A Multi-center Randomized Controlled Trial of Acupuncture Treatment for Knee Osteoarthritis With Sensitive Acupoints and Tender Points
Phase: NA
Conditions: Acupuncture, Knee Osteoarthritis, Sensitive Acupoints, Tender Points
Sponsor: West China Hospital

Acupuncture Treatment for Knee Osteoarthritis With 
Sensitive Acupoints and Tender Points  
(A multicenter randomized controlled trial) 
ClinicalTrials.gov identifier: NCT03299439 
 
 
 
 
 
 
 
STUDY PROTOCOL AND STATISTICAL ANALYSIS PLAN 
 
 
 
 
 
 
 
 
 
 
 
West China Hospital of Sichuan University 
 
January 10, 2017 

1. Background 
Knee osteoarthritis (KOA), the most common form of osteoarthritis, resulting in 
significant mobility limitations and a substantial socioeconomic burden1. International 
recommendations for management of KOA follows a stepwise approach that starts with 
conservative non-drug treatment (i.e., education and exercise), medications (i.e., 
nonsteroidal anti-inflammatory drugs (NSAIDs)) and ends with joint replacement 
surgery2-4. Given the potential side effects of long-term pharmacological therapy and 
the increasing economic burden of knee surgery5-7, complementary and alternative 
treatments are frequently used in clinical practice8. Acupuncture is the most popular 
complementary and alternative treatments, with increasing use over time9. Up to 1.5% 
of the US population has received acupuncture for chronic pain10. 
 
Previous studies have found that certain acupoints or ashi points within the medial 
regions of knee in patients with KOA were sensitized, particularly presenting as pain11. 
A previous trial showed that acupuncture at pain-sensitized points could achieve a 
superior effect in relieving muscle pain compared against non-sensitized points12. The 
pressure pain threshold (PPT) is a valid and reliable measure of quantifiable localized 
pain, reflecting the magnitude of pain sensitivity13. Hence, a hypothesis can be 
generated that KOA patients receiving higher-sensitized (lower PPT) points 
acupuncture can be more effective in treating pain and dysfunction, but little evidence 
is available to support this hypothesis. 
 
2. Study Aims 
We will conduct a randomized controlled trial (RCT) to examine whether acupuncture 
at acupoints with higher pain sensitivity (lower PPT) was more efficacious than lower 
pain sensitivity (higher PPT). 
 
3. Study Methods 
3.1 Study design  
A three-arm, parallel, 16-week, multi-center RCT will be conducted at the Affiliated 
Hospital of Chengdu University of Traditional Chinese Medicine, West China Hospital 
of Sichuan University, the Third Affiliated Hospital of Henan University of Traditional 
Chinese Medicine, and Wuhan Integrated Traditional Chinese Medicine and Western 

Medicine Hospital, all of which are teaching and tertiary hospitals. Participants will be 
recruited from the outpatient departments of Acupuncture and Moxibustion, Integrated 
Chinese-Western Medicine and Rehabilitation Medicine. Patient enrolment started late 
October 2017 and is expected to end in December 2019. Eligible and consented patients 
will be randomly assigned to three groups through central randomization in a ratio of 
1:1:1 (Figure 1). 
 
Figure 1 Trial design 
3.2 Participants 
Potentially eligible patients will be screened by the research physicians and research 
staff through physical examination and clinical tests. Patients will be informed of the 
aims and nature of the research both verbally and via an information sheet. They will 
be requested to complete and sign a consent form before enrollment. Patients 
information will remain confidential and they will have the right to withdraw without 
Assessment for eligibility 
Randomization (n =666) 
Higher sensitization (n = 
222): acupuncture at points 
with lower PPT 
 
Weeks: 1, 2, 3, 4 (three 
treatment sessions/week) 
Lower sensitization (n = 
222): acupuncture at points 
with higher PPT 
 
Weeks: 1, 2, 3, 4 (three 
treatment sessions/week) 
Waiting list (n =222): no 
acupuncture treatment  
 
(Standard 
acupuncture 
treatment 
on 
study 
completion) 
Follow up measurements: 4, 8, 12, 16 weeks 

WOMAC score, SF-12 Score 

Pressure-pain threshold of the five selected points 

Knee flexion, extension, internal rotation and external 
rotation ranges of motion 

Other treatments received for knee osteoarthritis 

Adverse events 
Excluded 

Not meeting inclusion criteria 

Refuse to participant 

Other reasons 

prejudice at any time. 
 
Inclusion criteria 
Participants aged 40 years or older and diagnosed with mild or moderate KOA are 
eligible to participate in the study. The diagnostic criteria were followed the Chinese 
Guideline for the Medical Management of KOA14:  
1) refractory knee pain for most days in the last month; 
2) joint space narrowing, sclerosis or cystic change in subchondral bone (as 
demonstrated by X-ray); 
3) laboratory examinations of arthritis: clear and viscous synovial fluid (≥2 times) and 
white blood cell count < 2000/mm3;  
4) aged 40 years or older;  
5) morning stiffness continues less than 30 minutes;  
6) bone sound exists when joints was taking flexion and/or extension.  
 
If a patient meets the following combination of criteria (1 and 2), (1, 3, 5, and 6), or (1, 
4, 5 and 6), a diagnosis of KOA is confirmed. 
 
Exclusion criteria 
Participants with any of the following conditions will be excluded: 
1) diagnosed with conditions leading to skeletal disorders, such as tuberculosis, 
tumors or rheumatism of the knee joint and rheumatoid arthritis;  
2) present with sprain or trauma in the lower limb;  
3) unable to walk properly due to foot deformity or pain;  
4) cannot answer the questionnaire due to mental disorders and/or intellectual 
disability;  
5) present with comorbidities including severe cardiovascular disease, liver or kidney 
impairment, immunodeficiency, diabetes mellitus, blood disorder or skin disease;  
6) females who are pregnant or lactating;  
7) are using or have used physiotherapy treatments for osteoarthritis knee pain in the 
past month;  
8) have used intra-articular injection of glucocorticoid or viscosupplementation in the 
past six months;  
9) received knee-replacement surgery on the affected side(s);  

10) diagnosed with severe (stage 4, according to Kellgren and Lawrence radiographic 
classification) or late clinical stage of KOA;  
11) have a swollen knee or positive result of floating patella test;  
12) are participating in the other clinical trials of acupuncture. 
 
3.3 Recruitment and strategy 
Each PI and other investigator will recruit subjects from her/his individual practice as 
well as faculty/resident continuity clinic. Flyers will be posted in the medical center 
and local clinics or other public places where allowed. 
 
3.4 Randomization 
Eligible patients who consent to participate will be randomly assigned to a higher 
sensitization group (patients receive acupuncture at acupoints with lower PPT), a lower 
sensitization group (patients receive acupuncture at acupoints with higher PPT) or a 
waiting-list group (no acupuncture) via a central randomization system for clinical 
research using 1:1:1 ratio. Randomization will be stratified by participating site in block 
sizes of 3 or 6. The study coordinator at each site will ensure that the informed consent 
form has been obtained from each participant prior to randomization. He/she will then 
log onto the central randomization system using a password-protected account and enter 
inclusion and exclusion criteria to ensure eligibility before entering the patient’s name, 
identification card number to generate a random sequence. 
 
3.5 Blinding 
Patients in higher sensitization group and lower sensitization group will be blinded to 
acupuncture treatment, and were required not to release their treatment information to 
outcome assessors during the study. Study investigators, acupuncturists will be aware 
of the treatment allocation. Outcome assessors and data analysts will be blinded and 
participants will be asked not to reveal their allocation to assessors.  
 
3.6 Identification, measurement and selection of acupoints for acupuncture 
Identification of acupoints 
Based on literature and expert consensus, we identified 13 candidate acupoints, namely 
Heding (EX-LE2), Neixiyan (EX-LE4), Dubi (ST35), Xuehai (SP10), Liangqiu (ST34), 
Yinlingquan (SP9), Yanglingquan GB34), Zusanli (ST36), Weizhong (BL40), Yingu 

(KI10), Xiguan (LR7), Ququan (LR8), Weiyang (BL39).  
 
We will also identify candidate ashi points using pre-specified approach. The front and 
back of the knee regions of each participant are divided into a total of 12 testing zones 
(Figure 2). The surface marking methods are as follows: (1) draw a line horizontally 
three body inches (cun) above the patella (the upper boundary of the testing zones); (2) 
draw a line horizontally across Zusanli (ST36) (the lower boundary of the testing zones); 
(3) draw two lines which horizontally trisect the area between the upper and lower 
boundaries; (4) in the front region, draw two lines vertically across the top corners of 
the basis patellae respectively; (5) in the back region, draw two lines which vertically 
trisect the popliteal area.  
 
Figure 2 The front and back testing zones of the knee region 
 
Ashi points in the testing areas will be identified when the participant reports the pain 
sensation while acupuncturist pressing vertically downward about 6~10 millimeter 
(mm) at an even speed with the thumb. 
 
Measurement of PPT of acupoints 
The electronic von Frey detector (2390 series, IITC Inc. Life Science) will be used by 
trained acupuncturists to measure the PPT of selected acupoints and ashi points. The 
acupuncturist moves the probe tip vertically downward the skin at an even speed. 
He/she will remove the probe immediately once the patient feels the pain. The data 
revealed by the detector (reported as numbers) will then be recorded as the PPT. Each 
point will be tested two times at an interval of two minutes. If the difference of two data 
values is larger than 15, the point will be measured for the third time. The average of 
the two values with the smallest difference will be taken as the final threshold. 

 
Selection of acupoints for interventions 
All points will be ranked based on PPT. The five points with the lowest PPT are 
identified as the higher sensitive points, whereas the five points with the highest PPT 
are selected as the lower sensitive points. 
 
3.7 Interventions 
The acupuncturists were specialists in traditional Chinese medicine and received 
specialized training in the acupuncture protocols prior to the start of the study. 
Acupuncture was performed by an acupuncturist who did not participate in 
identification and measurement of acupoints. 
 
Participants in the higher sensitization group receive acupuncture treatment at the five 
higher sensitive (lowest PPT) points. Sterile, single-use filiform acupuncture needles 
(Hwato Needles, Sino-foreign Joint Venture Suzhou Hwato Medical Instruments Co., 
China) with a length of 40 mm and a diameter of 0.30 mm will be inserted to a depth 
of 15-30mm in acupoints. The insertion will be followed by stimulation performed with 
lifting and thrusting combined with twirling and rotating the needles sheath in order to 
produce the sensation known as achieve “Deqi”. The needles placed in the acupoints 
will be manually stimulated every 15 minutes and removed after 30 minutes. 
Participants receive three treatment sessions per week (every other day) for four 
consecutive weeks.  
 
Participants in the lower sensitization group receive acupuncture treatment at the five 
lower sensitive (higher PPT) points. All other treatment settings will be the same as in 
the higher sensitization group.  
 
In the higher and lower sensitization groups, the intervention will be performed on the 
affected side for patients with unilateral KOA, whereas bilateral KOA patients will have 
their most painful side treated and assessed. Furthermore, the non-trial affected lower 
limbs will receive standard acupuncture treatment on DUBI (ST35), NEIXIYAN (EX-
LE4), YANGLINGQUAN GB34), ZUSANLI (ST36) and XUEHAI (SP10).  
 
Patients in the waiting-list group will not receive any acupuncture during the study. For 

the ethnic consideration, we will offer free, non-study standard acupuncture treatment 
at the following traditional acupoints after the study is completed: DUBI (ST35), 
NEIXIYAN (EX-LE4), YANGLINGQUAN GB34), ZUSANLI (ST36) and XUEHAI 
(SP10).  
 
3.8 Basic treatment 
All the participants will be advised not to take any other treatments for KOA. NSAIDs 
are allowed if patients have intolerable pain and the outcome assessment is not 
scheduled in the next 48 hours. In addition, non-acupuncture treatments, such as 
application of medicinal liquor on the knee, heat therapy using the Teding Diancibo Pu 
(TDP) device, massage and moxibustion, are allowed if patients in the waiting-list 
group request treatment during the study period. Patients will be asked to document all 
such treatments (including the name, dosage/frequency and duration of treatment) 
receiving for KOA. 
 
3.9 Follow up 
The pain, stiffness and physical function of the knee joint, quality of life, and knee 
ranges of motion (ROMs) of all the participants, as well as pressure-pain threshold of 
the points and the safety of treatment of patients in the higher and lower sensitization 
groups will be measured at follow ups at 4, 8, 12 and 16 weeks after randomization.  
 
The following measures will be taken to optimize the retention of participants: free 
acupuncture treatments for other diseases provided they do not affect the treatment of 
KOA; text messages and phone calls to remind the participants about the impending 
appointments; flexibility in making appointment to suit the participants’ schedule; in 
addition to contact details of the participants, phone numbers of close family members 
will also be recorded upon permission to facilitate tracking.  
 
The outcome assessments will be performed by nurses or completed by patients in a 
separate space at the outpatient department of each participating site. All of the outcome 
assessors will be trained on conducting interviews and performing measurements 
before the study begins and will follow a standard protocol. The schedule of 
measurements is present in Table 1. 
 

Table 1 Measurements to be taken at each point in trial 
TIMEPOINT 
STUDY PERIOD 
Enrolment 
Allocation 
Post-allocation 
Post-allocation 
-1 week 
(-7~0 day) 
Day 0 
4 weeks 
(±3 days)  
8 weeks 
(±3 days)  
12 weeks 
(±3 days)  
16 weeks 
(±3 days)  
ENROLMENT 
Eligibility screen 
Informed consent 
Allocation 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
 
INTERVENTIONS 
High sensitization group 
Low/non-sensitization group 
Waiting-list group 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
ASSESSMENTS 
X-ray examination of the knee joint 
Measurement of sensitization 
intensity 
Measurement of PPT of the five 
selected points 
WOMACa score 
SF-12b score 
Knee ranges of motion 
Adverse events 
Other treatments received for knee 
osteoarthritis 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X=Measurements to be taken at this point 
a Western Ontario and McMaster Universities Osteoarthritis index 
b Short Form-12 health survey 
 
3.10 Drop outs 
Patients who withdraw from the trial for any reason will be considered a drop out. The 
common reasons for dropping out including AEs, poor compliance with the protocol, 
unsatisfied efficacy, withdraw and quit, and others. Investigators should complete the 
case report form (CRF) and record the reason for dropping out. 
 
3.11 Outcomes 
Primary outcome 

The primary outcome is the change of Western Ontario and McMaster Universities 
Osteoarthritis index (WOMAC) total score from baseline to 16 weeks. The Chinese 
version of WOMAC will be used. It consists of 24 items assessing the KOA patients’ 
pain (5 items), stiffness (2 items), and physical function (17 items). Each of the 24 
items will be graded on a visual analog scale ranging from 0 to 10, with higher scores 
reflecting more pain, stiffness and poorer physical function. The score ranges for the 
pain, stiffness and physical function subscale are, respectively, 0-50, 0-20 and 0-170, 
resulting in a total range of 0-240. Each WOMAC item is rated on a Visual Analogue 
Scale (VAS) of 0 to 10, with a high score indicating a worse symptom. 
 
Secondary outcomes 
The secondary study outcomes are: (i) the change of Short Form (SF)-12 health survey 
score from baseline to 16 weeks, (ii) the changes of knee ranges of motion (ROMs) 
from baseline to 4 and 16 weeks, and (iii) the changes of PPT of the five selected points 
from baseline to 4 and 16 weeks. 
 
The validated Chinese version of SF-12 includes 12 items: 2 items on physical 
functioning, 2 items on role limitations because of physical health problems, 1 item on 
bodily pain, 1 item on general health perceptions, 1 item on vitality (energy/fatigue), 1 
item on social functioning, 2 items on role limitations because of emotional problems, 
and 2 items on general mental health (psychological distress and psychological well-
being). The knee ROMs will be assessed both actively and passively by using a standard 
goniometer. It will include flexion, extension, internal rotation and external rotation. 
The PPT of the five selected acupuncture points will be measured using the electronic 
von Frey detector. 
 
Assessment of safety 
All unfavorable or unintended events affecting patients in the study, such as bleeding, 
bruising and/or soreness at the needle sites (assessment taken immediately after 
acupuncture by acupuncturists’ and patients’ report) and elevated blood pressure 
(standard measurement at each follow up), will be recorded during the study. 
 
3.12 Monitoring 
We will develop an independent Data Monitoring Committee (DMC), responsible for 

the monitoring for quality and regulatory compliance of the trial, as well as ensuring 
the safety of participating patients. The DMC will consist of five members with 
expertise in acupuncture, trial methodology, and biostatistics (Table 2). Two DMC 
regular meetings will be held during this study. We will develop a procedural document 
for the DMC meeting, and strictly follow the document. 
 
Table 2 DMC members 
Name 
Role on IDMC 
Affiliation 
Chen Yao, 
Professor 
Chair of DMC voting 
member 
Peking University First Hospital and Peking 
University Clinical Research Institute 
Zhaoxiang Bian, 
Professor 
Voting member 
Chinese Medicine Clinical Study Center, School of 
Chinese Medicine, Hong Kong Baptist University 
Hongcai Shang, 
Professor 
Voting member 
Key Laboratory of Chinese Internal Medicine of the 
Ministry of Education, Dongzhimen Hospital,  
Beijing University of Chinese Medicine 
Honglai Zhang, 
Professor 
Voting member 
Guangzhou University of Chinese Medicine 
Deying Kang, 
Professor  
Voting member 
Clinical Epidemiology and Evidence-based 
Medicine Research Center, West China Hospital, 
Sichuan University 
 
3.13 Data Management 
This study will use electronic Data Capturing (EDC) system for centralized data 
management.  
Complete and upload case Report Form (CRF) 
 
The CRF should be completed by the investigator or an authorized person, and they 
must be read carefully before completing the CRF. 
 
Input the data of the CRF into the EDC system on the day of each visit, so that the 
general leader, the head of each center and the data manager can timely understand 
the progress of the study and the data collection situation. 
 
Data review and modification 
The data auditor will check the data in the EDC system, and the missing and wrong 
data will be returned to the investigator in time for verification, and the data will be re-

uploaded after supplement or modification. The data auditor rechecks whether the 
supplementary or modified data are correct. Repeat until all corrections are added or 
corrected. 
 
The data review process is as follows: the investigator of each center initially review 
the uploaded data, and then the general coordinator reviews all uploaded data and 
completes the final review of all data; the another investigator of each center is required 
to manually compare a certain number (10%) of CRFs randomly selected from time to 
time with the data in the EDC system to ensure that the data in the database are 
consistent with the data in the original record form. 
 
Data locking 
After confirming the correctness of the data in the EDC system, a researcher from 
Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University 
will lock the data. Locked data files cannot be modified. Problems found after data 
locking can be corrected in the statistical analysis after confirmation. 
 
3.14 Statistical analysis plan 
Sample Size  
Our primary study hypothesis is that acupuncture on higher sensitive points would 
achieve more reduction in the total WOMAC score than acupuncture on lower sensitive 
points or waiting list group.  
 
The sample size calculation was based on the mean difference of WOMAC total score 
changes from baseline to 16 weeks according to the pilot trial15. The following 
assumptions were made to calculate the sample size: a mean difference of 12 between 
the higher and lower sensitization groups, standard deviation of total score of 33, a two-
sided significance level of 0.025 (adjusted for multiple testing), and a power of 0.9. 
With these assumptions, a sample size 189 patients per arm is required. This sample 
size would provide adequate power to detect the difference between high-sensitization 
group versus waiting list group, on the ground that the treatment effect between higher 
sensitization group and lower sensitization group would be smaller than that between 
higher sensitization group and waiting list group. To allow for a loss to follow up of 
15%, a minimum sample size of 666 patients (222 patients per arm) at baseline was 

required. 
 
Statistical analysis  
We will descriptively summarize patient characteristics, medical characteristics, 
outcome variables and the adverse events.  
 
The primary analyses will examine if acupuncture at higher sensitive points will 
achieve statistically better treatment outcomes than acupuncture at lower sensitive 
points and waiting list group, respectively. To accommodate the correlation of repeated 
measures from the same participant and the nesting of observations within research 
sites, mixed-effect linear models with random effects (participants and research sites) 
will be fitted to assess the intervention effect on outcome variables over time, while 
accounting for the effects of potential confounders (e.g. baseline WOMAC total score, 
age, gender, BMI). We will also examine, in an exploratory analysis, if acupuncture at 
lower sensitization would achieve statistically better outcomes than waiting list.  
 
The outcome analyses will be performed both on the intention-to-treat population, 
which includes all patients randomized, and on the per-protocol population, which 
includes eligible patients who adhere to the planned treatment and follow ups. We will 
use the multiple imputed or last value carried forward method to impute missing data 
for the primary and secondary outcomes. 
 
We will also conduct subgroup analyses according to the following pre-specified 
baseline variables: BMI (<18.5 vs.18.5-23.9 vs. ≥ 24 kg/m2), type of KOA (single vs. 
bilateral KOA), stage of KOA according to X-ray imaging, and duration of disease. 
 
P values less than 0.05 will be considered significant and tests were 2-sided. All 
analyses will be implemented using R software. 
 
4. Ethical Requirements and Registration 
Ethics approval has been granted by the Bioethics Subcommittee of West China 
Hospital, Sichuan University: 2017(Number 228). The trial was registered in 
ClinicalTrials.gov with approval number NCT03299439. 

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