Efficacy of acupuncture in the treatment of post-stroke depression: A study protocol of a randomized controlled trial

Introduction Post-stroke depression (PSD) is an emotional disease characterized by loss of interest and depression after a stroke. Acupuncture, one of the most critical non-drug therapies for the treatment of PSD, has significant clinical efficacy, but the mechanism is not fully understood. Previous study has shown that acupuncture can reduce the level of proinflammatory cytokines and increase the level of anti-inflammatory cytokines, suggesting that regulating the dynamic balance of inflammatory cytokines may be the basis for acupuncture to improve PSD symptoms. Methods and analysis A total of 84 patients with PSD will be recruited and randomly assigned to one of two groups at a 1:1 ratio. Based on the conventional stroke treatment, the control group will receive XingnaoKaiqiao (XNKQ) acupuncture, and the experimental group will receive antidepressant acupuncture at the same time as XNKQ acupuncture. The intervention will last four weeks, and data will be collected before and after treatment. The Hamilton depression scale (HAMD-17) is the primary outcome measure, and the secondary outcome measures include the Self-rating Depression Scale (SDS), the National Institute of Health stroke scale (NIHSS), and the Modified Barthel Index (MBI). Serum IL-1β, IL-4, 5-HT, and BDNF will be used as laboratory indicators. The scales will be assessed at baseline, two weeks, and four weeks, and serum items will be measured at baseline and four weeks after treatment. This study will observe the clinical effect of acupuncture on PSD and the changes in serum-related inflammatory cytokines and explore the possible mechanism of acupuncture against depression from the perspective of inflammatory response. Ethics and dissemination This study protocol was approved by the Medical Ethics Committee of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine (item number: TYLL2023[Z]004). Findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

Clinical study of acupuncture for depression after stroke 1. research topic Clinical study of acupuncture for depression after stroke.

purpose of research
Observe the clinical efficacy of acupuncture on post-stroke depression, provide new ideas for clinical research, and explore the possible mechanism from the perspective of inflammation.

Test background
Post-stroke depression (Poststroke depression, PSD) is a complication of stroke depression, loss and depression, which has attracted more attention in recent years.According to statistics, the incidence of PSD in the first year of stroke is about 10%~15%, and the 5-year incidence is 39%~52% [1] , The incidence rate in China is about 34.9%, which is higher in women than in men [2] .P S D The main manifestations are emotional apathy, weight change, sleep, sleep disorders, fatigue, a sense of no value and anhedonia [3] , Stroke increases the risk of PSD, and PSD is also an adverse factor affecting stroke recovery, often resulting in higher mortality, poorer functional recovery, significant cognitive impairment and lower quality of life [4] .The occurrence of PSD is the result of social psychological factors and biological factors, and its pathophysiological mechanism is complex, mainly related to the regulation of hypothalamic-pituitary-adrenal (HPA) axis, increased inflammatory factors, decreased levels of monoamines, glutamatemediated excitotoxicity and abnormal neurotrophic response [5][6] .Among them, the inflammatory response theory is one of the focus of PSD mechanism research, a variety of inflammatory factors involved in the occurrence of PSD, mainly by pro-inflammatory cytokines and antiinflammatory cytokines mutual antagonism, and in different stages of PSD differential expression, through antidepressants can cause changes of inflammatory factors, so change the balance of inflammatory factors may be one of the mechanisms of treating PSD [7] 。 Currently, the first clinical line treatment of PSD is selective serotonin reuptake inhibitors (Selective Serotonin Reuptake Inhibitor, SSRIs), which can prevent and treat depression in PSD patients, but increase adverse reactions such as cerebral hemorrhage, epilepsy, and gastrointestinal symptoms [8] .Considering the limitations of drug therapy, several non-drug therapies have been used for clinical treatment of PSD, including noninvasive brain stimulation, psychotherapy, exercise therapy, acupuncture, music, literary and artistic means [9] .Acupuncture is an important part of traditional Chinese medicine in the treatment of PSD.Many clinical reports show that acupuncture can significantly improve depressive symptoms in patients with PSDLive quality [10][11][12][13][14] .Systematic evaluation showed that acupuncture was significantly effective in improving HAMD and NIHSS scores [15][16] ，Another study showed that electroacupuncture was no less than antidepressants in improving symptoms in patients with PSD and had a higher safety profile [17] .
Acupuncture for the treatment of PSD is the overall regulation of multiple targets, and the specific mechanism mainly includes Regulating neurotransmitters, improving neuroendocrine disorders, reducing inflammatory factors, reducing oxidative stress, promoting neuronal protection, and promoting regeneration [18] .The author's previous research shows that [19] , Acupuncture can reduce the level of

Sample size estimation
According to the results of the previous small sample clinical study, the Hamilton Depression Scale score decreased in the observation group (Δ HAMD) As a result, the test group decreased by 6. 13 ± 1.96 and 4.57, while the control group n decreased by ± 1.87.The superiority test was used, and the formula was calculated according to the sample size Where α =0.05,1-β =0.9, σ =1.96, δ = (6.13-4.57)=1.56, with the same rate of 20%, n=42, or 42 patients in each group.

Randomization scheme
The 84 patients who met the criteria were included in a 1:1 ratio, independently using the software by the research nurses without the project.The assigned sequence was the acupuncture group and the double number was the control group.The resulting random assignment sequence was placed into sequentially coded, sealed, opaque envelopes, and when the investigator determined their eligibility, the envelopes were opened in order and assigned to the observation or control group.To minimize bias, the allocation sequence cards in the envelope are force-sensitive recording paper and will be qualified by the investigator before opening the envelope δ

=
The name of the subject is written on the surface of the envelope.

Blind method
The investigators and operators know the group of patients, and the acupuncture treatment of two acupuncture doctors in the acupuncture department, do not participate in the study design, and are not allowed to communicate with the patient about the choice of acupuncture points at the specified time, blindly evaluate the efficacy, and the efficacy evaluator does not participate in the treatment process of patients, that is, the evaluator does not know the specific grouping of patients.Due to the different methods of acupuncture intervention, the patients are not blinded.③ Course criteria: symptom criteria and severity criteria have been met for at least 2 weeks.

Inclusion criteria
(1) Meet the diagnostic criteria for post-stroke depression; (2) experience the first stroke, the duration of the disease is 1 to 6 months; (3) Age: 35~80 years old (including); (4) The Hamilton Depression Scale (HAMD-17) score of 8-17 points (including); (5) Clear awareness, stable life signs, and physical examination and cooperation.3.Exclusion criteria (1) Those who have received antidepressant drug treatment or are attending other antidepressant clinical trials within 2 weeks; (2) Patients with consciousness disorder or obvious cognitive impairment (MMSE scale <17 points); (3) there is a severe aphasia and unable to communicate; (4) A history of depression before the stroke event occurred; (5) Patients with severe liver and renal dysfunction (alanine transaminase exceeds 3 times the normal upper limit, and blood creatinine> 180 μ mol / L); (6) pregnant and lactating women; (7) Intolerant or refuse to accept acupuncture / electroacupuncture.

Removal and shedding standards
(1) If serious adverse events, the trial is stopped according to the doctor's judgment; (2) The disease progress during the trial, which affects the efficacy and safety determination; (3) Poor subject compliance (<80% trial treatment compliance), or subjects automatically receiving other treatment; 5. Discontinuation, study criteria (1) Serious safety problems occurred during the study; (2) The effect of acupuncture is much lower than that of the western medicine group, so this study does not have clinical value.

Vi. Treatment plan 1. Basic treatment of stroke
For stroke and its high-risk basic diseases (such as hypertension, diabetes, etc.), both groups received symptomatic treatment by referring to the 2019 edition of the Guidelines for the Clinical Management of Cerebrovascular Diseases in China.

Treatment plan
In view of stroke dysfunction, conventional acupuncture was treated according to the "stroke disease" in the textbook "Acupuncture".
Operation: The patient was placed in the supine position, with 75% alcohol and skin disinfection, and the disposable acupuncture needle (Huatuo brand, Suzhou Medical Supplies Factory Co., LTD., specification: 0.25mm 40mm) was used for acupuncture.The ditch is 5-10 mm to the nasal septum, peck to wet the eye; 10-15 mm, and thrust for 1 min; the affected limb is smoked 3 times, the depth of the other acupoints is 20-25 mm and the needle is left for 30 minutes.Acupuncture was performed 6 times weekly for 4 weeks of treatment.(1) Control group: oral escitalopram tablets for 10mg Q d daily for 4 weeks.
Operation: The patient took the semi-decubitus position, and the bed was raised 45°.After 75% alcohol disinfection, the "brain opening" acupuncture was performed first.The method was the same as before, and then the anti-depression related acupoints were acupuncture after of the obtained data, after the XCMS processing in R, was normalized and formed into a two-dimensional data matrix.

Safety indicators
Possible adverse reactions and incidence of adverse reactions.

Observation time point
The scales were evaluated before, 2 weeks and 4 weeks of intervention, and serum indicators as well as metabolomics analysis were tested before and after 4 weeks of treatment.

Statistical analysis
All the data were analyzed by SPSS 26.0 meter software.The measurement data were tested for normality and homogeneity of variance first.For those conforming to the normal distribution, independent sample t-test was used, and for those not conforming to the normal distribution, non-parametric test was used.Count data were tested by chi-square (χ 2).The grade data are tested as nonparametric tests.A P <0.05 was considered as a statistically significant difference.6. Record and reporting of adverse events 6.1 Record of adverse events In the case report form, the "Adverse Event Record Form" is set up to require the investigator to truthfully fill in the occurrence time, severity, duration, measures taken and outcome of the adverse event.
.26 Adverse event reporting If any serious adverse event occurs in the trial, the investigator must take immediate measures to protect the safety of the subjects, and timely report to the research responsible unit and the ethics committee.The investigator should sign and date the report.The Sponsor will guarantee reporting procedures meeting all legal and regulatory requirements.For patients with possible pregnancy, the patient must be informed that if they are pregnant during the study, the study may pose a risk to the fetus, and the patient must use contraception to participate in the study.If the patient is suspected to be unable to do so, they must not be admitted to the study.
Since the study involves a clinical trial, the investigator declares that the results will be published whether the relevant study results are positive or negative.Xi.Schedule

The Hamilton Depression Scale (HAMD-17)
The Hamilton Depression Scale (HAMD-17) (please type "×") in the "□" before the answer closest to the patient's true situation  Even if there is no comprehensive evaluation (such as endotracheal intubation, language impairment, tracheal trauma, bandage dressing, etc.), the examiner must choose one reaction.申办单位： 天津中医药大学第一附属医院

方案设计： 李孟汉
调节神经递质、改善神经内分泌紊乱、降低炎症因子、减少氧化应激、神经元保 护及促进再生等方面 [18] 。笔者前期研究表明 [19] ， proinflammatory factors and increase the level of anti-inflammatory factors to regulate the dynamic balance of inflammatory factors, and may be one of the mechanisms by which acupuncture can improve PSD.In the early small sample of clinical observation found that acupuncture can improve the depression symptoms, improve limb movement function, improve the quality of life.Therefore, while evaluating the clinical efficacy of acupuncture treatment of PSD, observe the effect of acupuncture on inflammatory factors in PSD patients, further explore the mechanism of acupuncture treatment of PSD, to provide a theoretical basis for clinical acupuncture treatment of PSD.IV.Overall design of the test 1.Overall design type This study used a single center, randomized controlled design.In patients with post-stroke depression, Both groups underwent conventional acupuncture treatment according to the "stroke" in the textbook "Acupuncture", The control group received oral escitalopram tablets, Trial group plus acupuncture treatment with antidepressant, With the Hamilton Depression Scale (HAMD17), the Depression Self-Assessment Scale (Self-rating depression scale, SDS), The NIHSS Scale, Modified Barthel Index (MBI), And serum IL 1 β, IL 10,5-HT, BDNF as efficacy indicators, Efficiency to calculate HAMD17 score and determine efficacy, The effect of acupuncture on post-stroke depression and its effect on related inflammatory factors were observed.

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Na row standard 1.Diagnostic criteria Standards for stroke diagnosis: formulated according to the Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China 2018 and the Guidelines for the Diagnosis and Treatment of Cerebral Hemorrhage in China 2019; Criteria for post-stroke depression: refer to the diagnostic criteria for depression episodes in the Diagnostic and Statistical Manual of Mental Disorders compiled by the American Spiritual Association."Mooddisorders characterized by depression or with severe depressive episodes due to stroke can also be manic or mixed features.(DSM-4) " 。"Depression disorder from other medical conditions" (DSM-5 ICD-9-CM code 293.83), mainly prominent persistent depressive mood, or significantly less interest or pleasure in all or almost all activities; evidence from medical history, physical examination or laboratory findings is a direct and pathologic result of other physical disorders; this disorder cannot be better explained by other mental disorders; not only instantaneous; clinically significant pain, or leading to social, occupational, or other important damage.The diagnostic criteria for the diagnosis of depressive episodes in the 3rd edition of China Mental Disorders Classification Scheme and Diagnostic Standards were also referred to.① Symptoms criteria: low mood is mainly, and at least the following 4: a. Loss of interest in daily activities, no pleasure; b.Significant loss of energy, unexplained persistent fatigue; c.Psychomotor retardation or agitation; d.Self-evaluation is too low, or self-blame, or have a sense of guilt, can reach the level of delusion; e. Difficulties in association, or a significant decline in self-conscious thinking ability; f.Repeated thoughts of dying, or suicidal behavior; g insomnia, or early awakening, or excessive sleep; h loss of appetite, or significant weight loss; i significant loss of libido.② Serious standard: social function damage, causing pain or adverse consequences.
getting gas.Baihui flat stab 3~5mm, Yintang to nasal root 10~15mm, wind needle to 15~20mm, eararmor is equivalent to 2~ 3mm in the heart and kidney, then a group of electric acupuncture (SDZ-IIB electric needle instrument), frequency is 2 / 15 Hz, strength 2 mA, time 30min, two sides of the ear point alternating acupuncture / electric acupuncture.Acupuncture was performed 6 times weekly for 4 weeks of treatment.1. Observation indicators 1.1 Demographic data: age, gender, height, weight, educational level, course of disease, concomitant drug use, etc.1.2General physical examination: body temperature, heart rate, respiration, blood pressure, etc.2.The effect index 2.1 main efficacy index Hamilton depression scale (HAMD17): used to assess the severity of depression symptoms, depression depression including depression, guilt, suicide, sleep difficulty, sleep, early, work and interest, slow, provoke, mental anxiety, physical anxiety 17 items, is the most widely used.2.2 Secondary efficacy indicators ① Clinical effectiveness: the efficacy index was calculated by the reduced value of HAMD17 score and the efficacy was determined.②Depression Self-assessment Scale (Self-rating depression scale, SDS): It is used for the self-assessment of post-stroke depression patients, including 20 items, and is commonly used clinically.③NIHSS: To assess the severity of neurological deficit symptoms in stroke patients.④ Modified Barthel Index (MBI): used to evaluate the self-care ability of stroke patients, the higher the score, the stronger the self-care ability.⑤ Laboratory indicators: serum IL 1 β, IL 10,5-HT, BDN F levels.⑥ Serum metabolomic analysis.Methods: After thawing at room temperature, 100 μ L was transferred to a new tube, adding 300 μ L methanol and 10 μ L internal standard (2-chlorophalanine 2.5 g / L) to each sample.After the samples were mixed and centrifuged, 200 μ L of supernatant was absorbed into the sample tube for liquid chromatography MS testing using the Acquity TM UPLC-Q-TOF-MS platform (Al fa Chemistry, USA).The extraction of the advanced data features

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Number, according to the management All people involved with data collection need to be confirmed and describe their work.Clinical investigators must fill in the CRF accurately, timely, completely and properly according to the original data information.CRF, the modification of the data must follow the standard operating procedures and retain the modification traces.Once errors or discrepancies are identified, the investigator should be notified to ensure all data recorded and reported are correct and complete.If necessary, the data management plan can be updated and revised in time according to the changes in the study protocol, but the corresponding procedures need to be completed.Data managers shall conduct adequate verification of the primary and secondary effectiveness indicators and key safety indicators specified in the protocol to ensure the correctness and completeness of these data.IX.Quality controlImplement the process quality control and data quality control.Including investigator compliance control, subject compliance control, and follow-up information integrity control.Data quality control includes data supervisor personnel composition, responsibilities and workflow, entry process, mid-term analysis plan, study termination standard, data verification, data cleaning, etc.X.Research ethics requirements and statementsThis clinical study will follow the Declaration of Helsinki (2010 edition) and relevant Chinese clinical research practices Stattes proceed.The study shall be conducted only before the approval of the ethics committee of the responsible unit.Before each patient is enrolled for the study, the study physician has the responsibility to provide a complete, comprehensive presentation of the purpose, procedures or the possible risks of the study.Patients should be informed that they have the right to withdraw at any time.An informed consent form must be given to each patient before inclusion.It is the responsibility of the study physician to ensure that each patient signs the informed consent form before entering the study and remains in the study file.

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Depression Self-Assessment Scale (SDS) Depression Self-Assessment Scale (SDS) Description: According to the actual situation of the subject, type "" in the "□" before the answer closest to the actual situation of the patient.code of points 1 I felt unhappy and depressed.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 2 I think the morning is the best in all day.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 3 I burst out crying or felt like I wanted to cry.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 4. I don't sleep very well at night.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 5 I eat as much as usual.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 6 I was as happy as ever in close contact with the opposite sex.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 7 I noticed that my weight was losing weight.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 8 I have constipation.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 9 My heart beats faster than usual.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 10 I feel tired for no reason.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 11 My mind is as clear as usual.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 12 I don't think doing things is difficult.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 13 I felt uneasy and restless.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 14 I have hope for the future.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 15 I'm more angry than usual.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 16 I think it is easy to make a decision.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 17 I feel like a useful person, and someone needs me.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time 18 I have had a interesting life.4a fat lot 3A small part of the time 2A considerable amount of 1Most of the time 19 I think other people will live better if I die.1a fat lot 2A small part of the time 3A considerable amount of time 4Most of the time 20 I am still interested in what I am usually interested in.4a fat lot 3A small part of the time 2A considerable amount of time 1Most of the time grade: __ __ co mp on en t The 3.NIHSS scale National Center of Health Neurological Deficiency Score (NIHSS) Fill in the form description: Please read each item carefully, clearly understand each item, conduct clinical physical examination, and then score according to the actual situation of the patient.(Fill in by the clinician), please type "" in the "□" before the answer closest to the true situation of the patient.numb er check up code of points score 1a level of consciousness:

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Modified Barthel Index (MBI) Modified Barthel Index (MBI) (please select one of the alternative results and mark the "×") in the corresponding "□" Daily activity items code of points 1 Eat 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on 2 Take a bath 5Completely independent 4Small help 3 medium help 1 large help 0be completely dependent on 3 Personal hygiene 5Completely independent 4Small help 3 medium help 1 large help 0be completely dependent on 4 Dress (including tying shoelaces) 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on 5 Fecal control 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on 6 Urine control 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on 7 Go to the toilet (including cleaning and arranging clothes after using the toilet) 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on 8 The bed chair transfer 15Completely independent 12A small amount of help 8Medium help 3 massive help 0be completely dependent on 9 Flat ground walking (45m) / wheelchair operation 15Completely independent 12A small amount of help 8Medium help 3 massive help 0be completely dependent on 10 to take up and down the stairs 10Completely independent 8A small amount of help 5Medium help 2 and lots of help 0be completely dependent on Note: The code indicates that the score is 15=15 points 12=12 points 10=10 points 8=8 points 5=5 points 2=2 points 1=1 point 0=0 Points 针刺治疗脑卒中后抑郁的临床研究方案 (版本号 1.2 版本日期 20230307)
3 points only if the patient does not respond to noxious stimuli (not reflex).Lower limb movements:Place the limb in the appropriate position: raise the lower limb in the horizontal position of 30 o , If the lower limbs fall within 5 seconds, record 1 to 4 points.Encourage the aphasia with language or action, without harmful stimulation.Each limb was examined in turn, starting from the upper limb on the nonparalyzed side.