length and 0.25 mm in diameter. Needles with a length of 13 mm and a diameter of 0.18 mm will be used as auxiliary needles without manipulation. DeQi sensation will be achieved in the acupoints of the AE group by lifting and thrusting combined with twirling and rotating the needles. However, DeQi sensation will not be achieved in the non-acupoints of the control group by the same needle manipulation methods. Needles will be retained in the AE group and the NAE control group for 30 minutes, afterwhich the acupoint holes will be closed using clean cotton balls to avoid bleeding when withdrawing the needle. Participants in the two groups will be administered with 7 treatments over a period of 1 week, once a day.
Blank control group
Participants in the blank control group will not given any treatment.
Sleep deprivation procedures
The SD trial will be performed at the Clinical Centre for Acupuncture and Moxibustion at the First Affiliated Hospital of Changchun University of Chinese Medicine, China. Sleep deprivation will start at 7:00 am (baseline). Total sleep deprivation will be 30 hours. During their free time, participants will spend most of their time in a large common room with both natural and electric lighting. During SD, participants will be permitted to play games, read, review school work, and use their personal electronic devices for entertainment. They will also be allowed to freely interact among each other and with research staff. Napping, caffeinated beverages, and strenuous physical activity will be prohibited. Participants will be served breakfast, lunch, and dinner in the hospital cafeteria, with free access to snacks during their free time in the common room. Throughout the trial, participants will be constantly supervised by the researcher to ensure they do not fall asleep.
Criteria for discontinuing or modifying allocated interventions {11b}
Participants will be allowed to leave the study at any time for any reason if they wish to, without any consequences. Participation in this study will also be ended by the investigator if the participant is uncooperative and/or does not attend study visits. This study will be prematurely ended in case of any adverse events or procedural-related complications, or if the independent specialist in acupuncture and moxibustion advises its termination. The criteria for study termination will also include any serious adverse event (SAE).
Strategies to improve adherence to interventions {11c}
All acupuncture treatments and laboratory tests will be provided for free to improve adherence to the intervention protocol. All subjects will be required to sign a written informed consent before participating, and will be compensated monetarily. Participant and acupuncturist signatures will be required after each acupuncture session to monitor adherence.
Relevant concomitant care permitted or prohibited during the trial {11d}
To ensure that participants within the three groups get adequate sleep (at least 7 h per night for a week before the first clinical trial) during the sleep baseline period, we will use sleep logs and Actigraph (an automatic-scoring actigraph for measuring sleep in healthy adults) for recording. Throughout the study, participants will wear an Actigraph (Micro Motionlogger SleepWatch®, Ambulatory Monitoring, Inc.; AMI) and report their bedtime, sleep onset latency, and wake time on a daily sleep diary. Alcoholic drinks, caffeinated beverages, prescription, over-the-counter medicines and other preventive interventions will be prohibited during the trial.
Provisions for post-trial care {30}
This is not applicable.
Outcomes {12}
Primary outcome
Profile of Mood States Scale
The POMS [24] is a well-validated, 65-item self-report measure comprising of six subscales: Tension/Anxiety, Depression/Dejection, Anger/Hostility, Energy/Activity, Fatigue/Vigor, and Confusion/Bewilderment. Participants will report on their mood using a 5-point scale (“Not at all” to “Extremely”).
Secondary outcomes
Positive and Negative Affect Schedule Scale
The PANAS [25] will be used to assess positive and negative effects. Participants will be shown 20 adjectives with 10 describing positive moods and 10 describing negative moods. They will respond using a five-point Likert scale (1 very slightly, 5 extremely).
Noldus FaceReader
The Noldus FaceReader Software (FR; Version 7.0, Noldus Information Technology) [26] is a facial analysis program that detects emotional facial expressions in film and photographs. The FaceReader can detect six basic emotions, happiness, sadness, anger, fear, surprise, and disgust, as well as neutral states. The FaceReader can also analyse the valence of facial expressions as well as general state of arousal. The video stimuli are analysed frame-by-frame to detect the intensity by which each of the six basic emotions are expressed on a scale of 0 to 1, where 0 indicates the absence of emotion while 1 indicates maximum intensity. In this study, focus will be on the participants’ emotions after sleep deprivation. Prior to analysis, all videos will be calibrated to each participant’s own neutral expression to achieve the most accurate results. The videos will then be analysed using the batch analysis mode, which sequentially analyses each video without the need for supervision. Videos of participants’ facial expressions will be recorded using Logitec HDC 920 PRO Webcamera, which will be placed above the computer screen. The videos will be processed using Noldus FaceReader Software and Observer XT (Version 12.5, Noldus Information Technology). The software’s artificial intelligence is trained to register the activation of 20 action units (AUs) and to indicate scores for; happiness, surprise, anger, sadness, disgust, and scared faces as proposed by the basic emotion framework.
Participant timeline {13}
The trial will comprise; 1-week baseline, 1-week preventative treatment, 30-hours TSD, and 24-hours after waking follow-up periods. During the 30-hours TSD period, participants will be assessed every 3 hours for a total of 11 sessions. They will be evaluated at 7:00 am (baseline), 10:00 am, 1:00 pm, 4:00 pm, 7:00 pm, 10:00 pm, and on the next day at 1:00 am, 4:00 am, 7:00 am, 10:00 am and13:00 pm. AE will also be recorded. Table 2 shows the participant timeline. The SD study participants’ timeline of activities and assessments during hospitalisation is shown in Figure 3.
Sample size {14}
This is an RCT study with three groups: an AE group, a NAE group and a blank control group. The POMS will be the primary outcome measure observed. According to the findings of the clinical pre-trial study, the means of the POMS scores for each group are 8.26, 18.25 and 15.24, with standard deviations of 3.18, 5.96 and 5.42, respectively. Sample size was calculated by PASS software (version 15.0.5, NCSS, LLC) [27] and at least 33 subjects will be needed in our study if power is 0.9 and α set to 0.05. To compensate for a 20% loss to follow-up, the sample size will be increased to 42 participants, of which at least 14 participants will be required in each group.
Recruitment {15}
Several strategies will be applied in participant recruitment. Forty-two healthy male volunteers will be recruited by advertisement on notice boards at local Chinese universities. Advertisements will be placed across WeChat and websites. The posters and advertisements will contain brief introductions about the population to be enrolled, the free acupuncture treatments offered to volunteers, and contact information of the researchers. All subjects will be required to sign a written informed consent before participating and will be monetarily compensated.
Assignment of interventions: allocation
Sequence generation {16a}
Randomization will be done using the Excel random number method. The participating volunteers will be strictly screened according to the inclusion and exclusion criteria. Once inclusion is confirmed, participants will be numbered in the order by which they will be included. Random numbers will be generated by the rand function using Excel numbering after which they will be fixed and reordered.
Concealment mechanism {16b}
Randomization will be performed by a person who will not be engaged in the study in order to blind the identity of the participants.
Implementation {16c}
The randomization sequence will be generated using a random number table by an independent statistician. A sealed envelope will be used to hide the group assignments. Then, the envelopes will be numbered in a sequential order and stored by a research assistant who will not be involved in the enrollment process. When an eligible volunteer is enrolled into the study, an envelope will be opened by research assistants that will be responsible for enrolling the volunteers.
Assignment of interventions: Blinding
Who will be blinded {17a}
Blinding methods will be applied to data statisticians and outcome evaluators throughout the trial. They will not be able to obtain information regarding grouping and treatment of participants. Acupuncturists will not be masked due to the nature of acupuncture. However, acupuncturists will not participate in data collection, statistics, and final outcome evaluation. For the intervention, different volunteers will be assigned to different treatment rooms with independent beds so as to avoid contact among subjects. Personnel in charge of random grouping, acupuncture treatment, data processing, and outcome evaluation will be completely separated so as to ensure the authenticity of the outcome of the trial to the greatest possible extent.
Procedure for unblinding if needed {17b}
At the end of the trial, we will first perform a first blinded unblinding to clarify the differences between the 3 groups, but will not know the content of the interventions in the 3 groups, on the basis of which statistical analysis will be performed. A second unblinding will then be performed, which will reveal which group is the AE group, which group is the NAE control group and which group is the blank control group, to further analyze the results of the clinical trial.
Data collection and management
Plans for assessment and collection of outcomes {18a}
Prior to the start of the trial, all data assessors will be uniformly trained in order to improve the quality of the data assessment. The primary outcome measure will be obtained using POMS while the secondary outcome measures will be obtained using PANAS and FaceReader. These three instruments have been widely used in trials related to the detection of mood changes [24-26]. During the 30-hours TSD period, participants will be assessed every 3 hours for a total of 11 assessments. During the 24-hours after waking follow-up period, participants will also be assessed once.
Plans to promote participant retention and complete follow-up {18b}
During the recruitment period, participants will receive extensive information about the clinical trial requirements. The importance of completion of the follow-up will be stressed. Participants will be allowed to discontinue the study at any time and will not be obliged to give a reason for their discontinuation. Throughout the study, participants will be reminded to fill out the questionnaires during study visits, while during the follow-up period, investigators will check responses and if necessary contact participants for completion of their follow-up.
Data management {19}
A special data collector will record the participants’ personal data in the Case Report Form (CRF). At least 5 completed CRFs from each clinical trial center shall be sent to the data manager in a timely fashion by the supervisor so as to establish a corresponding database. All data will be double entered using the data entry program run on a software platform. The data administrator shall ensure that the data in the CRF forms are completely and truly entered into the computer.
Confidentiality {27}
Only researchers will have access to the personal data in the trial. These data will not be published, and they will be discarded after the publication of results.
Plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33}
This is not applicable. Researchers confirm that there will be no laboratory and storage of biological specimens for genetic or molecular analysis in this study.
Statistical methods
Statistical methods for primary and secondary outcomes {20a}
Descriptive statistics will be used to describe the study population. Comparisons of the study groups by age, gender, and outcome characteristics will be done using analysis of variance (ANOVA) or chi-square tests. Depending on whether the data are normally distributed, the continuous variables will be described as the mean (standard deviation) or the median. One-way analysis of variance (ANOVA) will be used for comparisons among the three groups. Continuous variables, including the POMS scores, PANAS scores and FaceReader, will be compared among the three groups at all time points using ANOVA. The Student-Newman-Keuls method will be used for pairwise comparisons. Adverse events will be summarized for each group and compared using Fisher’s exact tests. Statistical analyses will be performed using SAS 9.1.3. Statistical significance will be set at p ≤ 0.05.
Interim analyses {21b}
There are no interim analyses planned.
Methods for additional analyses (e.g. subgroup analyses) {20b}
There are no interim analyses planned.
Methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c}
The intention-to-treat analysis will be used for all allocated participants in the baseline condition. Baseline characteristics will be summarized across the treatment groups. Missing values will be imputed by the last observation carried forward (LOCF) method.
Plans to give access to the full protocol, participant level-data and statistical code {31c}
Information from the full protocol will be published in a peer-reviewed journal. The relevant data obtained from this study protocol will be available upon reasonable request from the corresponding author.
Oversight and monitoring
Composition of the coordinating centre and trial steering committee {5d}
This is a monocenter study designed, performed and coordinated at the First Affiliated Hospital of Changchun University of Chinese Medicine. Day to day support for the trial will be provided by the:
Principle investigator: will supervise the trial and take medical responsibility of the participants.
Data manager: will organize data collection and safeguard its quality.
Study coordinator: trial registration, coordinate study visits and document annual safety reports.
Study physician: will identify potential recruits, administer informed consent, ensure follow-up according to the protocol.
The study team will have biweekly meetings. There will be no trial steering committee or stakeholder and public involvement group.
Composition of the data monitoring committee, its role and reporting structure {21a}
In accordance with the requirements of the standard for quality control and quality assurance of clinical research in TCM, a 4-level quality supervision system will be established. One supervisor will be appointed and a supervision committee set up to regularly monitor the data collected in clinical research, so as to ensure the authenticity and reliability of the project. The supervision team will supervise the entire process of information collection and input.
Adverse event reporting and harms {22}
Any adverse events reported by the participants will be recorded in the CRF, including the time, symptoms, signs, degree, duration, laboratory test index, treatment and outcome, follow-up, and follow-up time. Common treatment-related adverse events to be tested will include subcutaneous hematoma, continuous post-needling pain, itching at the sites of the needle insertion, and dizziness.
Frequency and plans for auditing trial conduct {23}
The Ethics Committee of the First Affiliated Hospital of Changchun University of Chinese Medicine will be responsible for the monitoring. Every 2 days, a report will be sent to the auditor. The process will be independent from investigators and the sponsor.
Plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25}
This is not applicable.
Dissemination plans {31a}
We will share the results of this study with key stakeholders through presentations in related seminars and publications in peer-reviewed journals.