2.1. Study design
We have designed a multi-center, randomized positive-controlled clinical trial protocol (Fig. 1). The primary objective of the study is to standardize and optimize the TCM treatment of KOA, and to evaluate the clinical efficacy and safety of the regimen. A total of 144 patients will be recruited at four medical institutions in Shanghai, China: Longhua hospital, affiliated with Shanghai University of Traditional Chinese Medicine; the Community Health Service Center, Pengpu Xincun Sub-district, Jing ′an District, Shanghai; the Community Health Service Center, Lingyun Street, Xuhui District, Shanghai; and Lujiazui Health Service Center, Pudong New District, Shanghai. The patients will be randomly assigned to a TCM group (Qubi Yangge Decoction combined with three steps and nine methods of whole knee) or a control group (conventional medicine and physiotherapy).
Participants in the TCM group will take one packet of Qubi Yangge decoction twice a day, after breakfast and dinner, for 4 weeks; and undergo three steps and nine methods of whole knee manipulation three times a week, for 4 weeks. Participants in the control group will take celecoxib (CelebrexR, Jiangsu Zhongxing Pharmaceutical Co. Ltd; H32026145) 0.2 g daily, once daily for 1 week and glucosamine hydrochloride (BumaixinR, Zhejiang Sincerity Pharmaceutical Co. Ltd; AJPTTJN-2) 0.24 g three times daily for 4 weeks; and undergo physiotherapy using a thermal low-frequency apparatus three times a week for 4 weeks.
Fig. 1 Study flow chart
2.2 Medication and its administration
The Qubi Yangge decoction was developed by Professor Shi Qi combining with years of clinical experience on the basis of Jinbi decoction and Niubangzi decoction, which two decoctions has been proved to have a very good effect inthe treatment of knee osteoarthritis[30-31]. The Qubi Yangge decoction will be manufactured as granules, packaged, and labeled by a factory in Shanghai, according to good manufacturing practice. Each pack comprises Astragalus membranaceus (Huang Qi), 30 g; Angelicae sinensis radix (Dang Gui) 9 g; Paeonialactiflorapall (ShaoYao), 15g; Rhizoma Chuanxiong (Chuan Xiong), 15 g; Prunus persica (Tao Ren), 9 g; Carthamus tinctorius (Hong Hua), 9 g; Gentianae macrophyllae radix (Qin Jiao), 12 g; Cyathulae radix (Chuan Niuxi), 12 g; Fructus arctll (Niu Bangzi), 9 g; Bombyx batryticatus (Bai Jiangcan), 9 g; Sinomenium acutum(Han Fangji), 12 g; Caulis sinomenii (Qing Fengteng), 12 g; Drynariae rhizome (Gu Suibu), 12 g; desert-living Cistanche (Rou Conrong), 15 g; Ligustrum lucidum Ait (Nv Zhenzi), 12 g; Cyperus rotundus L. (Xiang Fu), 12 g; and radix Glycyrrhizae (GanCao), 6 g. The materials will be supplied in a single batch from Longhua hospital and will be stored in a cool, dry place.
Celecoxib and glucosamine hydrochloride will be supplied by the Western Pharmacy of the Longhua Hospital, affiliated with Shanghai University of Traditional Chinese Medicine.
During the study, NSAIDs will be able to be taken to control pain if necessary. The principal investigator will retain all the medication records during the study. Furthermore, other conditions and treatments will be documented in the management manual. Both groups will undergo a 4-week period of treatment and a 12-week period of follow-up. The participants will undergo investigations at baseline and 2, 4, and 12 weeks after treatment.
2.3 Ethical approval
The trial will be conducted in accordance with the Declaration of Helsinki and the Ethical Guidelines for Clinical Research, and the trial protocol has been approved by the Research Ethics Committee of Longhua Hospital, affiliated with Shanghai University of Traditional Chinese Medicine, Shanghai, China, (approval number: 2021LCSY053), ethical approval has been reviewed on April 29, 2021 . During the study period, any modification of the clinical study protocol or informed consent will be submitted to the Ethics Management Committee of the unit for approval.Individuals in this manuscript have given written informed consent (as outlined in the PLOS Consent form) for publication of these case details.
Physicians will invite patients to participate in the trial, tell them in detail why it is being performed, and explain their rights, obligations, and the risks associated with participating. The care provider will then provide them with a consent form. Only patients who fully understand the above information and provide their written informed consent will be able to participate in the trial.Personal information regarding the potential and enrolled participants will be collected for use only in the present study, and we will not share or retain this information unnecessarily.
2.4 Patient recruitment
The patients will be recruited at four medical institutions (the Pengpu Xincun Community Health Service Center, Jing ′an District, Shanghai; Longhua Hospital, affiliated to Shanghai University of Traditional Chinese Medicine; Lingyun Community Health Service Center, Xuhui District; and Shanghai lujiazui Community Health Service Center). All the participants will provide their written informed consent prior to randomization.
2.5 Sample size calculation
We will perform a randomized controlled clinical trial of a TCM and a control group. We have estimated the sample size based on the Western Ontario and McMaster Universities Arthritis index (WOMAC) scores [32] (the primary outcome measure for knee dysfunction) that were achieved during a preliminary study of the treatment of KOA using three steps and nine methods of whole knee manipulation or celecoxib in combination with physiotherapy (n=10 per group). The primary efficacy parameter was the improvement in WOMAC between baseline and the end of the 8-week treatment period, and the results showed that 80% of the participants improved while taking Qubi Yangge decoction and undergoing three steps and nine methods of whole knee manipulation, and 67% improved while taking celecoxib and undergoing physiotherapy (P = 0.735). We adopted a significance level of 0.05, a test effectiveness (1–β) of 0.8, and equivalent standard (δ) of 0.2. Because we are using a positive control group, we calculated the required number of participants using non-inferiority testing and the following formula:
n=2×(Uα+Uβ)2×p(1–p)/δ2,
where 2×(Uα+Uβ)2 is 12.365, the equivalence standard (boundary value) is δ, the mean improvement rate is P, the probability of a type I error is Uα, the unilateral standard normal deviation margin is Uβ, and the sample size is n. When the above numbers are substituted in, N is calculated to be 59.2; therefore, the required sample size for each group is 60. Allowing for a 20% loss of participants, the sample size for each group was determined to be 72, and for a 1:1 ratio in the treatment and control groups, a total of 144 participants are required [33].
2.6 Criteria
2.6.1 Inclusion criteria
①Patients who meet the Western diagnostic criteria and TCM syndrome differentiation criteria of knee osteoarthritis are classified as grade I-III [34].
②Age 40-75 years old, gender unlimited.
③No steroid or non-steroidal anti-inflammatory and analgesic drugs were used in the 3 months prior to enrollment, and no other related treatment was received.
④Patients who have signed informed consent and pledged to complete the treatment course and follow-up.
2.6.2 Exclusion criteria
①Women who are breastfeeding, pregnant or preparing to become pregnant;
②Have a history of multiple drug allergy;
③Combined with liver, kidney, hematopoietic system, endocrine system, cardiovascular and cerebrovascular system, nervous system and other serious primary diseases; Tuberculosis, vertebral deformity, malignant tumor and mental patients; Suspected history of sedative and hypnotic drugs, opioid analgesics and alcohol abuse; Patients with skin diseases and infectious diseases; Patients with gastric ulcer and gastric bleeding history;
④Patients who are unsuitable or cannot apply this treatment method for other reasons;
⑤Patients with mental disorders, language disorders, motor dysfunction and psychological diseases can not cooperate.
2.6.3 Shedding and rejection criteria
①Subjects were not eligible for randomization and did not receive treatment after randomization.
②The subject's compliance was poor(<50%,>120%).
③Subjects received other treatments during the observation period.
2.6.4 Interventions
Participants in the TCM group will be administered Qubi Yangge decoction granules twice daily for 4 weeks (one packet of 200 mg dissolved in hot water) and will undergo three steps and nine methods of whole knee manipulation for 20 min three times a week for 4 weeks. The specific details of the therapy are shown in Figure 2.
3.3.1. Three steps and nine methods of whole knee manipulation
3.3.1.1 Tendon soothing (Fig. 2 a–c)
Petrissage: The operator first put the affected limb into a slight internal rotation posture, and then from the outside of the affected limb along the foot three Yang by the following part from the distal end to the proximal end of the kneading operation 2-3 times; Then the patient's lower extremities mild external rotation, with the thumb from the lower extremities medial sanyin from the proximal to the distal line of kneading method in the process of kneading method, select the key points in the six meridians, such as: Zusanli; Bilateral; Gb 34; Yin ling spring; Each point is operated 6 times.
Kneading manipulation: The operator first lifts the affected side of the calf to a certain height, and uses the holding method to operate 3 times in the upward direction of the rear heel of the calf. Hold and press the patella 3 times; Lower the patient's calf, and then hold the thigh tendons 3 times from the patella up in front of the thigh.
Rolling manipulation: rolling manipulation is applied to the front, medial, and lateral aspects of the thigh and calf.
3.3.1.2 Osteopathic manipulation (Fig. 2 d–f)
Knee lifting: The patient lies flat on the bed, the buttocks are fixed on the bed surface, the knee joint of the affected side is bent, and the knee is bent 45 degrees as far as possible. After the fixed position, the proximal tibia of the affected side is held by the surgeon with both hands and pulled toward the self direction for 6 times.
Knee support: The patient was lying on the bed, the surgeon used one hand to press the patella of the affected side, the other hand to hold the ankle joint of the affected side, moderate force to bend the hip and knee of the affected side clockwise 6 times, counterclockwise 6 times, and then the affected knee joint inside and outside 3 times; To maintain the above two-handed actions, hold the hand on the patella to fix the thigh, hold the patient's hand on the ankle joint and rotate the calf clockwise and counterclockwise for 6 times with the other hand.
Knee pulling: The surgeon maintained the above two hand movements, make the affected limb bend the hip and bend the knee to the maximum tolerance degree, then stretch the affected limb straight, and press the hand on the patella gently for 6 times.
3.3.1.3 Dredging of the channels and collaterals (Fig. 2 g–i)
Ear massage: The surgeon uses the distal interphalangeal joint of the index finger and the tip of the thumb to twist the beginning of the upper foot of the opposite auricle at the same level as the upper edge of the lower foot of the opposite auricle. Press and knead for 30 seconds to accept the pain and distension of the subject. At the same time, the patient is asked to actively extend and bend the affected limb.
Grinding and pushing manipulation: After 3 times of rapid flexion and extension of the knee, the surgeon pushed the patient from the proximal end to the distal end in front of the thigh for 3 times, and applied the rubbing method counterclockwise and clockwise to the patella for 3 times.
Shaking manipulation: With the patient lying flat on the bed, the surgeon held the ankle joint of the affected side with one hand, and held the popliteal fossa of the affected side with the other hand, and performed rapid up and down loosening and shaking for 3 times.
Control group: Celecoxib (manufacturer: Pfizer Pharmaceuticals LLC, China Pharmaceutical Approval J20120063, 0.2g×6 tablets/plate ×1 plate/box) was taken orally, 0.2g, once a day, 1 tablet per time, for 1 week.Glucosamine hydrochloride capsules (manufacturer: Sichuan Xinsdon Pharmaceutical Co., LTD., Sinophosphics Approval number H20051301, 0.24g×42 tablets/bottle) were taken orally, 0.24g, 3 times a day, 1 capsule each time, for 4 weeks.
Low frequency therapy was administered. Methods: The low-frequency fields of two guide (-) placed in patients with knee inside and outside, both guide with warm water infiltration, after fixation with a bandage, select automatic, time 15 min, 3 ~ 100 hz frequency, the temperature of guide to comfort, according to the scope of patients pain and pain tolerance about balance slider, adjust the output to feel appropriate intensity, After that, the kneading frequency was selected as 100Hz and the time was adjusted to 15min. Three times a week for a total of 4 weeks.
Supportive therapy for the two groups: If patients have a visual analog scale (VAS) score of >7, analgesics may be administered during the trial, but the participants will be asked to provide a detailed list of the drugs they used during the study observation period. Researchers will record the names of the drugs, their dosage, frequency of administration, and duration of administratio.
Fig. 2 Detail presentation of manipulative treatment
2.6.5 Randomization and allocation
Participants will be allocated to treatment groups using the method of sub-centers. At each of the four clinical trial centers 36 participants will be recruited (n=18 per group). After screening, the patients will be randomly allocated to two groups at a 1:1 ratio (n=38 in the test and control groups). Randomization will be performed using random numbers generated by SPSS version 21.0 (IBM Corp, Armonk, NY, USA). The group assignment will be concealed from the researchers by a senior data manager who will not be involved in the study. The group assignments will be sealed in opaque envelopes and opened by the researchers following the acquisition of informed consent.
2.7. Outcome measures
2.7.1 Primary outcome measure
The primary outcome will be the change in the WOMAC Global score (0–100 scale) [25–27]. The WOMAC sub-scales assess the dimensions of pain, functionality, and joint stiffness using 24 questions (rated 0–100 on a VAS). It has been subjected to numerous validation studies and was successfully used in the pilot study [19] and in dose-optimization studies [35]. The minimal clinically significant difference in the total WOMAC score has been reported to be a 12% or 16% improvement from baseline [36].
2.7.2 Secondary measurements
VAS: This consists of a line of 100 mm in length and anchor descriptors, such as “no pain” and “worst pain imaginable”, as depicted in Fig. 1 [37].
The Short Form-36 (SF-36) for the evaluation of quality of life: Eight aspects of health are rated using the SF-36: physical functioning (PF), bodily pain (BP), role limitations due to physical health problems (RP), role limitations due to personal or emotional problems (RE), general mental health (MH), social functioning (SF), energy/fatigue or vitality (VIT), and general health perceptions (GH) [38].
Circumference of the quadriceps femoris: the circumference of the quadriceps femoris 10 cm above the patella will be measured during knee extension.
Degree of knee joint swelling: the circumference of the joint at the level of the patella will be measured during knee extension.
Range of motion of the knee joint: the knee flexion and extension angles will be measured [39].
These assessments will be made before, and 2, 4, and 12 weeks after the treatment.
Infrared thermal imaging: The anterolateral and medial sides of the affected knee will be assessed using an infrared thermal imager and the mean temperatures will be calculated [40].
Gait analysis: Kinematics parameters, including velocity, cadence, stride length, maximum knee flexion angle (stance), minimum knee flexion angle (stance), maximum knee flexion angle (swing), mean hip rotation angle (stance), and mean ankle rotation angle (stance), will be analyzed using a gait capture system [41].
Gait analysis and infrared thermal imaging will be performed before and 4 weeks after treatment.
2.7.3 Safety assessments
The Qubi Yangge decoction has been used for hundreds of years in China, and the quantities of herbs included in the decoction are safe, according to the Pharmacopoeia of the People’s Republic of China (2015 version). Furthermore, a number of studies have shown no significant adverse reactions to be associated with three steps and nine methods of whole knee manipulation, thermal low-frequency physiotherapy; or celecoxib or glucosamine hydrochloride administration. The incidence and severity of adverse reactions will be recorded at each visit during the study; and joint swelling, tenderness, and morning stiffness will be monitored. Additionally, routine blood, urine, and fecal analyses, including the assessment of kidney and liver function, will be performed at the beginning and end of the trial.
2.7.4 Participant timeline
The participants will be studied over a 24-month period, from 1 October 2020 to 30 September 2022, by which time the interventions, follow up, data entry, statistical analysis, and quality control of the data should be complete.
2.7.5 Data collection and monitoring
The trial will last 16 weeks, comprising 4 weeks of medication and manipulation or physiotherapy, followed by 12 weeks of follow up. The participants will be assessed at baseline, and after 2 weeks, 4 weeks, and 12 weeks of follow up.
Longhua Hospital, affiliated with Shanghai University of Traditional Chinese Medicine, will be responsible for quality control and the training of the investigators. The results will be independently documented by two investigators using EpiData version 3.1 (EpiData Association, Odense, Denmark), and differences will be resolved through discussion with a third investigator.
2.7.6 Statistical methods
The main indicator of efficacy (WOMAC) will be analyzed in the full analysis set (FAS) and on a per-protocol (PPS) basis. SS will be used as a safety indicator. Baseline equilibrium analysis will also be performed using FAS. Quantitative data will be described using the mean, standard deviation, median, and minimum and maximum values, as appropriate; and qualitative data will be described using a frequency table and composition ratio. Statistical inference will be performed using interval estimation and hypothesis testing. Bilateral 95% confidence intervals will be calculated for quantitative data. Two-sided tests will be conducted for each index of efficacy, using α=0.05 and a null hypothesis that there is no difference between the test and control groups. The null hypothesis will be rejected when P < 0.05 and the difference between the two groups will be considered statistically significant. Data will first be analyzed for normality, and normally distributed data will be expressed as mean ± SE. The paired t-test will be used to compare data for the same group before and after the treatment, and the independent samples t-test will be used for inter-group comparisons. Non-normally distributed data will be analyzed using the rank sum test and categorical data will be analyzed using the chi-square or a non-parametric test. The Ridit test will be used to analyze the semi-quantitative data. Two-tailed values of P < 0.05 will be considered to represent statistical significance. Statistical analyses will be performed using SPSS version 22.0 (IBM, Inc.).