Conditions: Knee Osteoarthritis Kidney Yin Deficiency Kidney Yang Deficiency
Keywords: Needling Techniques Randomized Reinforcing Reducing Acupuncture
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 64
Healthy volunteers: no

Brief summary:
The thirty-nine-week open-label clinical study investigates the efficacy of acupuncture for Knee Osteoarthritis (KOA) as adjunctive therapy to analgesics compared to analgesics only and assesses the effects after 9 and 24 weeks, with safety assessment provided.

The study seeks to find possible additional benefits of acupuncture on Kidney Deficiency (KD) while treating KOA with an acupuncture protocol designed to treat KOA following Traditional Chinese Medicine (TCM) theory, which connects KOA with KD as its root cause. The points prescription uses local and Kidney-related points to treat KOA.

The chronic conditions require a higher number of acupuncture treatments. This study will provide acupuncture treatments in three cycles, each three weeks long, with frequency three times weekly. Twenty-seven acupuncture treatments of KOA during fifteen weeks tend to improve KOA and KDS; symptoms are assessed in 10 successive time points, and treatment effects and effect persistence are analysed.

64 patients with symptomatic KOA are randomly allocated into the Acupuncture (A) or Control (C) group according to their permanent, unique, and coincidental Personal Identification Number, which is randomly given to all citizens in Croatia. Before the experiment starts, demographics and disease parameters of all participants are compared. To objectify acupuncture effects, the enrolled physiatrist's measures included knee measures at 3 time points: baseline, at the end of acupuncture (Week 15), and nine weeks later (Week 24). Subjective evaluations of symptoms are assessed by Western Ontario and McMaster University Arthritis Index (WOMAC) total and subscales scores, Numeric Rating Scale (NRS), and Kidney Deficiency Syndrome Questionnaire (KDSQ) every 3 weeks till the 24th week (9 assessments). Analgesics taken by participants (DRUG) in the last three days before the assessments are recorded. Acupuncture treatment was promised to all participants. Therefore, at Week 25, the between-group analysis ended, and the C group crossed over to receive the identical acupuncture protocol. The 10th assessment in Week 39 was used to estimate, by within-group analysis, the immediate effects of the acupuncture in group C and the effect persistence in group A.

The Lequesne index was introduced additionally at Week 24 as another measure of the knee's functional state.

Detailed description:
KOA's high prevalence assures the trial's participation motivation of patients regarding associated pain and functional impairment. Besides pain and stiffness, patients experience muscle weakness, poor balance, and joint distortion in an advanced stage. KOA attacks the diseased ones at the age of 50. Pain worsens with joint loading and becomes relieved by rest. KOA supposes bones remodelling, cartilage thinning, synovial thickening, and joint space narrowing. The advanced stage is presented by joint instability, squaring, and even subluxation.

KOA involves both knees and the contributing symptoms of old age from the scope of Kidney deficiency syndromes, such as weakness, insomnia, depression, tinnitus, forgetfulness, feeling cold, hot, low back pain, thirst at night, and disturbed urination could be manifested.

The acupuncture treatment of KOA follows syndrome differentiation. The treatment principle distinguishes the deficient root (primary Kidney deficiency and secondary Blood deficiency) as the cause, and the excessive branch (knee bone Bi syndrome) when in empty Cou Li spaces, the external factor becomes entraped, consequently. An aspiration with treatment is to tonify the Kidney, nourish Qi, tonify and invigorate Blood, remove Damp and Cold by transferring them toward the deficiency rather than expelling, and relieve the channels and collaterals from the obstruction. Moreover, knee meridians should be dredged to improve knee symptoms by a simultaneous reinforcing-reducing technique on local points and reinforcing on KD-related points. Eventually, the improvements of KD indicate better life quality.

The study's design involves two groups: an acupuncture (A) group that receives acupuncture treatment adjunctive to analgesics, and a control (C) group that receives only analgesics. Participants were recruited from the target population of patients over 50 from 2 Family Medicine practices with confirmed KOA. The study sample was formed with inclusion and exclusion criteria. 64 patients were recruited. All medical data of the participants were available to the investigator. After fulfilling the SOAP form (Subjective, Objective, Assessment, Plan) and getting informed written consent, the study sample was randomly allocated into two groups by size of their permanent, unique eleven-digit long Personal Identification Numbers (OIB), which is assigned to all Croatian citizens. Its first ten digits are accidentally chosen, and the last is a control number. Every second participant ordered by the size of OIB belongs to the same group; odd ones belong to the A group, and even ones to the C group. Demographic and disease parameters are compared at baseline to determine if the groups are comparable. All study participants received analgesics and could modify dosages according to their needs. Analgesics were nonsteroidal anti-inflammatory drugs (NSAIDs) and/or tramadol. Taken analgesics were recorded at Weeks 0, 3, 6, 9, 12, 15, 18, 21, 24, and 39. The dose represents an average daily dose of analgesics from the last three days. The dose was recorded after conversion to the comparable dose of the selected representative (ibuprofen), the most prescribed one. The given data will be statistically processed and analyzed.

Patients in the A group started with acupuncture treatment in September 2021, with the first treatment cycle. Each of the 3 treatment cycles, in total, is three weeks long, each consists of 9 treatments, patients will receive acupuncture three times per week and the two adjacent acupuncture cycles are separated by three weeks without acupuncture.

Acupuncture treatment protocol includes local treatment points Dubi (ST-35), Neixiyan (EX-LE-4) and Heding (EX-LE-2), Xuehai (SP-10), Yanglingquan (GB-34), Yinlingquan (SP-9), Zusanli (ST-36), Sanyinjiao (SP-6), and points targeting Kidney deficiency syndrome Taixi (KI-3), Guanyuan (CV 4), and Shenshu (BL-23).

Disposable sterile acupuncture needles 0.30 × 40 mm are used. The depth and angle procedure predicted straight needling on 1-1.5 inches deep, with a mild reinforcing-reducing method for local points, further straight and 0.5-1 inch deep with the reinforcing method for points based on KD syndromes. Complete treatment lasts 30 minutes, and the manipulations are provided every 10 minutes, three times in total.

The sample size was calculated based on the Berman et al. (1999) study. The sample size was calculated by envisioning a two-sided test with unequal variances: type I error 0,05, power 0,95. Group sample sizes of 16 and 16 (i.e. complete study population of 32 subjects) achieve 95,78% power to reject the null hypothesis of equal means and with a significance level (alpha) of 0,050 using a two-sided two-sample unequal-variance t-test.

From a longer treatment period of this study and higher participants' drop-off expected, the population was doubled to 64 subjects in total.

Research methods were determined upon the clinical question "Could the prolonged design of acupuncture treatments on patients with knee osteoarthritis (KOA) decrease pain and improve the function of the knee joints and additionally achieve positive effects on the debilitating symptoms of a Kidney deficiency as a root cause of KOA, measured by recognized questionnaires?".

Evaluation of the therapeutic effects of acupuncture on KOA included WOMAC, VAS, KDSQ scores, and DRUG at Weeks 0, 3, 6, 9, 12, 15, 18, 21, 24, and 39. WOMAC is a renowned questionnaire for KOA evaluation. It measures 5 items for pain, 2 for stiffness, and 17 for functional limitation. VAS is a continuous numeric rating scale of 100 mm in length that is widely used for pain intensity assessment. The KDSQ questionnaire is a valid and reliable measure constructed in 2012 to evaluate Kidney Yin and Yang deficiency syndromes of Hong Kong Chinese middle-aged women by Chen et al. KDSQ represents a valid questionnaire for KD assessment in this study population.

From a total of 10 assessments, the first 9 compared scores between groups A and C. Participants were promised to receive equal acupuncture treatment if they were randomised into the C group. So, group C crossed over to receive the identical protocol from Week 25 to 39, and the 10th assessment was added to both groups of participants to estimate the immediate effects of the acupuncture treatment in the C group and estimate treatment effect persistence in the A group over 24 weeks, in a within-group manner. The physiatrist's assessments at 3 time-points (baseline, 15th Week, and 24th Week) include the standard physiatrist KOA measurements (knee and thigh circumference, range of motion of the knee). The Lequesne index was added as the knee's functional state measure in Week 24.

Data is stored electronically with secured and restricted access. Data transfer will be encrypted, and all data that could identify individuals has been removed.

Study analysis serves to process the effects of acupuncture treatment. Baseline data are obtained before the experiment starts. Besides immediate effects, effects persistence was assessed at Weeks 24 (9 weeks after acupuncture of group A ended) and 39. WOMAC total score at the end of the acupuncture protocol (Week 15) is a primary outcome, while WOMAC subscales, VAS, and KDSQ scores, DRUG at Weeks 15, 24 and 39, and persistence of WOMAC total were secondary and supportive of the primary one. Secondary outcome measures include physiatrists' measures and the Lequesne index as well. Effect sizes are calculated from data comparison to the control group up to Week 24 or baseline at Week 39. Analyses were performed on 64 participants, randomised for the intention-to-treat (ITT) analysis using the maximum available data set (i.e. excluding the missing values) from repeated measures of variables of interest and their variances. ITT analysis, excluding missing values, was selected regarding dropouts that emerged in the study, completely random without any causal clustering. Dropouts produced missing values. Omitting missing values can compromise the statistics and produce bias. Therefore, sensitivity analyses were provided to compare those who dropped out and those who completed the study to determine if data significantly differed. Also, a test calculation with the Last observation carried forward technique (LOCF) with the imputed last observed value in the missing one was performed to check if the obtained effects still stand. All statistical tests are two-sided. The Shapiro-Wilk test tests the normality distribution. The non-parametric Mann-Whitney U test was used for comparability testing with 95% power and α=0,05. The main efficacy indicators tested the comparability of the groups with the Mann-Whitney U test and quantified observed effects by mean differences and Cohen's d.

A participant will be considered to have withdrawn from the trial when consent is revoked or if the participant cannot be contacted or located. Participants will not be withdrawn from the trial for protocol violations. Withdrawal due to an adverse event should be distinguished from withdrawal due to insufficient response.

All adverse events will be recorded in the Adverse Event Report Form at every treatment. If this happens, an adverse event will be followed until its resolution. The serious adverse event must be reported to the Medical Ethics Committee.

It is expected to relieve pain and increase joint mobility, along with alleviating KD and reducing the use of analgesics and confirming the safety of acupuncture.

This is a prospective, interventional, randomized, open-label, controlled trial. It is supported by recent scholarly, peer-reviewed literature. The research method reflects the approach needed to answer the research questions. Research is addressing a gap in the literature that would contribute new findings. The research topic is based on a tangible and cited problem. The research collects and analyses the data, any deviations are documented and approved by NJUCM. The study was designed originally. The acupuncture treatment plan for KOA is designed with the assistance of Professor Xueping Zhou. The study will be conducted in a Family Medicine practice by the experimenter. All financial and operating burdens will be funded from practice resources.

Arms:
arm 1: Participants in Acupuncture group will get acupuncture treatments to their symptomatic knee/knees according to the study protocol. Acupuncture will be provided to participants in three cycles, each three weeks duration, with frequency three times weekly. Period between the cycles is three weeks long. Participants will get acupuncture as adjunctive therapy to conventional medical treatment (analgesic therapy) which dose could vary according to participant symptoms intensity. Participants and investigator are not blinded for treatment type. arm 2: Participants in Control group will get their standard conventional treatment (analgesics) which dose could vary according to participant symptoms intensity. Participants and investigator are not blinded for treatment type.

Interventions: intervention 1: Acupuncture intervention 2: Conventional Medical Treatment
Intervention descriptions: intervention 1: Acupuncture treatment includes pricking the skin with acupuncture needles 0.3 x 40 millimetres in size, in the places of prescribed acupuncture points. Placed needles should be manipulated three times, every ten minutes, three times in total. The complete time of treatment is 30 minutes. All treatments will be equal. intervention 2: Participants could take their standard conventional medical treatment or analgesics. Analgesics therapy is prescribed by their general practitioner. The dose of analgesics could be modified according to participants' symptoms intensity.

Protocol document:
ICF_002.pdf: 
 
Needling Techniques for Tonifying Kidneys and Dredging Meridians for Knee Osteoarthritis: A 
Randomized Clinical Trial 
NCT05014542 
 
 
 Document date: December 3, 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


INFORMED CONSENT TO PARTICIPATE IN RESEARCH 
RESEARCH TITLE The effects of acupuncture as an additional therapy for osteoarthritis of the knee 
assessed by renowned questionnaires 
PLACE OF RESEARCH Zagreb, Sesvete, Ninska 10 
NAME AND SURNAME OF RESEARCH MANAGER Svijetlana Perčulija Đurđević 
Dear Sir, 
We invite you to take part in a scientific study examining the effect of acupuncture on pain and 
improvement of skin function in patients suffering from osteoarthritis of the knee. The research is 
open, the total number of respondents will be divided into two groups, acupuncture and control. 
Patients will not be compensated for participating in the study. It is expected that patients will be 
motivated to complete the trial due to the benefits of the therapy received. Patients in the 
acupuncture group were additionally motivated to complete the trial because of possible additional 
effects of acupuncture on other symptoms related to the underlying cause of the disorder. Patients 
in the control group who complete the study by completing the provided questionnaires will be 
offered the same therapeutic protocol as patients in the acupuncture group, after the study has 
ended. 
We want you to participate in the research because you suffer from knee osteoarthritis. The leader 
of the research is Svijetlana Perčulija Đurđević, MD, specialist in family medicine, acupuncturist. The 
research will be carried out in the Private Specialist Practice he runs at Ninska 10, Sesvete, and it is 
financed independently. The research is conducted for the purpose of creating a doctorate. Please 
read carefully this Informed Consent for Research Participation, which explains why the study is 
being conducted and what the risks to your health might be if you agree to participate. 
If you do not understand any part of the Informed Consent, please contact the research examiner for 
an explanation. Your participation in this trial is voluntary and you may withdraw at any time. If you 
decide to participate in this research, you will be asked to sign an Informed Consent with an 
indication of the date. The informed consent is also signed by the researcher, and you will receive a 
signed copy of the informed consent in person before the start of the said research. The original 
Informed Consent is with the researcher of this trial. 
The physician-researcher conducting this research will not receive any financial compensation. 
RESEARCH DATA 
The research aims to confirm the positive effect of acupuncture as an additional therapy to drug 
therapy for patients suffering from chronic osteoarthritis. A total of 64 patients will be divided into 
two groups. The acupuncture group will receive their chronic pain pill therapy that they have 
previously received with acupuncture, while the control group will only receive their chronic pain pill 
therapy. The evaluation of the effect of the therapy will be measured with three different 
questionnaires every three weeks from the beginning of the trial. Acupuncture therapy will be 
provided in three cycles of three weeks, three times a week. The interval between cycles will be 
three weeks. The duration of each acupuncture treatment will be 30 minutes. Patients will be 
admitted at the time they are ordered for treatment. The study ends with the last filling of the 
questionnaire in the 24th week of the study (9 weeks from the last treatment). 
Patients will be randomly selected into groups (like a coin toss). Patients from the group that will not 
receive acupuncture, upon completion of the trial, will be able to receive the same therapeutic 


protocol described above. and other possible positive effects on the health of patients related to the 
disorder causing the disease under investigation. 
What is expected of the respondents 
At each individual meeting, the patient will be treated with acupuncture needles that are disposable 
and sterile, the place where the needle is placed will be previously disinfected with alcohol. The 
patient will be placed a total of around 10 needles during the treatment, locally in the knee area and 
a few in more distant places. Each subject will receive a total of 27 acupuncture treatments in 15 
weeks. Acupuncture therapy will be provided in three cycles of three weeks, three times a week. The 
interval between cycles will be three weeks. The duration of each acupuncture treatment will be 30 
minutes. The trial is planned to begin in September, 2021. 
Patients in both groups will be given three different questionnaires to examine their own symptoms 
every three weeks from the beginning of the study until the end at week 24. 
POSSIBLE RISKS AND INCONVENIENCES! 
This research does not involve any risk other than normal everyday risk. 
POSSIBLE BENEFITS: you may have the following benefits from participating in the trial: reduction of 
pain in the knee/knees, improvement of knee function, possible additional positive effects on health. 
CONFIDENTIALITY AND PROTECTION OF PERSONAL DATA 
The personal medical data of the respondents will be protected. Each respondent will be assigned a 
code, and the data will be visible only to the examiner. The database will be stored in a computer, 
and access to the computer will be protected by a code. 
Research data will be stored by the examiner for a period of 10 years. 
The data in the research will not be used for further research. 
According to the data protection law of the European Union (Data Protection Directive, which was 
replaced by the General Data Protection Regulation on May 25, 2018), your researcher makes 
important decisions in the use and disclosure of your personal data and, as the "controller", will be 
jointly responsible for compliance with that law. 
Through the researcher, you have the right to access all data collected about you and to request 
their corrections if they are incorrect during the conduct of the research/after the end of active 
participation in the research. 
You have the right to complain about the way your data is handled, and you can send it to the 
competent authority responsible for the enforcement of the law on the protection of personal data. 
The list of competent authorities in the European Union is available at this link: 
http://ec.europa.eu/justice/data-protection/article29/structure/data-protection-
authorities/index_en.htm. For the Republic of Croatia, the competent authority to which you can 
send a complaint is the Personal Data Protection Agency, Selska cesta 136, HR - 10 000 Zagreb. 
If you withdraw from the research, data collected before your withdrawal may still be processed 
together with other data collected as part of the research. 
This research can only be conducted by collecting and using the personal data of respondents in the 
manner described in this informed consent, and you can participate in it only if you agree to it. 


If you have any questions, comments or complaints regarding the way your data is handled, you 
should first contact the researcher, who will forward your request to the staff responsible for data 
protection. 
BENEFIT FOR THE RESEARCHER 
The results of the research will be used for the purpose of creating the examiner's doctoral thesis. 
WHO APPROVED THIS RESEARCH 
This research was approved by the ethics committee of the Health Center Zagreb-istok, Švarcova 20, 
Zagreb. 
VOLUNTARY PARTICIPATION 
Participation in this research is completely voluntary. Your decision on whether or not you want to 
participate in this research will in no way affect the way, procedures and course of your treatment. If 
you decide to participate in the research, you can stop your participation in it at any time. You will 
inform the researcher of your decision in writing (address provided in this survey). The decision to 
stop participating in the research will in no way affect the way, procedures and course of your 
treatment. 
QUESTIONS ABOUT THE TEST AND CONTACT INFORMATION 
For additional questions about the research itself, you can contact Svitelana Perčulija Đurđević, MD, 
tel. 012050758. 
If you fall ill or suffer an injury during this examination, please contact the researcher Svijetlana 
Perčulija Đurđević, MD, tel. 012050758. 
Read this text together with the researcher and/or family members. 
With my signature, I confirm that I am informed about the goals, advantages and risks of this 
research and I agree to participate in it: 
In Zagreb, __________________ (Date). 
 
__________________ __________________ 
Signature of the participant or his Signature of the research leader 
of the legal representative 
 (indicate here the name and surname and the title of the researcher, institution) 
I, the research doctor confirm that I have verbally provided the necessary information about this trial 
and provided a copy of the Informed Consent signed by the subject and the researcher 
______________________ 
Signature of the research leader 
(indicate here the name and surname of the researcher, institution) 

Prot_000.pdf: 
 
 
Study protocol 
Needling Techniques for Tonifying Kidneys and Dredging Meridians for 
Knee Osteoarthritis: A Randomized Clinical Trial 
NCT05014542 
Document date: March 10, 2025 
 
The randomised control open-label study supported by recent scholarly 
peer-reviewed literature was originally designed and aimed to evaluate the 
effectiveness and safety of acupuncture with a predefined acupuncture 
protocol in KOA participants over 50. Due to the experiment's nature, 
participants and the researcher will not be blinded, but an independent 
observer who collected participants' answers wil be. The control group 
(group C) will continue with taking analgesics from before the study, while 
the acupuncture group (group A) will take acupuncture as an adjunct to the 
same analgesic regimen. All participants will take analgesics in an“as 
needed“ manner to avoid the disadvantages to their health when taking them 
regularly. 
Used methods reflect the need to answer the research question: Could 
acupuncture on patients with KOA decrease pain, improve the function of the 
knee joints, and additionally achieve positive effects on debilitating 
symptoms of a Kidney deficiency as a root cause of KOA, estimated by 
recognized questionnaires? The research was directed towards adding new 
findings to the body of knowledge. KOA is based on a tangible and 
frequently cited condition. The research protocol was confirmed by NJUCM 
board committee, and any deviations from the protocol will be documented 
and approved. 
The KOA may be diagnosed easily and confidently with only clinical 
conclusions in patients with painful knees above 50 years if recent trauma 
is excluded. Typically pain aggravates with motion and load, alleviates 
with rest, and the persistence of morning stiffness is less than 30 
minutes. Atypical presentation of KOA (inflamed knees, marked pain at rest 
or night, rapidly progressive pain, or systemic symptoms) supposes the need 


for clinical differentiation. A typical presentation does not need 
confirmation with additional investigations. Moreover, there is no 
consistent correlation between clinical symptoms of KOA and radiographic or 
blood findings. Altman constructed applicable KOA diagnosis criteria, 
recommended by the American College of Rheumatology (ACR) which are 
incorporated as the study criteria. 
Participants mutually substantially varied by comorbidity, emotional 
response, habits, beliefs, and expectations. Because all suffered from KOA 
and KD the acupuncture protocol was so designed to enable uniform treatment 
to all. Comorbidities could affect symptoms and make treatment less or more 
effective. The researcher estimated that with the equally provided 
treatments, no one participant could be harmed and the protocol may be 
sufficiently effective for all included. 
The study proposal was accepted in 2020. The approval of the Ethical 
Committee of Health Center Zagreb-East was received on June 7, 2021, REF.NO 
01-830-1/21. The study is registered on ClinicalTrials.gov PRS under ID 
NCT05014542.  
Treatments will be performed in the researcher's private family 
medicine practice in Zagreb. The collection of participants was enabled by 
open access to data of four thousand patients from two family medicine 
practices connected by the group contract. The Central Health Information 
System of the Republic of Croatia (CEZIH) enabled the data search. The 
researcher got agreement from the other physician to approach all 
population data for experimental purposes. Also, the target population 
represents the general population regarding the explored topic involving 
all age groups besides preschool children. KOA prevalence in the general 
population enabled sufficient enrollment. The severity of KOA symptoms 
guarantees patients' motivation to participate and finish the envisioned 
protocol. A researcher who is a certified acupuncturist with over twenty 
years of experience provided TCM-style acupuncture.  
Berman et al. study in 1999 serves for sample size calculation: the 
calculated 32 was doubled and 64 participants made the sample size from the 
expected greater attrition of participants from a longer study period. The 
CEZIH's database enabled searching the target population by the default 


criteria of 50 years and above and M17 diagnosis criteria from four 
thousand patients. The International Classification of Diseases (ICD-10) 
encrypts KOA by M17. 180 patients made the study population. They were 
contacted by telephone, and if they showed a willingness to participate in 
the trial, they were invited to the researcher's office for more detailed 
arrangements. Those unavailable, with incorrect diagnosis, or unwilling to 
participate fell off and the first 64 who satisfied enrollment criteria 
were enrolled, Figure 1.  
 
 
Figure 1  Pre-experimental research part   
 
KOA is confirmed with “knee pain and three out of six associated 
characteristics: patient of any gender over 50 years, less than 30 minutes 
of morning stiffness, crepitus on active motion, bony tenderness, bony 
enlargement, and no palpable warmth“.[97,145] For the recruitment process, 
radiographic or laboratory findings were not essential because clinical 
criteria alone reached 95% sensitivity in diagnosis confirmation, while the 
X-rays had a specificity of only 69%.[9]  Those who lacked a knee radiogram 
were referred to obtain it. In the pre-experimental week, 64 enrolled 
participants were examined, and baseline assessments were filled in with 


the assistance of a blinded independent assessor. Participants were 
randomised and in a concealed manner allocated to interventional group (A) 
or control (C), Figure 1.  
On September 6, 2021, the experiment will start. Group A will receive 
acupuncture and analgesics, and group C analgesics only. All in “as 
needed” regimen and free to change the dose. At Week 1 Group A should 
start with the first of three acupuncture treatment cycles, each consisting 
of nine acupunctures, and two adjacent cycles will be separated by a 3-week 
treatment-free period. Thus the entire treatment period of Group A covers 
15 weeks, followed by a 9-week treatment-free period to assess short-term 
therapeutic effects. The first 24 weeks comprises the acupuncture treatment 
of group A and nine successive assessments of both groups, while all 
participants took analgesics identically, according to their needs. The 
same acupuncture treatment protocol should be offered to group C in Week 25 
as a reward for participation as a control if interested. The identical 
acupuncture treatment of Group C will be provided from Week 25 to Week 39. 
The whole experiment lasted 39 weeks, the assessment at Week 39 was 
introduced after the participants of group C mostly showed interest in 
acupuncture treatments; this deviation from the study protocol was approved 
and accepted by the authority. Add-assessment at Week 39 will assess 
available participants of group A 24 weeks after acupuncture ended to 
observe medium effects and immediate effects of acupuncture in group C, 
Figure 2. 
 


 
Figure 2  Experimental research part 
Figure 2 The First study part lasted until Week 24. The Additional study part 
lasted from the Week 25 to 39. Each of three acupuncture cycle was 3-week long 
each, participants received acupuncture 3 times weekly, cycles were separated by 
3-week period. At all 10 assessments, participants fulfilled WOMAC, NRS, KDSQ 
and DRUG. Assessments 6, 9, and Add evaluated immediate-, short-, and medium-
term effects. The number of existing participants at specified time points was 
presented from n=n(A)+n(C), where the total number is equal to the sum of those 
in both groups. Add-additional, No-number, pt–participant, n–number of 
participants  
 
The acupuncture treatment protocol envisioned 27 treatments per 
participant. The number of performed treatments was recorded. Acupuncture 
treatment was uniform for all participants. The design embraced the basic 
theoretical concept of the causal connection between KOA (knee Bone Bi 
syndrome) and KD. The selection of points consisted of 8 local and 3 aimed 
to affect KD, which were needled bilaterally with prescribed techniques and 
the intention to elicit de Qi.[139]  
In total 10 assessments were provided at weeks 0, 3, 6, 9, 12, 15, 
18, 21, 24, and 39. The time and day of treatments or assessments were 


adapted to the patient's possibility to participate as much as possible. 
The observer was independent and blinded to which group a participant 
belonged. 
WOMAC total and subscales, KDSQ, NRS, and DRUG were evaluated. DRUG 
was calculated from the average daily dose of analgesics in the last 3 days 
before assessment, according to the participant's statement. Different 
types of analgesics were converted into comparable doses of ibuprofen as 
the most prescribed one and expressed in IBU (ibuprofen milligrams units). 
  Methods 
  1 Sample size calculation  
Calculation was performed from the Berman[23]   study with a similar 
research design, which achieved significant differences by acupuncture 
between the experimental and standard medication groups. Berman used a 
shorter treatment period than the one envisioned for the present study (8 
vs. 15 weeks). Otherwise, the protocols were similar. From Berman’s study, 
WOMAC total scores in the A and C groups were comparable at the baseline, 
after the treatment period of 8 weeks WOMAC total scores were in group A 
28,08 with standard deviation (SD) 17,96 and in group C 50,11 (SD=14,52). 
The sample size was calculated using the PASS software package[146]  
envisioning a two-sided test with unequal variances: type I error 0,05 and 
0,95 power. Group sample sizes of 16 and 16 (i.e. the calculated sample 
size of 32 subjects) achieve 95,78% statistical power to reject the null 
hypothesis (H0) of equal means when the population mean difference is μ1-
μ2=28,1-50,1=-22,0 with SD(group A)=18,0 and SD(group C)=14,5, and with a 
significance level α=0,050 using a two-sided two-sample unequal-variance 
t-test.[146–150] Taking into account that in the study the treatment period 
will be significantly longer compared to Berman's and that a certain 
proportion of subjects is expected to be lost to follow-up, the study 
population was doubled to a total of 64 subjects. The sample size was large 
enough to control the risk of false-negative or false-positive findings, to 
increase the precision of the results, and to provide 95% power of the 
study for conclusion. 


  2 Inclusion and exclusion criteria 
Study criteria were predetermined for the enrollment of participants. 
Inclusion criteria were patients aged 50 years or older with confirmed KOA 
for at least six months, at least moderate knee pain in the last month, 
taking analgesics for pain control during that period, by the radiographs 
confirmed KOA's Kellgren-Lawrence (K-L) grade 2 or higher, and signed 
informed consent. Exclusion criteria were receiving knee intra-articular 
injection three months before the participant entered the study, unstable 
chronic or uncontrolled concomitant disease, bleeding diathesis or using 
anticoagulants. Those who satisfied all criteria were assigned to the 
study. 
The knee radiographs and K-L grading served as additional 
conformation of KOA. Participants were not asked to renew existing images 
because radiographs do not follow the clinical presentation 
unambiguously.[7]  New ones were done only for those who did not have them 
before. Because of the researcher's confidence in recognizing KOA from 
rheumatoid arthritis, psoriatic arthritis, rheumatic fever, and other knee 
conditions, the conditions were not listed as excluding factors. Two 
participants were enrolled with unilateral total knee endoprosthesis. 
  3 Randomisation and concealed allocation  
Patients were assigned to the study after the enrolment criteria were 
applied. A population of 64 patients was evenly randomly allocated into two 
groups: the experimental or acupuncture (A) group and the control (C) 
group. Randomisation and concealed allocation were achieved using the 
participants’ permanent unique randomly generated and coincidentally 
assigned Personal Identification Number (OIB). The acronym OIB stands for 
“Osobni identifikacijski broj” in Croatia; all citizens receive it at 
birth. OIBs mutually differ according to their size, but all possess eleven 
digits. 
OIBs were sorted from the greatest to the smallest and attached to 
numbers from 1 to 64, the biggest OIB was linked to the smallest number. 
Those scheduled under the even numbers were allocated to group A, while odd 
numbers formed group C, according to the alphabet order of the first letter 
of the involved word (i.e. "A" with "even" and "C" with "odd"). The 


experimenter could not know to which group any participant would be 
allocated and the criterion of concealment was satisfied. 
  4  Safety assessment 
The adverse events were spontaneously reported and recorded 
successively throughout the experiment. The practitioner addressed open 
questions to the patient at every session to increase the possibility of 
side effect reporting. Identified side effects were monitored and followed 
until resolution. Reporting serious adverse reactions to the competent 
authority was obligatory. The study presented side effects in detail in 
Section 11. 
Also, participants’ radiographs were not renewed to prevent 
unnecessary radiation of patients for a more precise KOA staging because X-
ray images and clinical presentation do not correlate directly in KOA.[9]    
  5  Study protocol 
From the need to preserve Essence and restrain the Ming Men Fire 
tonifying the Kidney from the adult age is important. Yin and Yang are 
opposed poles but exist inseparably; deficiency of one depletes the other, 
and one becomes produced from the other in favourable circumstances. Yin 
can be obtained from Yang, and Yang can be enriched with the tonifying of 
Yin in the balanced treatment.[137]  According to Xun Zi,” myriad beings 
form when the heaven and earth meet together, and all changes and 
transformations start when Yin and Yang meet together“. [138] The quote 
emphasises the clinical reasoning of simultaneous mild tonifying of Kidney 
Yin and Yang while treating KD. Another saying from the Essential Reading 
in Medicine: “Without Yang, Yin cannot engender, without Yin, Yang cannot 
transform“,[124] confirms the previous statement.  
The Bi syndrome could be superficial (tendons, muscles) as arises 
from the interaction of localised weaknesses (local Qi and Blood flow are 
impeded) and sufficiently strong pathogenic factor invasion. The treatment 
strategy requires removing obstructions and stimulating the local Qi and 
Blood flow only.[119]   
Knee Bone Bi syndrome has a more complicated evolution. Bones and 
cartilage share the same developmental lineage, their formation and 
maintenance relate to Kidney Essence. It is a chronic and degenerative 


condition which primarily originates from KD while external factors 
invasion contributes to symptomatic manifestation formation. Both amplify 
each other; unresolved pathogenic factor lingers and weaken internal 
organs, and vice versa depleted organs exhaust the organ-representative 
distinct parts and make them prone to further pathogens invasion.[119] In 
combined patterns, an obligatory strategy is to tonify the deficient root 
and drain the excess because a strong root provides Qi and Blood for 
related regions and enables excess to be expelled, further if only the root 
has been nourished it will be difficult to expel the excess, or if only the 
excess becomes drained disorder will reoccur with more intensity.[133,140,141] 
Therefore, KOA should be treated with simultaneous tonifying of KD and 
expelling pathogens with mild reinforcing-reducing or even technique on 
local points to treat manifestation by support local Qi and Blood flow but 
not in a dispersive way rather to derive excess toward the deficiency. [79,142] 
When the described methods act, the reinforcing-reducing effect should be 
produced by the regulation of Qi on combined full-empty conditions such as 
knee Bone Bi syndrome and KD as a requirement for treatment success. 
Points selection (poins are descibed at Attachment 1): 
- 
local points are Dubi (ST-35), Neixiyan (EX-LE-4), Heding (EX-LE-2), 
Xuehai (SP-10), Yanglingquan (GB-34), Yinlingquan (SP-9), Zusanli 
(ST-36), and Sanyinjiao (SP-6), 
- 
points based on KD are Taixi (KI-3), Shenshu (BL-23), and Guanyuan 
(CV-4). 
Needle selections: Disposable sterile acupuncture needles 0.30 × 40 mm of 
the brand Green Nature, manufactured by Suzhou Zhong Jing Life & Science 
Technology Co., Ltd. Wujiang, China were used.  
The depth and angle procedure: perpendicular and 1-1.5 inches deep for SP-
10, EX-LE-2, GB-34, SP-9, ST-36, SP-6, BL-23, and CV-4 and perpendicular 
and 0.5-1 inch deep for KI-3. Points ST-35 and EX-LE-4 should be needled in 
the horizontal insertion and up to 2 inches deep. 
Acupuncture techniques: reinforcing method for KI-3, BL-23, and CV-4, while 
the mild reinforcing-reducing or even technique for all other local points.  
Points were needled bilaterally, so the acupuncture treatment 
included 21 points. Complete treatment lasted 30 minutes, and reinforcing 
and reducing manipulation were provided every 10 minutes, three times in 


total, except at BL-23, which was reinforced briefly three times in a 
sitting position and needles were withdrawn immediately after manipulation 
to allow the participants to lie down in supine position for treatment 
continuation. From ST-35 and EX-LE-4 position (directly in the knees) an 
even milder reinforcing-reducing manipulation form was required. The 
needles were placed at the intended depth to elicit de Qi.  
Providing acupuncture treatments in 15 weeks: The complete treatment 
period includes three therapeutic cycles three weeks long, and two adjacent 
cycles were separated by 3 weeks without acupuncture. Treatments were 
attended 3-time weekly during any of the treatment cycles. Thus, the 
complete treatment protocol contained 27 possible acupuncture sessions. 
The points were selected to treat the KOA and KD simultaneously. 
Envisioned treatment follows syndrome differentiation and understanding of 
the theoretically substantiated genesis of KOA. The points for KOA 
treatment are determined without individual adjustment because all 
participants suffer from KOA and KD. It was concluded that not a single 
point could harm any patient concerning the assessed state of health when 
the exclusion criteria for enrollment were applied. Knee Bone Bi syndrome 
and KD are interconnected in the onset of the disease and the recovery 
process. Treatment should target the pathology from the evolution of Bone 
Bi syndrome: excess of Damp-Cold pathogen and deficiency of Blood, Qi, Yin, 
Yang, and Essence. By the treatment, tonifying of the Kidney enables 
nourishing of related knee region and meridians to allow meridian-dredging 
by deep activation of Qi and Blood as a requirement for leaching out Damp 
supported with manipulation of local points on Spleen's transportation and 
transformation processes to solve local Dump congestion and improve body 
nourishment, to invigorate Blood, and release consequential joint 
constriction. [79]   
This acupuncture protocol was designed by textbook 
exploration[19,79,118,124,139] and literature mining. [54,115,119,133,140,142]  supported by 
supervisor *** and approved by the *** committee during the thesis proposal 
defence.  


  6 Needling techniques  
A reinforcing method of KD was performed with slow needle insertion 
to strengthen the intention of stimulation at the predicted depth. 
Simultaneously the experimenter inhaled, intending to obtain de Qi. Six 
slow and short needle rotations formed one manipulation. Three 
manipulations were provided in total, every 10 minutes in one treatment. 
The rotation includes both directions with amplitude <180˚ by the speed 
one-time in two seconds; one direction lasted one second. The withdrawal 
was quick with the exhalation of the experimenter to strengthen the mild 
form of tonifying, firstly under the skin surface, then from the skin with 
an immediate covering of the hole.[143]  
A mild reinforcing-reducing method at local points was performed with 
an even speed of inserting and withdrawing the needle. After the needle 
reached the desired depth, six up-and-down vertical needle movements of <10 
mm in depth made one manipulation. One up-and-down movement was performed 
with a frequency of both needle directions in one second.[143] One treatment 
was supposed three manipulations, every 10 minutes.  
ST-35 and EX-LE-4 points required even milder manipulation to be 
applied from their position. Also, in the case of participants with a 
weaker constitution, a slightly milder form of local points manipulation 
was performed to prevent the appearance of weakness. That supposes lowering 
of vertical needle movement depth and decreasing the manipulation 
frequency. 
From a TCM perspective, the agreed-upon strategy for knee Bone Bi 
treatment is to calmly tonify the Kidney and Liver Blood, nourish Qi and 
Blood, invigorate them, and expel the Damp-Cold pathogen from obstructed 
channels and collaterals without harming the vital Qi.[54,119,120] The expelling 
of the pathogens from KOA is assured by reinforcing Kidney Qi and dredging 
the local meridians by even technique, not to disperse pathogens but rather 
to process and transfer them toward existing deficiences to achieve 
balance.  
From so designed treatment of the knee Bone Bi syndrome is expected: 
1. by reinforcing Kidney, KD and knee Bone Bi syndrome should be 
treated, 


2. when knee Bone Bi syndrome is nourished systematically with Qi and 
Blood, a stronger and more persistent treatment effect could be expected 
compared to local treatment only, 
3. additional improvements in KD's scope of symptoms which intensity 
decreased, but improved the patient's general health. The unintentional 
improvements of general body conditioning arise when general Qi is 
reinforced, Blood moved, and Yin and Yang are produced.  
  7 Groups A and C 
Each participant, regardless of the group, had the same number, 
order, and structure of treatments, and the difference between the groups 
was in that, in the first 24 weeks of the study, the experimental group A 
(henceforth, group A) received a combination of an acupuncture and an 
analgetic treatment, whereas the control group C (henceforth, group C) 
received the analgetic treatment only. After the 24th week, group C receives 
a combined acupuncture and analgetic treatment while group A receives 
analgesics only, Figure 8-2.  
The crucial 24 weeks was organised so that each patient of group A 
underwent three three-week treatment cycles, each week consisting of three 
in-person treatments for a total of 27 treatments per patient. At the end 
of the first and second treatment cycles, patients were given a three-week 
break from treatment. At the end of the final cycle (15 weeks from the 
start of the study) patients underwent immediate-term assessment, and then 
the patients entered a 9-week observational period during which they did 
not receive acupuncture. At the end of the observational period (24 weeks 
from the start of the study), they underwent an assessment which gauged the 
short-term efficacy of their treatment, Figure 8-2. 
Following the initial 24 weeks, group A stopped receiving any 
acupuncture treatment, whereas group C started receiving the combined 
acupuncture and analgetic treatment, which was promised to incentivise 
participation. After the ensuing 15 weeks, another assessment was 
administered to both groups to assess the immediate effects of group C and 
the medium-term effects of 24 weeks follow-up of group A (Figure 8-2). 
During the complete study period, all participants took analgesics 
according to symptom intensity without the need for prior consultation. 


Recommendations to take analgesics "as needed" during the study continued 
from before. 
All participants underwent nine assessments simultaneously up to Week 
24 and the final at Week 39. Although both groups received identical 
acupuncture treatments, group A had four assessments along the acupuncture 
treatments, unlike group C. 
  8. Assessments   
The study comprised 10 identical assessments at Weeks 0, 3, 6, 9, 12, 
15, 18, 21, 24, and 39, 4 variables (WOMAC, NRS, KDSQ, and DRUG) were 
assessed for all available participants. The intensity of knee symptoms 
(WOMAC, NRS), KD intensity (KDSQ), and dose of analgesics taken (DRUG) were 
assessed. Fulfilling the forms by participants was observed by the blinded 
and independent nurse who did not know to which group participants 
belonged. She took care of the timing to contact participants to fill out 
the forms, to obtain information about the dose of analgesics, and to 
provide explanations if needed. 
WOMAC is a renowned questionnaire with high reliability and good 
validity for the assessment of KOA.[151]  It measures 5 items for pain, 2 
for stiffness and 17 for functional limitation, and its maximal score is 
96 points. WOMAC is highly responsive to clinical changes[152]  and is 
commonly utilised for KOA treatment assessment.  
The NRS continuous scale designed as 100 mm long, is a widely used 
and recognized scale for pain intensity assessment. The intermediate part 
of the scale was divided into ten enumerated parts for easier browsing 
and filling the scores: the maximal 100 scores signified unbearable pain, 
and the minimal 0 no pain. WOMAC and rating scales for pain are widely 
accepted, and commonly used in KOA trials.[29,30,42]  
Chinese medicine's routine diagnostic methods (inspection, inquiry, 
auscultation, and palpation) have not been shown as reliable measures; only 
examination and auscultation were shown as methods from which conclusions 
can be drawn toward the Chinese medicine modalities research endpoints. [153]  
However, Chen[49] constructed KDSQ, a valid and reliable measure for 
assessing Kidney Yin and Yang deficiency syndromes and evaluating syndrome-
specific therapies, explained and presented in Section 6.6.3 and Appendices 


2 and 3. From 39 symptoms of KD from the literature, symptoms related to 
childhood or male gender were excluded, and not relevant to this study 
either.  
In this study, KDSQ evaluates the therapeutic effect of acupuncture 
on KD symptoms intensity in urination, sexual drive, aversion to Wind and 
Cold, tiredness, sleep quality, hot flashes, heat in the hands and soles, 
tinnitus, dizziness, lower back pain, pain in knees and other joints. Also, 
it was confirmed valid for use in Croatia because no population or 
territorial circumstances exist that change the content or its usefulness. 
Also, KDSQ represents a valid measure for the examined topic in a 
population older than 50 years and is suitable for use in the study of both 
sexes after the question of vaginal dryness was excluded. All questions 
well present the grade of intensity of listed symptoms and patients clearly 
understood how to respond to them. Some questions conclude more about 
Kidney Yin or Kidney Yang deficiency, others relate to both entities.  
Eight questions were selected to assess Kidney Cold syndrome and 
eight for Kidney Heat syndrome. Cold-type questions were about urination 
(night-time, day-time frequency, dripping, incontinence, increased urine 
volume), low energy feeling, swellings, and cold feeling in the back. Heat-
type questioned the feelings of heat (hot flushes, tidal waves, five palms 
heat), night sweating, sleeping disturbances, high-pitch tinnitus, night 
thirst, and increased dreaming. KDSQ with 23 questions in total can produce 
a maximum of 69 points when the question about vaginal dryness was 
excluded. 
All participants took prescribed analgesics before the study started, 
they were advised to reduce the dose in the period of remission or to 
increase it if the pain aggravated. The dose varied according to the pain 
intensity. The assessor recorded the dose of analgesics taken according to 
the participants' statements from the last three days before the assessment 
or DRUG, the only objective study measure. The types of analgesics 
participants used were presented in Table 9-1. Ibuprofen was the most 
prescribed one and was selected as the representative analgesic. To enable 
the presentation of the impact of acupuncture on medication intake, doses 
of all taken analgesics were recalculated in the comparable doses of the 


representative one. Comparable doses were determined from the 
pharmacological maximal daily doses (High daily dose) and single doses (Low 
daily dose)[104] as presented in Table 9-1.  This calculation is adopted 
from a clinical approach in daily practice, when a change of analgesics is 
required then a comparable dose represents an alternative remedy. All could 
not be transferred to the same analgesic due to existing affinities or 
intolerance. The doses are expressed as ibuprofen units (IBU), IBU 
correspond to ibuprofen milligrams. 
Table 1  DRUG - Comparable doses of analgesics - crude approximation 
Study analgesics  
Low daily dose 
Medium daily dose 
High daily dose 
Diclofenac 
50 mg 
100 mg 
150 mg 
Ketoprofen 
50 mg 
100 mg 
200 mg 
Tramadol 
37.5 mg 
75 mg 
150 mg 
Ibuprofen 
600 mg 
1200 mg 
2400 mg 
DRUG IBU* 
600 IBU 
1200 IBU 
2400 IBU 
Table 1 Comparable doses of ibuprofen were calculated from minimal, medium 
and maximal daily doses of analgesics used in the study.[104]  IBU* – ibuprofen 
unit, the dose of taken analgesics corresponds to number of milligrams of 
ibuprofen. 
Of all variables the higher scores imply the greater symptom intensity. 
      8.1 Study outcomes  
The study's outcomes were formed from all assessed variables of 
interest WOMAC total, WOMAC pain, WOMAC stiffness, WOMAC functional 
disability, NRS, DRUG, and KDSQ to observe the effects of acupuncture at 
specified moments: the immediate-term effects at Week 15 which coincided 
with end of acupuncture, the short-term effects at Week 24 of nine weeks 
period after acupuncture treatment of group A ended, and Week 39 brought 
two sorts of outcomes depending on the group being observed: the medium-
term effects of group A 24 week after acupuncture and the immediate term 
effects of group C. 
The primary outcome is the WOMAC total score at Week 15 (WOMAC 15) 
when treatment of group A ends; it represents the sum of three measures of 
three disturbed KOA quality. It was selected as the primary outcome to 
present the most important immediate-term effect of group A produced by the 
designed protocol. All other outcomes were secondary and considered 
supportive ones. 


    9. Quality assurance, data storing and general terms 
The study used randomisation and concealed allocation of participants 
to ensure the normality of data distribution and the similarity of baseline 
data between groups. From calculated required size the sample size was 
doubled to ensure the precision of inferences and decrease the probability 
of type I error. The participants and the researcher were not blinded due 
to the surgical nature of the experiment. Blinding of the independent 
observer was performed to reduce study bias. During the assessment week, 
the evaluator collected the completed forms in a room where acupuncture was 
not performed. He invited participants in alphabetical order, different 
from the order obtained by randomization. Patients were given 
questionnaires to fill out, and an observer was available to help them if 
needed. Patients who wished could submit the forms via e-mail. Side effects 
were thoroughly described.  
The trial was overseen and monitored by the researcher. Data is stored 
electronically on a computer with secure and limited access. Data transfers 
were encrypted and all information that could identify individuals was 
removed. The experimenter of this study was responsible for data management 
and statistical analysis of the study. Approval for research was obtained 
from the Ethics Committee of the Zagreb East Health Centre on June 7, 2021, 
REF. NUMBER 01-830-1/21. All study participants signed a written informed 
consent. The project was fully financed by the funds of the private 
practice of family medicine run by the researcher. 
 

SAP_001.pdf: 
Statistical Analysis Plan 
Needling Techniques for Tonifying Kidneys and Dredging Meridians for Knee Osteoarthritis: 
A Randomized Clinical Trial 
NCT05014542 
Document date: March 11, 2025 
 
Analyses should be performed on 64 participants, randomised for the 
intention-to-treat (ITT) analysis using the maximum available data set 
(i.e. excluding the missing values) from repeated measures of variables of 
interest and their variances. Data will be collected from validated 
questionnaires, and a DRUG variable was constructed. 
Trials could be prone to dropouts. They were expected in this trial 
due to the high number of planned treatments and long study period. ITT 
analysis excluding missing values was selected regarding dropouts that 
emerged in the study completely random without any causal clustering.[154] 
Dropouts produced missing values. Omitting missing values can compromise 
the statistics and produce bias. Sensitivity analyses will be provided to 
compare those who dropped out and those who completed the study to find if 
data significantly differed. 
Sensitivity analysis compared completers and non-completers from 
baseline (assessment 1) with the assumption that if both do not differ 
mutually significantly then it could be inferred that non-completers would 
gain similar scores as completers if they completed the trial. Also, test 
calculation with the Last observation carried forward technique (LOCF) 
technique with imputed last observed value in missing one was performed at 
the time-point of the biggest participant attrition in group A to check if 
obtained effects still stand. Sensitivity analyses found consistency with 
data of the primary analysis, which suggests accepting the treatment effect 
of the primary analysis as valid, therefore the missing values had no 
bigger impact on the primary analysis conclusions, the primary analysis 
produces the robust data and the primary results still stand. 
The Shapiro-Wilk test will test the normality distribution of all 
study measures. The normality distribution will be tested to select an 
appropriate test for further data processing. All statistical tests were 
two-sided. For gender at baseline, the significant difference between 
groups will be tested by Chi-square test and the Student t-test for age, 
BMI, and K-L grade regarding the observed categorical or numeric variables. 
The non-parametric Mann-Whitney U test will test with 95% power and α=0,05  
if a significant difference exist when two groups' data are compared, 
regardless if parametric or non-parametric.  


The first study part will compare interventional group A which will 
receive acupuncture adjunctive to analgesics with control group (C) which 
receive analgesics only. 9 assessments will provide observed data from 
baseline to Week 24 for WOMAC total and subscales, NRS, KDSQ, and DRUG. 
Variables' values of all assessed time points will be compared between 
groups to find if data at specified time points significantly differed.  
The second study part will last from Week 25 to 39, and will start 
with the crossover of group C to receive the same acupuncture treatment as 
A before. Added assessment at Week 39 will compare groups with their 
baseline by within-group analysis. The Mann-Whitney U test tested if 
significant differences exist within groups' two various time points, 
separately for each group.  
Repeated measures analyses will present data and calculations for all 
10 assessments. 
The main efficacy indicators will test the comparability of the 
groups with the Mann-Whitney U test and quanify effects by mean differences 
and Cohen's d. 
The testing of the existence of significant differences or that is 
observed by chance by Mann Whitney U test, with α=0,05 and 95% statistical 
power is a prerequisite to test the significance before considering the 
meaningness of achieved effects. Also when the relatively small sample size 
of a study affects significance testing, quantification of effects is 
suggested.[155,156] 
Mean differences will be introduced to compare achieved differences 
with previous trials[157] with similar study designs using WOMAC as an 
outcome measure, and to calculate the reduction of effect or its 
persistence where appropriate. Mean differences will be presented as 
absolute or relative: to observe absolute differences or percentage of lost 
or kept effect accordingly, either between or within groups.  
Cohen's d will present with calculated standardised mean differences 
(SMD) effect intensity. Cohen explains that SMD signifies a small 
therapeutic effect if ≥0.2, medium ≥0.5, and large ≥0.8. It was a 
suitable absolute outcome measure for continuous variables. Its calculation 
adjusts two compared sample differences from their pooled SD for the 


precision of scale measurement and the sample size used. SMD increases with 
increased differences between treatments/groups and the measurement 
precision or lower SD. Its relation to the Number Needed to Treat (NNT) 
signifies when the SMD=1 then the NNT=2 means that of two treated patients 
one will have a good outcome, and if the SMD=2 almost all.[155,156] 
The DRUG variable had outliers which influence the statistic, they 
will not be excluded from the analysis because they do not represent the 
clerical errors, and do not emerge from a different population than the 
sample. 
Compliance of participants to treatment attendance and their 
withdrawal will be thoroughly presented.