Review Article

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Journal of Acupuncture Research 2023; 40(4): 293-307

Published online November 30, 2023

https://doi.org/10.13045/jar.2023.00220

© Korean Acupuncture & Moxibustion Medicine Society

A Bibliometric Analysis of Acupuncture Treatment of Osteoarthritis over the past 20 Years: 2003−2022

Jisu Lee1 , Hyonjun Chun2 , Sungjun Joo2,4 , Yubin Kim3 , Seonghyeon Jeon5 , Hyewon Yeum1

1Department of Acupuncture & Moxibustion Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
2Department of Rehabilitation Medicine of Korean Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
3Department of Internal Korean Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
4Department of Clinical Korean Medicine, College of Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea
5Department of Internal Korean Medicine, Dong-Seo Korean Medicine Hospital, Seoul, Korea

Correspondence to : Hyewon Yeum
Department of Acupuncture & Moxibustion Medicine, Dong-Shin Korean Medicine Hospital, 351, Omok-ro, Yangcheon-gu, Seoul 07999, Korea
E-mail: now153@hanmail.net

Received: October 5, 2023; Accepted: October 20, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This study uses bibliometric methods to analyze publications regarding the use of acupuncture in osteoarthritis over the past 20 years and presents an overview of global research trends. Publications related to acupuncture in osteoarthritis from 2003 to 2022 were retrieved from the Web of Science Core Collection Database. An analysis of the extracted records was conducted according to their publication year, research area, journal title, country, organization, author, and keywords. The VOSviewer program was used to visualize the research trends on acupuncture in osteoarthritis. An analysis of 380 articles indicated a consistent increase in the use of acupuncture for osteoarthritis treatment over the past 20 years. Many articles have been published in research areas such as “integrative complementary medicine” and “general internal medicine.” The most prolific journal was Evidence- Based Complementary and Alternative Medicine. In terms of article publication, the most productive country and research organization were China and the Beijing University of Chinese Medicine, respectively. The most frequently occurring keywords were “acupuncture,” “knee osteoarthritis,” and “pain.” This study used a bibliometric analysis to provide an overview of global research trends on acupuncture in osteoarthritis. These findings may suggest the future direction of research on the treatment of acupuncture in osteoarthritis.

Keywords Acupuncture; Bibliometric analysis; Osteoarthritis; VOSviewer

Osteoarthritis is a chronic degenerative disease that occurs with aging. It involves inflammation and changes in the tissues around the joints, resulting in symptoms such as pain, dysfunction, and swelling [1]. According to the World Health Organization, worldwide, knee osteoarthritis affects 40% of people aged 70 years and older [2], and the number of people with osteoarthritis has more than doubled in the past 30 years. South Korea has the highest global age-standardized prevalence of knee osteoarthritis [3].

Conservative treatment of osteoarthritis includes both pharmacologic and nonpharmacologic therapies. In terms of pharmacologic treatment, nonsteroidal anti-inflammatory drugs, muscle relaxants, and even narcotic analgesics may be used in cases of severe pain [4]. However, the use of medications is associated with numerous side effects, including nausea, vomiting, digestive disorders, and liver disease [5]; thus, most primary care providers prefer nonpharmacologic treatments, including lifestyle management, physical therapy, ultrasound, and acupuncture [6]. Acupuncture is a popular nonpharmacologic treatment for various conditions and symptoms. In their 2019 “Guideline for the Management of Osteoarthritis,” the American College of Rheumatology/Arthritis Foundation conditionally recommended acupuncture for patients with osteoarthritis of the knee, hip, or hand [7].

Bibliometric analysis applies mathematical and statistical methods to visualize the results of published and ongoing research in a specific field and to analyze these quantitatively using measurement properties [8]. Thus, this analysis is advantageous for identifying major research directions and interrelationships between articles based on the measured frequency of co-occurrence between information in articles [9]. Bibliometric studies have been conducted on acupuncture treatment of knee osteoarthritis [10], treatment of osteoarthritis in Chinese medicine [11], and clinical studies on knee osteoarthritis [12]; however, no bibliometric study has analyzed the trend of acupuncture treatment for osteoarthritis over the past two decades.

Therefore, in this study, we seek to determine the research trends, interrelationships between articles, and characteristics of data on acupuncture research on osteoarthritis in the past 20 years using bibliometric analysis. Based on the findings, we suggest future directions for acupuncture treatment of osteoarthritis.

1. Data extraction and preprocessing

We conducted a search for articles on June 26, 2023, using the literature search database Web of Science (www.webofscience.com) for articles published between 2003 and 2022. We used the following keywords: “Topic” : (“Acupuncture” OR “Electroacupuncture” OR “Electro-acupuncture” OR “Pharmacoacupuncture” OR “Acupotomy” OR “Acupuncture Therapy” OR “Acupuncture, Ear” OR “Manual Acupuncture” OR “Auricular Acupuncture” OR “Body Acupuncture” OR “Dry Needling” OR “Fire Needling”) AND (“Osteoarthrit*” OR “Osteoarthrosis”). Of the 1,009 articles returned, we excluded 127 by extracting those categorized as “Article” or “Review article” and written in English. We checked the titles and abstracts of 844 articles to exclude (1) studies of conditions unrelated to osteoarthritis, (2) studies of treatments unrelated to acupuncture, and (3) articles with no abstract or unavailable full text. Because the keyword “acupuncture” implies both invasive and noninvasive treatments, we included invasive treatments including acupuncture, ear acupuncture, electroacupuncture, herbal acupuncture, and warm needling acupuncture in the search to clarify the distinction; we excluded noninvasive treatments, including acupressure and transcutaneous nerve stimulation. As a result of this process, 380 articles were finally selected, which were exported to .txt format for subsequent data processing (Fig. 1).

Fig. 1. Flow chart of stages of the literature search.

After we checked the keywords and author names of the articles, we applied the following preprocessing methods to improve the accuracy of keyword analysis: If the extracted data contained both keywords with and without subscripts (−), we removed the subscripts to unify the keywords (e.g., low-back-pain→low back pain). Additionally, we unified the plural forms into singular forms (e.g., clinical trials→clinical trial), we unified synonyms into a single word (e.g., adverse reaction, adverse events→adverse effect). With regard to the authors’ names, we found a mix of full names and initials, and we therefore unified them into full names (e.g., Freedman, J→Freedman Jonathan).

2. Data analysis

We extracted all data, including publication year, field of study, author, institution, journal, country, and keywords, from Web of Science, and then downloaded and analyzed the data VOSviewer v.1.6.18 (Centre for Science and Technology Studies, Leiden University).

The program VOSviewer visualizes relationships by tracking similarities across data [13], where similarity is determined by the frequency of co-occurrence [14]. In the program, circle size represents the number of occurrences of keywords, countries, institutions, and authors of the articles on a topic; a distance-based approach is used to represent related nodes as proximate and less related nodes as distant [15]. Each node is also automatically classified into a number of clusters based on their proximity, and the number of clusters is determined by the resolution parameter, with different colors assigned to different clusters [16].

1. Article analysis by condition

According to the Korean Classification of Diseases, the term “osteoarthritis” is used synonymously with “arthrosis” and “osteoarthrosis”, and the comorbidity codes include polyarthrosis (M15), hip arthrosis (M16), knee arthrosis (M17), arthrosis of the first carpometacarpophalangeal joint (M18), and other arthroses (M19). To identify trends in research by affected area, we categorized the osteoarthritis cases mentioned in 336 of the 380 papers (excluding 44 animal studies) by condition. If an article mentioned more than one affected area, each was independently counted (e.g., a study on osteoarthritis of both knee and hip was counted as one knee and one hip). We included articles using the term “osteoarthritis” without specifying the affected area in the polyarthritis category. The result indicated that 269 articles (80.1%) studied knee osteoarthritis (M17), 33 articles (9.3%) studied hip osteoarthritis (M16), 9 articles (2.7%) studied arthritis of the first carpometacarpophalangeal joint (M18), 6 articles (1.8%) studied other arthritis types (M19), and 57 articles (17.0%) studied polyarthritis (M15) (Fig. 2).

Fig. 2. Number of publications by Korean Classification of Disease code. M15, polyarthritis; M16, hip osteoarthritis; M17, knee osteoarthritis; M18, arthritis of first carpometacarpal joint; M19, other arthritis.

2. Article analysis by publication year

Over the past 20 years, an overall upward trend has been observed in the research on acupuncture for osteoarthritis, with some variation noted in the number of annual publications. The year with the most publications was 2022, with a total of 60 articles (15.8%) (Fig. 3).

Fig. 3. Number of publications by year over the past 20 years.

3. Article analysis by field

Among the research fields in the classification system of the Web of Science, most of the 380 analyzed articles were published in the field of integrative complementary medicine (140, 36.8%), followed by general internal medicine (73, 19.2%), neurosciences neurology (42, 11.0%), research experimental medicine (42, 11.0%), and rheumatology (32, 8.4%) (Table 1).

Table 1 . Distribution by research area

RankingResearch areaRecords (n)Percentage (of 380)
1Integrative complementary medicine14036.8
2General internal medicine7319.2
3Neurosciences neurology4211.0
3Research experimental medicine4211.0
5Rheumatology328.4
6Anesthesiology215.5
7Orthopedics205.3
8Rehabilitation133.4
9Health care sciences services82.1
9Science technology other topics82.1


4. Article analysis by journal

The largest number of articles were published in the journal Evidence-Based Complementary and Alternative Medicine (32, 8.4%), followed by Medicine (28, 7.4%) and Acupuncture in Medicine (25, 6.6%) (Table 2).

Table 2 . Distribution by journal

RankingJournal titleRecords (n)Percentage
(of 380)
Impact factor*
1Evidence-Based Complementary and Alternative Medicine328.42.65
2Medicine287.41.6
3Acupuncture in Medicine256.62.5
4Trials205.32.5
5Journal of Pain Research102.62.7
6Journal of Alternative and Complementary Medicine92.42.6
6Journal of Traditional Chinese Medicine92.42.6
8Chinese Journal of Integrative Medicine82.12.9
8Clinical Journal of Pain82.12.9
8Journal of Acupuncture and Tuina Science82.10.5

*The impact factor was reported based on Journal Citation Reports (JCR) 2022.



5. Article analysis by country

At least one article was published in 37 countries, with the largest number of articles being published in China (180 papers, 47.4%). This was followed by the United States (79 papers, 20.8%), the United Kingdom (51 papers, 13.4%), and South Korea (30 papers, 7.9%) (Table 3).

Table 3 . Distribution by country

RankingCountryRecords (n)Percentage (of 380)
1People’s Republic of China18047.4
2United States7920.8
3England5113.4
4South Korea307.9
5Germany287.4
6Spain153.9
7Australia143.7
8Switzerland133.4
8Taiwan133.4
9Canada112.9
10The Netherlands51.3


For the 11 countries that published five or more articles, we conducted a cluster analysis using VOSviewer. The larger the number of publications, the larger the size of the circle and the closer the countries were to each other. Cluster 1 included the United Kingdom, South Korea, Canada, and the Netherlands; Cluster 2 included China, Australia, and Taiwan; Cluster 3 included Germany and Switzerland; and Cluster 4 included the United States and Spain (Fig. 4A).

Fig. 4. (A) Network map of countries. (B) Distribution of countries according to the average publication year. (C) Distribution of countries according to average citations.

We analyzed the average year of publication by country and used the color yellow for more recent years and indigo for older years (Fig. 4B). We also analyzed the average number of citations by country and used yellow to indicate more citations and indigo to indicate fewer citations (Fig. 4C).

6. Article analysis by institution

Scholars at Beijing University of Chinese Medicine published the most studies (32, 8.4%), followed by Capital Medical University (21, 5.5%), Charité-Universitätsmedizin Berlin (16, 4.2%), and Shanghai University of Traditional Chinese Medicine (16, 4.2%) (Table 4).

Table 4 . Distribution of organization

RankingOrganizationRecords (n)Percentage (of 380)
1Beijing University of Chinese Medicine328.4
2Capital Medical University215.5
3Charité-Universitätsmedizin Berlin164.2
3Shanghai University of Traditional Chinese Medicine164.2
5Kyung Hee University153.9
6China Academy Chinese Medicine Science143.7
7Chengdu University of Traditional Chinese Medicine143.7
8Technical University of Munich133.4
8University of Maryland Baltimore133.4
8Fujian University of Traditional Chinese Medicine133.4
11University of Zurich123.2
11University of York UK123.2
13University Zurich Hospital112.9
13University of Southampton112.9


Using VOSviewer, we conducted a cluster analysis of the 45 institutions that published five or more articles. Cluster 1 included 12 institutions, including Beijing University of Chinese Medicine and Capital Medical University; cluster 2 included eight institutions, including Charité-Universitätsmedizin Berlin and Technical University of Munich; cluster 3 included seven institutions, including Chengdu University of Traditional Chinese Medicine and University of Maryland Baltimore; cluster 4 included seven institutions, including Harvard Medical School and University of Exeter; cluster 5 included three institutions: Huazhong University of Science and Technology, University of Texas System, and Hubei University of Chinese Medicine; cluster 6 included three institutions: Korea Institute of Oriental Medicine, Kyung Hee University, and London Southbank University; cluster 7 included two institutions: University of Hong Kong and Chinese University of Hong Kong; cluster 8 included two institutions: Universidad De Valladolid and University of Zaragoza; and cluster 9 included one institution: Universidad Rey Juan Carlos (Fig. 5A).

Fig. 5. (A) Network map of organizations. (B) Distribution of organizations according to average publication year. (C) Distribution of organizations according to average citations.

When analyzing the publication year by institution, we colored the average year yellow for more recent years and indigo for older years (Fig. 5B). We colored the average number of citations by institution yellow for a greater number of citations and indigo for fewer citations (Fig. 5C).

7. Article analysis by author

In the data analysis by author, we did not take into account author contributions. Claudia M. Witt published the largest number of articles (17, 4.5%), followed by Liu Cun Zhi (15, 3.9%), Tu Jian Feng (15, 3.9%), and Linde Klaus (13, 3.4%) (Table 5).

Table 5 . Distribution by author

RankingAuthorRecords (n)Percentage (of 380)
1Claudia M. Witt174.5
2Liu Cun Zhi153.9
2Tu Jian Feng153.9
4Klaus Linde133.4
5Hugh MacPherson123.2
5Wang Li Qiong123.2
7Lin Lu Lu112.9
7Yang Jing Wen112.9
9Wang Tian Qi102.6
10George Lewith92.4
10Wang Tong92.4
12Nadine E. Foster82.1
12Guo Chang Qing82.1
12Lao Li xing82.1
12Shi Guang Xia82.1
12Stefan N. Willich82.1


We conducted cluster analysis for the 46 authors who published five or more studies, with larger circles indicating larger numbers of publications and related authors being given identical colors, whereas closer node distances indicated closer correlations. Cluster 1 had 13 authors, including Li Jing Ling, Li Yong Ting, and Lin Lu Lu; cluster 2 had 13 authors, including Brinkhaus Benno, Nadine E. Foster, and George Lewith; cluster 3 had six authors, including Guo Chang Qing and Jing Xiang Hong; cluster 4 had five authors, including Jia Peng Li and Liang Fan Rong; cluster 5 had three authors, Luis Ceballos-Laita, Elena Estebanes De Miguel, and Sandra Jimenez Del Barrio; cluster 6 had two authors, Ernst Edzard and Lee Myeong Soo; cluster 7 had two authors, Baek Yong Hyeon and Park Yeon Cheol; cluster 8 had one author, Kligler Bengamin; and cluster 9 had one author, Liu Xian Xiang (Fig. 6A).

Fig. 6. (A) Network map of authors. (B) Distribution of authors according to average publication year. (C) Distribution of authors according to average citations.

We analyzed the average publication year for each author, with yellow denoting more recent years and indigo older years (Fig. 6B). We also analyzed the average number of citations; yellow was used for a greater number of citations and indigo for fewer citations (Fig. 6C). A comparison of the average publication year and average number of citations showed that authors in cluster 2 had an older average publication year and a greater average number of citations than authors in other clusters did.

8. Article analysis by keywords

We analyzed the keywords from 380 articles in VOSviewer. Among a total of 1,021 keywords appearing in the titles and abstracts, we analyzed 66 keywords that appeared more than 10 times (Fig. 7A). The more frequently occurring keywords were represented by larger circles, and the more relevant keywords were represented by closer distances. We divided the keywords into four clusters. The color of each cluster was as follows: red for cluster 1, green for cluster 2, blue for cluster 3, and yellow for cluster 4.

Fig. 7. (A) Network map of keywords. (B) Distribution of keywords according to average publication year. (C) Distribution of keywords according to average citations.

The three most recent keywords were “inflammation” (2020.92 years), “myofascial trigger point” (2020.38 years), and “warm needling acupuncture” (2019.8 years), whereas the three oldest keywords were “double blind” (2010.32 years), “electrical nerve stimulation” (2012.67 years), and “nonsteroidal anti-inflammatory drug” (2012.7 years) (Table 6).

Table 6 . Keyword classification

RankingKeywordCountTLSClusterCitation scorePublication score
1Acupuncture2051,054224.942016.95
2Knee osteoarthritis153806334.12018.62
3Pain132739241.482017.54
4Osteoarthritis105564234.922015.24
5Electroacupuncture83491219.612017.12
6Hip82526351.282017.05
7Randomized controlled trial80508144.162014.88
8Management72467430.062017.29
9Meta-analysis553654101.62017.93
10Therapy51333331.082017.29
11Knee50255226.72015.76
12Low back pain48279165.772014.27
13Adjunctive therapy38228154.032013.74
14Clinical trial34219176.262013.44
14Arthritis34215231.712014.65
16Prevalence33218326.032017.09
16Recommendations332274108.72016.39
18Efficacy31181430.162016.26
18Systematic review31213451.972015.68
20Chronic pain29188132.662017.31
21Complementary251554642013.24
22Alternative medicine23145436.912013.61
23Exercise22131113.092018.09
23Placebo221431149.642013.64
23Outcomes22138329.092016.64
23WOMAC22144361.552013.77
27Double blind19941254.422010.32
28Analgesic effect18108252.282014.33
29Stimulation17102239.652015.76
29Rheumatoid arthritis1793234.412013.18
31Reliability1685117.752018.62
31Hip osteoarthritis16105163.752017.38
31Health16122312.692019.12
31Safety16834155.622017.69
35Trigger point1478138.142019.5
35Traditional Chinese medicine1488122.792017.57
35Expression1469212.292018.64
35Rat1468229.072016.64
35Mechanism1469261.292013.21
35Guideline1490346.072017.86
35Quality14884207.362013.43
42Myofascial trigger point1371120.312020.38
42Physiotherapy1376157.772014
42Older adult1380144.542013
42Burden1398218.852017.85
42Acupotomy135934.922019.69
42Protocol136332.152019.23
42Sham acupuncture138336.312018.77
49Pharmacological analgesics1292144.082018.5
49Quality of life12801180.832015.25
49Complementary medicine1273120.672013.92
49Electrical nerve-stimulation12801101.832012.67
49Inflammation126026.252020.92
49Risk1266215.672018.5
55Cost effectiveness1167140.552014.18
55Model1142211.642018.55
55Manual acupuncture1172311.822019.64
55Validation1156339.732015.45
55Impact1175413.912018.64
60Tension-type headache10631136.42015.4
60Nonsteroidal anti-inflammatory drug10561276.42012.7
60Moxibustion1054213.32019.4
60Disease1072211.62018.5
60Cartilage1052210.32017.5
60Warm needling acupuncture105731.12019.8
60Care1053480.42013

Count, number of occurrences; TLS, total link score; citation score, average number of citations; publication score, average publication year.



We analyzed the average publication year, using the color yellow for more recent years and indigo for older years (Fig. 7B). We also analyzed the average number of citations for each keyword: yellow was used for a greater number of citations and indigo for fewer citations (Fig. 7C).

1. Background

In South Korea, arthritis ranks as the second most common disease of public concern after cancer as a result of the high burden of medical costs and disruption to daily life [17]. South Korean society is aging rapidly, with the number of people aged ≥ 65 years exceeding 17.5% of the total population in 2022. The country is expected to be a super-aged society by 2025, with the elderly population exceeding 20% [18]; thus, the prevalence of osteoarthritis and its social costs can be expected to increase in the future.

Acupuncture is a representative nonpharmacologic treatment for osteoarthritis, and according to the results of the 2022 Korean Medical Utilization Survey, it has been the most commonly used treatment in Korean medical institutions [19]. After low-back pain, arthritis is the second most common condition to use outpatient Korean medicine, and the percentage increased from 32.1% in 2020 to 33.0% in 2022. Therefore, in this study, we intended use bibliometric analysis to quantitatively analyze the trends in acupuncture research for osteoarthritis.

2. Research trends in acupuncture treatment of osteoarthritis over the past 20 years

To identify the research trends in acupuncture treatment of osteoarthritis over the past 20 years, we analyzed 380 articles using a bibliometric method. The results showed that the knee was the most frequently studied joint, followed by studies on hip and carpometacarpal joints. The number of articles on knee osteoarthritis outnumbered articles on all other joints combined, which could be attributed to the fact that knee osteoarthritis accounts for more than four-fifths of the global disease burden and morbidity resulting from osteoarthritis [20]. In addition, to ongoing studies on knee osteoarthritis, more studies should be conducted on osteoarthritis of other joints in the future.

We observed a steady increase in the number of clinical studies of acupuncture for osteoarthritis, with roughly three times as many papers published in the most recent decade (2013–2022: 284 articles) as in the first decade (2003–2012: 96 articles).

In analyzing the distribution of articles by field, we found that the largest number of studies were conducted in integrative complementary medicine, followed by general internal medicine and neurosciences neurology, which suggests that acupuncture is frequently considered as a treatment for osteoarthritis in the field of integrative complementary medicine or complementary alternative medicine. In addition, numerous studies applied acupuncture in patients or animals with osteoarthritis to elucidate the therapeutic mechanisms through medical and neurologic follow-up.

An analysis of the distribution of articles by journal showed that the largest number of articles were published in Evidence-Based Complementary and Alternative Medicine, followed by Medicine and Acupuncture in Medicine. Of the top 10 journals, the Journal of Pain Research had the highest Impact Factor (IF) (2.7), whereas Medicine had the lowest IF (1.6). Of the top five journals, Evidence-Based Complementary and Alternative Medicine (2.65), the journal with the largest number of published articles, had the second highest IF.

An analysis of article distribution by country over the past 20 years showed that China, the United States, the United Kingdom, and South Korea accounted for the most published articles. China published more than 30% of the total number of articles, which suggests a recent invigoration of osteoarthritis research. It was noteworthy that, for each time period, most research was conducted in Western countries, including in the United States and Europe, whereas a substantial number of recent studies were conducted in China, Taiwan, and Spain. A comparison of the average publication year and average citation rate by country showed that the United Kingdom (2012.55 years, 102.37 articles) and Germany (2011.07 years, 124.14 articles), which were among the top five countries in terms of number of publications, had a longer average publication year and a higher average citation rate than other countries did, which likely reflects the fact that an earlier publication year is associated with a higher average citation rate. This suggests that earlier research laid the groundwork for later research. An early study demonstrating the effectiveness of acupuncture for osteoarthritis was a randomized study of acupuncture in patients with osteoarthritis published by the Charité-Universitätsmedizin Berlin in Germany [21], which included a large number of citations, and it likely influenced the direction of subsequent research, including research on osteoarthritis of knee and other areas, pain control mechanisms of acupuncture, and development of effective evaluation tools.

An analysis of article distribution by institution showed that, over the past 20 years, most articles were published by researchers at Beijing University of Chinese Medicine, Capital Medical University, Charité-Universitätsmedizin Berlin, and Shanghai University of Traditional Chinese Medicine. All of the top 10 institutions were universities; many had affiliated or neighboring hospitals. The institutions most actively engaged in research in recent years were Beijing University of Chinese Medicine, Capital Medical University, and Chengdu University of Traditional Chinese Medicine, all of which are located in China, which confirms that research in China has recently been on the rise, which is consistent with the findings of the country-by-country analysis. Notably, Beijing University of Chinese Medicine ranked first in terms of the number of publications, with the most recent average publication date among the top 10 institutions, and its most highly cited study compared the efficacy of intensive acupuncture to sham acupuncture for osteoarthritis of the knee [22]. The institution has also published a number of systematic reviews on the effects and mechanisms of acupuncture for knee arthritis [23] as well as conducted randomized controlled trials [24,25] and studies using animal models on the effects of acupuncture [26] and electroacupuncture [27] for cartilage regeneration. This is a good example of a university-hospital collaboration, as the research was conducted from a multidisciplinary perspective, involving both clinical and mechanistic studies on a given condition simultaneously.

In our analysis of article distribution by author, we found that Claudia M. Witt, Tu Jian Feng, Liu Cun Zhi, Klaus Linde, and Hugh MacPherson had the highest number of publications. Claudia M. Witt seems to have been at the forefront of research, consistently reporting on the effectiveness of acupuncture for chronic pain due to osteoarthritis, including a randomized study on acupuncture for knee osteoarthritis [21] and a randomized study on the effect of patient expectations of acupuncture treatment for chronic pain [28]. In cluster 5, Luis Ceballos-Laita, Elena Estebanez de Miguel, and Sandra Jimenez Del Barrio were all from the University of Valladolid and the University of Zaragoza, which averaged the most recent publications. These authors have conducted several randomized controlled trials since 2019 on the effects of acupuncture on the gluteal muscles in patients with hip osteoarthritis [29,30]. Their work is noteworthy because it is among the leading research on the hip joint, which is the second most commonly studied osteoarthritic joint.

3. Keyword analysis

The three most frequently detected keywords were “acupuncture”, “knee osteoarthritis”, and “pain”. This finding suggests that acupuncture for knee osteoarthritis has been one of the most widely studied topics in the field of osteoarthritis and that acupuncture has been used to reduce pain.

Among the keywords detected more than 10 times, the three most recent were “inflammation” (2020.92), “myofascial trigger point” (2020.38), and “warm needling acupuncture” (2019.8), while the three oldest ones were “double blind” (2011.06), “electrical nerve stimulation” (2012.67), and “nonsteroidal anti-inflammatory drug” (2012.7). This indicated that in the past, the analgesic effect of acupuncture treatment has been primarily studied through clinical trials, which shows that the research has recently expanded to include various acupuncture procedures and methods.

Using VOSviewer, we automatically divided the keywords into four clusters according to the similarity calculated based on the frequency of co-occurrence. We identified and named each cluster according to the most frequently published items within each cluster. Cluster 1 was named “Chronic pain clinical studies,” and it included 22 keywords related to clinical studies of acupuncture for chronic pain caused by osteoarthritis, such as “randomized controlled trial”, “low back pain”, “adjunctive therapy”, “clinical trial”, “chronic pain”, “exercise”, “placebo”, and” double blind”. Notably, the keywords “randomized controlled trial”, “placebo”, and “double blind” indicate that numerous studies have compared real acupuncture to sham acupuncture. Reflecting the characteristics of these keywords, the most cited study was a meta-analysis of acupuncture treatments for chronic pain caused by osteoarthritis and other related conditions [31]. The study authors concluded that acupuncture is effective for the treatment of chronic pain and that the difference between real and sham acupuncture was more than a mere placebo effect, which suggests that there is more to acupuncture than just “getting poked with needles.”

Cluster 2 was named “Research on Therapeutic Mechanisms,” and it contained 19 keywords, including “acupuncture”, “pain”, “osteoarthritis”, “analgesic effect”, “stimulation”, “rheumatoid arthritis”, “expression”, “rat”, and “mechanism”. This suggests that most studies were focused on the analgesic mechanisms of acupuncture for osteoarthritis pain. Acupuncture controls pain by modulating the rate of nerve conduction in the brain and inducing functional and structural changes in the nervous system [32]. In a study that applied acupuncture in patients with carpal tunnel osteoarthritis, the authors reported increased activity of the right dorsolateral prefrontal cortex, anterior cingulate cortex, and midbrain [33]. In a study in which acupuncture stimulation of the popliteal vein was applied to patients with osteoarthritis, the authors reported that the treatment affected the perception of nociception by modulating the functional connectivity of the dorsal raphe nucleus and right cortex [34]. Although these studies are significant in that they demonstrated the effects of acupuncture on various types of arthritis, they are limited by their small sample sizes and short-term acupuncture treatments. To identify the effects and mechanisms of acupuncture, further studies with larger sample sizes and long-term acupuncture treatments are needed. In addition, studies have shown that acupuncture can delay cartilage degeneration [35] and reduce inflammation and bone destruction [36], whereas electroacupuncture can delay cartilage degeneration and prevent cellular changes [37]. However, studies on cartilage degeneration and regeneration have been conducted on animals, with only few clinical studies being conducted on humans, and future research should thus involve clinical trials on acupuncture.

Cluster 3 was named “Current Research Trends,” and it contained 14 keywords, including “knee osteoarthritis”, “hip”, “therapy”, “prevalence”, “outcomes”, “womac”, “health”, and “guideline”. Compared with other clusters, the keywords in cluster 3 had more recent average publication dates, and keywords such as “prevalence”, “womac”, and “guideline” in this cluster reflected the latest trends of epidemiologic studies, evaluation tools, and treatments. Clinical practice guidelines (CPGs) incorporate these characteristics. These are evidence-based treatment recommendations that help lead to more appropriate and efficient decisions in clinical settings, and to ensure that high-quality, effective care is implemented, it is thus essential to assess the quality of CPGs. A quality assessment of CPGs for knee arthritis was conducted in 2021 [38]; however, the development and evaluation of CPGs for other areas of osteoarthritis is still lacking. Because the prevalence of osteoarthritis is expected to increase with an aging and the obese population, further studies should focus on osteoarthritis outside the knee.

Cluster 4 was named “Acupuncture as a Complementary and Alternative Medical Care.” It contained 11 keywords, including “alternative medicine”, “care”, “complementary”, “efficacy”, and “impact”. A study published in 2021 reported that, to improve the symptoms of knee arthritis, acupuncture and electroacupuncture are commonly used as nonpharmacologic treatments, and because localized thermal stimulation can reduce pain, treatments that combine acupuncture with thermal stimulation such as hot or warm needling have recently become popular [39]. Recently, in addition to simple acupuncture, various types of acupuncture from electroacupuncture and hot or warm acupuncture to miniscalpel acupuncture [40] have been used for osteoarthritis, and their therapeutic effects and mechanisms have been reported. On this basis, it is conjectured that further research on the safety and efficacy of various types of acupuncture should be conducted.

4. Limitations

This study has several limitations. First, the language of the articles was limited to English. However, a high proportion (92.5%) of the total articles retrieved from Web of Science (411) were in English (380); thus, it is likely that the results are representative of global research trends. Second, although a variety of keywords were used to describe acupuncture, including “acupuncture” and “dry needling”, it is possible that some articles were left out. Finally, because this study sought to identify research trends over the past 20 years, we could not determine which of the various acupuncture modalities is most effective for osteoarthritis.

The analysis by condition showed that knee osteoarthritis (M17) was the most common condition, followed by polyarthritis (M15) and hip osteoarthritis (M16). The analysis by publication year showed the among all years, the largest number of papers were published in 2022, and despite annual variation, an overall upward trend was identified. Active research on acupuncture for osteoarthritis treatment is ongoing in the fields of integrative and complementary and alternative medicine as well as internal medicine and neuroscience. Over the past two decades, the two leading research countries have been China and the United States. Although past research has mostly been conducted in the West, such as in the United States and Europe, recent studies have been conducted in East Asia, such as in China and South Korea. The three most recent keywords detected ≥ 10 times in the titles and abstracts of the 380 articles were “inflammation”, “myofascial trigger point”, and “warm needling acupuncture”. In VOSviewer, the keywords were automatically categorized into four clusters based on relevance. The keywords related to “clinical research in chronic pain” were placed in cluster 1, those related to “analgesic mechanisms of acupuncture” in cluster 2, those related to “current research trends” in cluster 3, and those related to “acupuncture as a complementary and alternative medicine management” in cluster 4.

Conceptualization: JL, HC. Data curation: JL. Formal analysis: JL. Methodology: JL, HC, Sungjun Joo. Writing – original draft: JL, YK. Writing – review & editing: All authors.

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Article

Review Article

Journal of Acupuncture Research 2023; 40(4): 293-307

Published online November 30, 2023 https://doi.org/10.13045/jar.2023.00220

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

A Bibliometric Analysis of Acupuncture Treatment of Osteoarthritis over the past 20 Years: 2003−2022

Jisu Lee1 , Hyonjun Chun2 , Sungjun Joo2,4 , Yubin Kim3 , Seonghyeon Jeon5 , Hyewon Yeum1

1Department of Acupuncture & Moxibustion Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
2Department of Rehabilitation Medicine of Korean Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
3Department of Internal Korean Medicine, Dong-Shin Korean Medicine Hospital, Seoul, Korea
4Department of Clinical Korean Medicine, College of Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea
5Department of Internal Korean Medicine, Dong-Seo Korean Medicine Hospital, Seoul, Korea

Correspondence to:Hyewon Yeum
Department of Acupuncture & Moxibustion Medicine, Dong-Shin Korean Medicine Hospital, 351, Omok-ro, Yangcheon-gu, Seoul 07999, Korea
E-mail: now153@hanmail.net

Received: October 5, 2023; Accepted: October 20, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This study uses bibliometric methods to analyze publications regarding the use of acupuncture in osteoarthritis over the past 20 years and presents an overview of global research trends. Publications related to acupuncture in osteoarthritis from 2003 to 2022 were retrieved from the Web of Science Core Collection Database. An analysis of the extracted records was conducted according to their publication year, research area, journal title, country, organization, author, and keywords. The VOSviewer program was used to visualize the research trends on acupuncture in osteoarthritis. An analysis of 380 articles indicated a consistent increase in the use of acupuncture for osteoarthritis treatment over the past 20 years. Many articles have been published in research areas such as “integrative complementary medicine” and “general internal medicine.” The most prolific journal was Evidence- Based Complementary and Alternative Medicine. In terms of article publication, the most productive country and research organization were China and the Beijing University of Chinese Medicine, respectively. The most frequently occurring keywords were “acupuncture,” “knee osteoarthritis,” and “pain.” This study used a bibliometric analysis to provide an overview of global research trends on acupuncture in osteoarthritis. These findings may suggest the future direction of research on the treatment of acupuncture in osteoarthritis.

Keywords: Acupuncture, Bibliometric analysis, Osteoarthritis, VOSviewer

INTRODUCTION

Osteoarthritis is a chronic degenerative disease that occurs with aging. It involves inflammation and changes in the tissues around the joints, resulting in symptoms such as pain, dysfunction, and swelling [1]. According to the World Health Organization, worldwide, knee osteoarthritis affects 40% of people aged 70 years and older [2], and the number of people with osteoarthritis has more than doubled in the past 30 years. South Korea has the highest global age-standardized prevalence of knee osteoarthritis [3].

Conservative treatment of osteoarthritis includes both pharmacologic and nonpharmacologic therapies. In terms of pharmacologic treatment, nonsteroidal anti-inflammatory drugs, muscle relaxants, and even narcotic analgesics may be used in cases of severe pain [4]. However, the use of medications is associated with numerous side effects, including nausea, vomiting, digestive disorders, and liver disease [5]; thus, most primary care providers prefer nonpharmacologic treatments, including lifestyle management, physical therapy, ultrasound, and acupuncture [6]. Acupuncture is a popular nonpharmacologic treatment for various conditions and symptoms. In their 2019 “Guideline for the Management of Osteoarthritis,” the American College of Rheumatology/Arthritis Foundation conditionally recommended acupuncture for patients with osteoarthritis of the knee, hip, or hand [7].

Bibliometric analysis applies mathematical and statistical methods to visualize the results of published and ongoing research in a specific field and to analyze these quantitatively using measurement properties [8]. Thus, this analysis is advantageous for identifying major research directions and interrelationships between articles based on the measured frequency of co-occurrence between information in articles [9]. Bibliometric studies have been conducted on acupuncture treatment of knee osteoarthritis [10], treatment of osteoarthritis in Chinese medicine [11], and clinical studies on knee osteoarthritis [12]; however, no bibliometric study has analyzed the trend of acupuncture treatment for osteoarthritis over the past two decades.

Therefore, in this study, we seek to determine the research trends, interrelationships between articles, and characteristics of data on acupuncture research on osteoarthritis in the past 20 years using bibliometric analysis. Based on the findings, we suggest future directions for acupuncture treatment of osteoarthritis.

MATERIALS AND METHODS

1. Data extraction and preprocessing

We conducted a search for articles on June 26, 2023, using the literature search database Web of Science (www.webofscience.com) for articles published between 2003 and 2022. We used the following keywords: “Topic” : (“Acupuncture” OR “Electroacupuncture” OR “Electro-acupuncture” OR “Pharmacoacupuncture” OR “Acupotomy” OR “Acupuncture Therapy” OR “Acupuncture, Ear” OR “Manual Acupuncture” OR “Auricular Acupuncture” OR “Body Acupuncture” OR “Dry Needling” OR “Fire Needling”) AND (“Osteoarthrit*” OR “Osteoarthrosis”). Of the 1,009 articles returned, we excluded 127 by extracting those categorized as “Article” or “Review article” and written in English. We checked the titles and abstracts of 844 articles to exclude (1) studies of conditions unrelated to osteoarthritis, (2) studies of treatments unrelated to acupuncture, and (3) articles with no abstract or unavailable full text. Because the keyword “acupuncture” implies both invasive and noninvasive treatments, we included invasive treatments including acupuncture, ear acupuncture, electroacupuncture, herbal acupuncture, and warm needling acupuncture in the search to clarify the distinction; we excluded noninvasive treatments, including acupressure and transcutaneous nerve stimulation. As a result of this process, 380 articles were finally selected, which were exported to .txt format for subsequent data processing (Fig. 1).

Figure 1. Flow chart of stages of the literature search.

After we checked the keywords and author names of the articles, we applied the following preprocessing methods to improve the accuracy of keyword analysis: If the extracted data contained both keywords with and without subscripts (−), we removed the subscripts to unify the keywords (e.g., low-back-pain→low back pain). Additionally, we unified the plural forms into singular forms (e.g., clinical trials→clinical trial), we unified synonyms into a single word (e.g., adverse reaction, adverse events→adverse effect). With regard to the authors’ names, we found a mix of full names and initials, and we therefore unified them into full names (e.g., Freedman, J→Freedman Jonathan).

2. Data analysis

We extracted all data, including publication year, field of study, author, institution, journal, country, and keywords, from Web of Science, and then downloaded and analyzed the data VOSviewer v.1.6.18 (Centre for Science and Technology Studies, Leiden University).

The program VOSviewer visualizes relationships by tracking similarities across data [13], where similarity is determined by the frequency of co-occurrence [14]. In the program, circle size represents the number of occurrences of keywords, countries, institutions, and authors of the articles on a topic; a distance-based approach is used to represent related nodes as proximate and less related nodes as distant [15]. Each node is also automatically classified into a number of clusters based on their proximity, and the number of clusters is determined by the resolution parameter, with different colors assigned to different clusters [16].

RESULTS

1. Article analysis by condition

According to the Korean Classification of Diseases, the term “osteoarthritis” is used synonymously with “arthrosis” and “osteoarthrosis”, and the comorbidity codes include polyarthrosis (M15), hip arthrosis (M16), knee arthrosis (M17), arthrosis of the first carpometacarpophalangeal joint (M18), and other arthroses (M19). To identify trends in research by affected area, we categorized the osteoarthritis cases mentioned in 336 of the 380 papers (excluding 44 animal studies) by condition. If an article mentioned more than one affected area, each was independently counted (e.g., a study on osteoarthritis of both knee and hip was counted as one knee and one hip). We included articles using the term “osteoarthritis” without specifying the affected area in the polyarthritis category. The result indicated that 269 articles (80.1%) studied knee osteoarthritis (M17), 33 articles (9.3%) studied hip osteoarthritis (M16), 9 articles (2.7%) studied arthritis of the first carpometacarpophalangeal joint (M18), 6 articles (1.8%) studied other arthritis types (M19), and 57 articles (17.0%) studied polyarthritis (M15) (Fig. 2).

Figure 2. Number of publications by Korean Classification of Disease code. M15, polyarthritis; M16, hip osteoarthritis; M17, knee osteoarthritis; M18, arthritis of first carpometacarpal joint; M19, other arthritis.

2. Article analysis by publication year

Over the past 20 years, an overall upward trend has been observed in the research on acupuncture for osteoarthritis, with some variation noted in the number of annual publications. The year with the most publications was 2022, with a total of 60 articles (15.8%) (Fig. 3).

Figure 3. Number of publications by year over the past 20 years.

3. Article analysis by field

Among the research fields in the classification system of the Web of Science, most of the 380 analyzed articles were published in the field of integrative complementary medicine (140, 36.8%), followed by general internal medicine (73, 19.2%), neurosciences neurology (42, 11.0%), research experimental medicine (42, 11.0%), and rheumatology (32, 8.4%) (Table 1).

Table 1 . Distribution by research area.

RankingResearch areaRecords (n)Percentage (of 380)
1Integrative complementary medicine14036.8
2General internal medicine7319.2
3Neurosciences neurology4211.0
3Research experimental medicine4211.0
5Rheumatology328.4
6Anesthesiology215.5
7Orthopedics205.3
8Rehabilitation133.4
9Health care sciences services82.1
9Science technology other topics82.1


4. Article analysis by journal

The largest number of articles were published in the journal Evidence-Based Complementary and Alternative Medicine (32, 8.4%), followed by Medicine (28, 7.4%) and Acupuncture in Medicine (25, 6.6%) (Table 2).

Table 2 . Distribution by journal.

RankingJournal titleRecords (n)Percentage
(of 380)
Impact factor*
1Evidence-Based Complementary and Alternative Medicine328.42.65
2Medicine287.41.6
3Acupuncture in Medicine256.62.5
4Trials205.32.5
5Journal of Pain Research102.62.7
6Journal of Alternative and Complementary Medicine92.42.6
6Journal of Traditional Chinese Medicine92.42.6
8Chinese Journal of Integrative Medicine82.12.9
8Clinical Journal of Pain82.12.9
8Journal of Acupuncture and Tuina Science82.10.5

*The impact factor was reported based on Journal Citation Reports (JCR) 2022..



5. Article analysis by country

At least one article was published in 37 countries, with the largest number of articles being published in China (180 papers, 47.4%). This was followed by the United States (79 papers, 20.8%), the United Kingdom (51 papers, 13.4%), and South Korea (30 papers, 7.9%) (Table 3).

Table 3 . Distribution by country.

RankingCountryRecords (n)Percentage (of 380)
1People’s Republic of China18047.4
2United States7920.8
3England5113.4
4South Korea307.9
5Germany287.4
6Spain153.9
7Australia143.7
8Switzerland133.4
8Taiwan133.4
9Canada112.9
10The Netherlands51.3


For the 11 countries that published five or more articles, we conducted a cluster analysis using VOSviewer. The larger the number of publications, the larger the size of the circle and the closer the countries were to each other. Cluster 1 included the United Kingdom, South Korea, Canada, and the Netherlands; Cluster 2 included China, Australia, and Taiwan; Cluster 3 included Germany and Switzerland; and Cluster 4 included the United States and Spain (Fig. 4A).

Figure 4. (A) Network map of countries. (B) Distribution of countries according to the average publication year. (C) Distribution of countries according to average citations.

We analyzed the average year of publication by country and used the color yellow for more recent years and indigo for older years (Fig. 4B). We also analyzed the average number of citations by country and used yellow to indicate more citations and indigo to indicate fewer citations (Fig. 4C).

6. Article analysis by institution

Scholars at Beijing University of Chinese Medicine published the most studies (32, 8.4%), followed by Capital Medical University (21, 5.5%), Charité-Universitätsmedizin Berlin (16, 4.2%), and Shanghai University of Traditional Chinese Medicine (16, 4.2%) (Table 4).

Table 4 . Distribution of organization.

RankingOrganizationRecords (n)Percentage (of 380)
1Beijing University of Chinese Medicine328.4
2Capital Medical University215.5
3Charité-Universitätsmedizin Berlin164.2
3Shanghai University of Traditional Chinese Medicine164.2
5Kyung Hee University153.9
6China Academy Chinese Medicine Science143.7
7Chengdu University of Traditional Chinese Medicine143.7
8Technical University of Munich133.4
8University of Maryland Baltimore133.4
8Fujian University of Traditional Chinese Medicine133.4
11University of Zurich123.2
11University of York UK123.2
13University Zurich Hospital112.9
13University of Southampton112.9


Using VOSviewer, we conducted a cluster analysis of the 45 institutions that published five or more articles. Cluster 1 included 12 institutions, including Beijing University of Chinese Medicine and Capital Medical University; cluster 2 included eight institutions, including Charité-Universitätsmedizin Berlin and Technical University of Munich; cluster 3 included seven institutions, including Chengdu University of Traditional Chinese Medicine and University of Maryland Baltimore; cluster 4 included seven institutions, including Harvard Medical School and University of Exeter; cluster 5 included three institutions: Huazhong University of Science and Technology, University of Texas System, and Hubei University of Chinese Medicine; cluster 6 included three institutions: Korea Institute of Oriental Medicine, Kyung Hee University, and London Southbank University; cluster 7 included two institutions: University of Hong Kong and Chinese University of Hong Kong; cluster 8 included two institutions: Universidad De Valladolid and University of Zaragoza; and cluster 9 included one institution: Universidad Rey Juan Carlos (Fig. 5A).

Figure 5. (A) Network map of organizations. (B) Distribution of organizations according to average publication year. (C) Distribution of organizations according to average citations.

When analyzing the publication year by institution, we colored the average year yellow for more recent years and indigo for older years (Fig. 5B). We colored the average number of citations by institution yellow for a greater number of citations and indigo for fewer citations (Fig. 5C).

7. Article analysis by author

In the data analysis by author, we did not take into account author contributions. Claudia M. Witt published the largest number of articles (17, 4.5%), followed by Liu Cun Zhi (15, 3.9%), Tu Jian Feng (15, 3.9%), and Linde Klaus (13, 3.4%) (Table 5).

Table 5 . Distribution by author.

RankingAuthorRecords (n)Percentage (of 380)
1Claudia M. Witt174.5
2Liu Cun Zhi153.9
2Tu Jian Feng153.9
4Klaus Linde133.4
5Hugh MacPherson123.2
5Wang Li Qiong123.2
7Lin Lu Lu112.9
7Yang Jing Wen112.9
9Wang Tian Qi102.6
10George Lewith92.4
10Wang Tong92.4
12Nadine E. Foster82.1
12Guo Chang Qing82.1
12Lao Li xing82.1
12Shi Guang Xia82.1
12Stefan N. Willich82.1


We conducted cluster analysis for the 46 authors who published five or more studies, with larger circles indicating larger numbers of publications and related authors being given identical colors, whereas closer node distances indicated closer correlations. Cluster 1 had 13 authors, including Li Jing Ling, Li Yong Ting, and Lin Lu Lu; cluster 2 had 13 authors, including Brinkhaus Benno, Nadine E. Foster, and George Lewith; cluster 3 had six authors, including Guo Chang Qing and Jing Xiang Hong; cluster 4 had five authors, including Jia Peng Li and Liang Fan Rong; cluster 5 had three authors, Luis Ceballos-Laita, Elena Estebanes De Miguel, and Sandra Jimenez Del Barrio; cluster 6 had two authors, Ernst Edzard and Lee Myeong Soo; cluster 7 had two authors, Baek Yong Hyeon and Park Yeon Cheol; cluster 8 had one author, Kligler Bengamin; and cluster 9 had one author, Liu Xian Xiang (Fig. 6A).

Figure 6. (A) Network map of authors. (B) Distribution of authors according to average publication year. (C) Distribution of authors according to average citations.

We analyzed the average publication year for each author, with yellow denoting more recent years and indigo older years (Fig. 6B). We also analyzed the average number of citations; yellow was used for a greater number of citations and indigo for fewer citations (Fig. 6C). A comparison of the average publication year and average number of citations showed that authors in cluster 2 had an older average publication year and a greater average number of citations than authors in other clusters did.

8. Article analysis by keywords

We analyzed the keywords from 380 articles in VOSviewer. Among a total of 1,021 keywords appearing in the titles and abstracts, we analyzed 66 keywords that appeared more than 10 times (Fig. 7A). The more frequently occurring keywords were represented by larger circles, and the more relevant keywords were represented by closer distances. We divided the keywords into four clusters. The color of each cluster was as follows: red for cluster 1, green for cluster 2, blue for cluster 3, and yellow for cluster 4.

Figure 7. (A) Network map of keywords. (B) Distribution of keywords according to average publication year. (C) Distribution of keywords according to average citations.

The three most recent keywords were “inflammation” (2020.92 years), “myofascial trigger point” (2020.38 years), and “warm needling acupuncture” (2019.8 years), whereas the three oldest keywords were “double blind” (2010.32 years), “electrical nerve stimulation” (2012.67 years), and “nonsteroidal anti-inflammatory drug” (2012.7 years) (Table 6).

Table 6 . Keyword classification.

RankingKeywordCountTLSClusterCitation scorePublication score
1Acupuncture2051,054224.942016.95
2Knee osteoarthritis153806334.12018.62
3Pain132739241.482017.54
4Osteoarthritis105564234.922015.24
5Electroacupuncture83491219.612017.12
6Hip82526351.282017.05
7Randomized controlled trial80508144.162014.88
8Management72467430.062017.29
9Meta-analysis553654101.62017.93
10Therapy51333331.082017.29
11Knee50255226.72015.76
12Low back pain48279165.772014.27
13Adjunctive therapy38228154.032013.74
14Clinical trial34219176.262013.44
14Arthritis34215231.712014.65
16Prevalence33218326.032017.09
16Recommendations332274108.72016.39
18Efficacy31181430.162016.26
18Systematic review31213451.972015.68
20Chronic pain29188132.662017.31
21Complementary251554642013.24
22Alternative medicine23145436.912013.61
23Exercise22131113.092018.09
23Placebo221431149.642013.64
23Outcomes22138329.092016.64
23WOMAC22144361.552013.77
27Double blind19941254.422010.32
28Analgesic effect18108252.282014.33
29Stimulation17102239.652015.76
29Rheumatoid arthritis1793234.412013.18
31Reliability1685117.752018.62
31Hip osteoarthritis16105163.752017.38
31Health16122312.692019.12
31Safety16834155.622017.69
35Trigger point1478138.142019.5
35Traditional Chinese medicine1488122.792017.57
35Expression1469212.292018.64
35Rat1468229.072016.64
35Mechanism1469261.292013.21
35Guideline1490346.072017.86
35Quality14884207.362013.43
42Myofascial trigger point1371120.312020.38
42Physiotherapy1376157.772014
42Older adult1380144.542013
42Burden1398218.852017.85
42Acupotomy135934.922019.69
42Protocol136332.152019.23
42Sham acupuncture138336.312018.77
49Pharmacological analgesics1292144.082018.5
49Quality of life12801180.832015.25
49Complementary medicine1273120.672013.92
49Electrical nerve-stimulation12801101.832012.67
49Inflammation126026.252020.92
49Risk1266215.672018.5
55Cost effectiveness1167140.552014.18
55Model1142211.642018.55
55Manual acupuncture1172311.822019.64
55Validation1156339.732015.45
55Impact1175413.912018.64
60Tension-type headache10631136.42015.4
60Nonsteroidal anti-inflammatory drug10561276.42012.7
60Moxibustion1054213.32019.4
60Disease1072211.62018.5
60Cartilage1052210.32017.5
60Warm needling acupuncture105731.12019.8
60Care1053480.42013

Count, number of occurrences; TLS, total link score; citation score, average number of citations; publication score, average publication year..



We analyzed the average publication year, using the color yellow for more recent years and indigo for older years (Fig. 7B). We also analyzed the average number of citations for each keyword: yellow was used for a greater number of citations and indigo for fewer citations (Fig. 7C).

DISCUSSION

1. Background

In South Korea, arthritis ranks as the second most common disease of public concern after cancer as a result of the high burden of medical costs and disruption to daily life [17]. South Korean society is aging rapidly, with the number of people aged ≥ 65 years exceeding 17.5% of the total population in 2022. The country is expected to be a super-aged society by 2025, with the elderly population exceeding 20% [18]; thus, the prevalence of osteoarthritis and its social costs can be expected to increase in the future.

Acupuncture is a representative nonpharmacologic treatment for osteoarthritis, and according to the results of the 2022 Korean Medical Utilization Survey, it has been the most commonly used treatment in Korean medical institutions [19]. After low-back pain, arthritis is the second most common condition to use outpatient Korean medicine, and the percentage increased from 32.1% in 2020 to 33.0% in 2022. Therefore, in this study, we intended use bibliometric analysis to quantitatively analyze the trends in acupuncture research for osteoarthritis.

2. Research trends in acupuncture treatment of osteoarthritis over the past 20 years

To identify the research trends in acupuncture treatment of osteoarthritis over the past 20 years, we analyzed 380 articles using a bibliometric method. The results showed that the knee was the most frequently studied joint, followed by studies on hip and carpometacarpal joints. The number of articles on knee osteoarthritis outnumbered articles on all other joints combined, which could be attributed to the fact that knee osteoarthritis accounts for more than four-fifths of the global disease burden and morbidity resulting from osteoarthritis [20]. In addition, to ongoing studies on knee osteoarthritis, more studies should be conducted on osteoarthritis of other joints in the future.

We observed a steady increase in the number of clinical studies of acupuncture for osteoarthritis, with roughly three times as many papers published in the most recent decade (2013–2022: 284 articles) as in the first decade (2003–2012: 96 articles).

In analyzing the distribution of articles by field, we found that the largest number of studies were conducted in integrative complementary medicine, followed by general internal medicine and neurosciences neurology, which suggests that acupuncture is frequently considered as a treatment for osteoarthritis in the field of integrative complementary medicine or complementary alternative medicine. In addition, numerous studies applied acupuncture in patients or animals with osteoarthritis to elucidate the therapeutic mechanisms through medical and neurologic follow-up.

An analysis of the distribution of articles by journal showed that the largest number of articles were published in Evidence-Based Complementary and Alternative Medicine, followed by Medicine and Acupuncture in Medicine. Of the top 10 journals, the Journal of Pain Research had the highest Impact Factor (IF) (2.7), whereas Medicine had the lowest IF (1.6). Of the top five journals, Evidence-Based Complementary and Alternative Medicine (2.65), the journal with the largest number of published articles, had the second highest IF.

An analysis of article distribution by country over the past 20 years showed that China, the United States, the United Kingdom, and South Korea accounted for the most published articles. China published more than 30% of the total number of articles, which suggests a recent invigoration of osteoarthritis research. It was noteworthy that, for each time period, most research was conducted in Western countries, including in the United States and Europe, whereas a substantial number of recent studies were conducted in China, Taiwan, and Spain. A comparison of the average publication year and average citation rate by country showed that the United Kingdom (2012.55 years, 102.37 articles) and Germany (2011.07 years, 124.14 articles), which were among the top five countries in terms of number of publications, had a longer average publication year and a higher average citation rate than other countries did, which likely reflects the fact that an earlier publication year is associated with a higher average citation rate. This suggests that earlier research laid the groundwork for later research. An early study demonstrating the effectiveness of acupuncture for osteoarthritis was a randomized study of acupuncture in patients with osteoarthritis published by the Charité-Universitätsmedizin Berlin in Germany [21], which included a large number of citations, and it likely influenced the direction of subsequent research, including research on osteoarthritis of knee and other areas, pain control mechanisms of acupuncture, and development of effective evaluation tools.

An analysis of article distribution by institution showed that, over the past 20 years, most articles were published by researchers at Beijing University of Chinese Medicine, Capital Medical University, Charité-Universitätsmedizin Berlin, and Shanghai University of Traditional Chinese Medicine. All of the top 10 institutions were universities; many had affiliated or neighboring hospitals. The institutions most actively engaged in research in recent years were Beijing University of Chinese Medicine, Capital Medical University, and Chengdu University of Traditional Chinese Medicine, all of which are located in China, which confirms that research in China has recently been on the rise, which is consistent with the findings of the country-by-country analysis. Notably, Beijing University of Chinese Medicine ranked first in terms of the number of publications, with the most recent average publication date among the top 10 institutions, and its most highly cited study compared the efficacy of intensive acupuncture to sham acupuncture for osteoarthritis of the knee [22]. The institution has also published a number of systematic reviews on the effects and mechanisms of acupuncture for knee arthritis [23] as well as conducted randomized controlled trials [24,25] and studies using animal models on the effects of acupuncture [26] and electroacupuncture [27] for cartilage regeneration. This is a good example of a university-hospital collaboration, as the research was conducted from a multidisciplinary perspective, involving both clinical and mechanistic studies on a given condition simultaneously.

In our analysis of article distribution by author, we found that Claudia M. Witt, Tu Jian Feng, Liu Cun Zhi, Klaus Linde, and Hugh MacPherson had the highest number of publications. Claudia M. Witt seems to have been at the forefront of research, consistently reporting on the effectiveness of acupuncture for chronic pain due to osteoarthritis, including a randomized study on acupuncture for knee osteoarthritis [21] and a randomized study on the effect of patient expectations of acupuncture treatment for chronic pain [28]. In cluster 5, Luis Ceballos-Laita, Elena Estebanez de Miguel, and Sandra Jimenez Del Barrio were all from the University of Valladolid and the University of Zaragoza, which averaged the most recent publications. These authors have conducted several randomized controlled trials since 2019 on the effects of acupuncture on the gluteal muscles in patients with hip osteoarthritis [29,30]. Their work is noteworthy because it is among the leading research on the hip joint, which is the second most commonly studied osteoarthritic joint.

3. Keyword analysis

The three most frequently detected keywords were “acupuncture”, “knee osteoarthritis”, and “pain”. This finding suggests that acupuncture for knee osteoarthritis has been one of the most widely studied topics in the field of osteoarthritis and that acupuncture has been used to reduce pain.

Among the keywords detected more than 10 times, the three most recent were “inflammation” (2020.92), “myofascial trigger point” (2020.38), and “warm needling acupuncture” (2019.8), while the three oldest ones were “double blind” (2011.06), “electrical nerve stimulation” (2012.67), and “nonsteroidal anti-inflammatory drug” (2012.7). This indicated that in the past, the analgesic effect of acupuncture treatment has been primarily studied through clinical trials, which shows that the research has recently expanded to include various acupuncture procedures and methods.

Using VOSviewer, we automatically divided the keywords into four clusters according to the similarity calculated based on the frequency of co-occurrence. We identified and named each cluster according to the most frequently published items within each cluster. Cluster 1 was named “Chronic pain clinical studies,” and it included 22 keywords related to clinical studies of acupuncture for chronic pain caused by osteoarthritis, such as “randomized controlled trial”, “low back pain”, “adjunctive therapy”, “clinical trial”, “chronic pain”, “exercise”, “placebo”, and” double blind”. Notably, the keywords “randomized controlled trial”, “placebo”, and “double blind” indicate that numerous studies have compared real acupuncture to sham acupuncture. Reflecting the characteristics of these keywords, the most cited study was a meta-analysis of acupuncture treatments for chronic pain caused by osteoarthritis and other related conditions [31]. The study authors concluded that acupuncture is effective for the treatment of chronic pain and that the difference between real and sham acupuncture was more than a mere placebo effect, which suggests that there is more to acupuncture than just “getting poked with needles.”

Cluster 2 was named “Research on Therapeutic Mechanisms,” and it contained 19 keywords, including “acupuncture”, “pain”, “osteoarthritis”, “analgesic effect”, “stimulation”, “rheumatoid arthritis”, “expression”, “rat”, and “mechanism”. This suggests that most studies were focused on the analgesic mechanisms of acupuncture for osteoarthritis pain. Acupuncture controls pain by modulating the rate of nerve conduction in the brain and inducing functional and structural changes in the nervous system [32]. In a study that applied acupuncture in patients with carpal tunnel osteoarthritis, the authors reported increased activity of the right dorsolateral prefrontal cortex, anterior cingulate cortex, and midbrain [33]. In a study in which acupuncture stimulation of the popliteal vein was applied to patients with osteoarthritis, the authors reported that the treatment affected the perception of nociception by modulating the functional connectivity of the dorsal raphe nucleus and right cortex [34]. Although these studies are significant in that they demonstrated the effects of acupuncture on various types of arthritis, they are limited by their small sample sizes and short-term acupuncture treatments. To identify the effects and mechanisms of acupuncture, further studies with larger sample sizes and long-term acupuncture treatments are needed. In addition, studies have shown that acupuncture can delay cartilage degeneration [35] and reduce inflammation and bone destruction [36], whereas electroacupuncture can delay cartilage degeneration and prevent cellular changes [37]. However, studies on cartilage degeneration and regeneration have been conducted on animals, with only few clinical studies being conducted on humans, and future research should thus involve clinical trials on acupuncture.

Cluster 3 was named “Current Research Trends,” and it contained 14 keywords, including “knee osteoarthritis”, “hip”, “therapy”, “prevalence”, “outcomes”, “womac”, “health”, and “guideline”. Compared with other clusters, the keywords in cluster 3 had more recent average publication dates, and keywords such as “prevalence”, “womac”, and “guideline” in this cluster reflected the latest trends of epidemiologic studies, evaluation tools, and treatments. Clinical practice guidelines (CPGs) incorporate these characteristics. These are evidence-based treatment recommendations that help lead to more appropriate and efficient decisions in clinical settings, and to ensure that high-quality, effective care is implemented, it is thus essential to assess the quality of CPGs. A quality assessment of CPGs for knee arthritis was conducted in 2021 [38]; however, the development and evaluation of CPGs for other areas of osteoarthritis is still lacking. Because the prevalence of osteoarthritis is expected to increase with an aging and the obese population, further studies should focus on osteoarthritis outside the knee.

Cluster 4 was named “Acupuncture as a Complementary and Alternative Medical Care.” It contained 11 keywords, including “alternative medicine”, “care”, “complementary”, “efficacy”, and “impact”. A study published in 2021 reported that, to improve the symptoms of knee arthritis, acupuncture and electroacupuncture are commonly used as nonpharmacologic treatments, and because localized thermal stimulation can reduce pain, treatments that combine acupuncture with thermal stimulation such as hot or warm needling have recently become popular [39]. Recently, in addition to simple acupuncture, various types of acupuncture from electroacupuncture and hot or warm acupuncture to miniscalpel acupuncture [40] have been used for osteoarthritis, and their therapeutic effects and mechanisms have been reported. On this basis, it is conjectured that further research on the safety and efficacy of various types of acupuncture should be conducted.

4. Limitations

This study has several limitations. First, the language of the articles was limited to English. However, a high proportion (92.5%) of the total articles retrieved from Web of Science (411) were in English (380); thus, it is likely that the results are representative of global research trends. Second, although a variety of keywords were used to describe acupuncture, including “acupuncture” and “dry needling”, it is possible that some articles were left out. Finally, because this study sought to identify research trends over the past 20 years, we could not determine which of the various acupuncture modalities is most effective for osteoarthritis.

CONCLUSION

The analysis by condition showed that knee osteoarthritis (M17) was the most common condition, followed by polyarthritis (M15) and hip osteoarthritis (M16). The analysis by publication year showed the among all years, the largest number of papers were published in 2022, and despite annual variation, an overall upward trend was identified. Active research on acupuncture for osteoarthritis treatment is ongoing in the fields of integrative and complementary and alternative medicine as well as internal medicine and neuroscience. Over the past two decades, the two leading research countries have been China and the United States. Although past research has mostly been conducted in the West, such as in the United States and Europe, recent studies have been conducted in East Asia, such as in China and South Korea. The three most recent keywords detected ≥ 10 times in the titles and abstracts of the 380 articles were “inflammation”, “myofascial trigger point”, and “warm needling acupuncture”. In VOSviewer, the keywords were automatically categorized into four clusters based on relevance. The keywords related to “clinical research in chronic pain” were placed in cluster 1, those related to “analgesic mechanisms of acupuncture” in cluster 2, those related to “current research trends” in cluster 3, and those related to “acupuncture as a complementary and alternative medicine management” in cluster 4.

AUTHOR CONTRIBUTIONS

Conceptualization: JL, HC. Data curation: JL. Formal analysis: JL. Methodology: JL, HC, Sungjun Joo. Writing – original draft: JL, YK. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

This research did not involve any human or animal experiment.

Fig 1.

Figure 1.Flow chart of stages of the literature search.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 2.

Figure 2.Number of publications by Korean Classification of Disease code. M15, polyarthritis; M16, hip osteoarthritis; M17, knee osteoarthritis; M18, arthritis of first carpometacarpal joint; M19, other arthritis.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 3.

Figure 3.Number of publications by year over the past 20 years.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 4.

Figure 4.(A) Network map of countries. (B) Distribution of countries according to the average publication year. (C) Distribution of countries according to average citations.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 5.

Figure 5.(A) Network map of organizations. (B) Distribution of organizations according to average publication year. (C) Distribution of organizations according to average citations.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 6.

Figure 6.(A) Network map of authors. (B) Distribution of authors according to average publication year. (C) Distribution of authors according to average citations.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Fig 7.

Figure 7.(A) Network map of keywords. (B) Distribution of keywords according to average publication year. (C) Distribution of keywords according to average citations.
Journal of Acupuncture Research 2023; 40: 293-307https://doi.org/10.13045/jar.2023.00220

Table 1 . Distribution by research area.

RankingResearch areaRecords (n)Percentage (of 380)
1Integrative complementary medicine14036.8
2General internal medicine7319.2
3Neurosciences neurology4211.0
3Research experimental medicine4211.0
5Rheumatology328.4
6Anesthesiology215.5
7Orthopedics205.3
8Rehabilitation133.4
9Health care sciences services82.1
9Science technology other topics82.1

Table 2 . Distribution by journal.

RankingJournal titleRecords (n)Percentage
(of 380)
Impact factor*
1Evidence-Based Complementary and Alternative Medicine328.42.65
2Medicine287.41.6
3Acupuncture in Medicine256.62.5
4Trials205.32.5
5Journal of Pain Research102.62.7
6Journal of Alternative and Complementary Medicine92.42.6
6Journal of Traditional Chinese Medicine92.42.6
8Chinese Journal of Integrative Medicine82.12.9
8Clinical Journal of Pain82.12.9
8Journal of Acupuncture and Tuina Science82.10.5

*The impact factor was reported based on Journal Citation Reports (JCR) 2022..


Table 3 . Distribution by country.

RankingCountryRecords (n)Percentage (of 380)
1People’s Republic of China18047.4
2United States7920.8
3England5113.4
4South Korea307.9
5Germany287.4
6Spain153.9
7Australia143.7
8Switzerland133.4
8Taiwan133.4
9Canada112.9
10The Netherlands51.3

Table 4 . Distribution of organization.

RankingOrganizationRecords (n)Percentage (of 380)
1Beijing University of Chinese Medicine328.4
2Capital Medical University215.5
3Charité-Universitätsmedizin Berlin164.2
3Shanghai University of Traditional Chinese Medicine164.2
5Kyung Hee University153.9
6China Academy Chinese Medicine Science143.7
7Chengdu University of Traditional Chinese Medicine143.7
8Technical University of Munich133.4
8University of Maryland Baltimore133.4
8Fujian University of Traditional Chinese Medicine133.4
11University of Zurich123.2
11University of York UK123.2
13University Zurich Hospital112.9
13University of Southampton112.9

Table 5 . Distribution by author.

RankingAuthorRecords (n)Percentage (of 380)
1Claudia M. Witt174.5
2Liu Cun Zhi153.9
2Tu Jian Feng153.9
4Klaus Linde133.4
5Hugh MacPherson123.2
5Wang Li Qiong123.2
7Lin Lu Lu112.9
7Yang Jing Wen112.9
9Wang Tian Qi102.6
10George Lewith92.4
10Wang Tong92.4
12Nadine E. Foster82.1
12Guo Chang Qing82.1
12Lao Li xing82.1
12Shi Guang Xia82.1
12Stefan N. Willich82.1

Table 6 . Keyword classification.

RankingKeywordCountTLSClusterCitation scorePublication score
1Acupuncture2051,054224.942016.95
2Knee osteoarthritis153806334.12018.62
3Pain132739241.482017.54
4Osteoarthritis105564234.922015.24
5Electroacupuncture83491219.612017.12
6Hip82526351.282017.05
7Randomized controlled trial80508144.162014.88
8Management72467430.062017.29
9Meta-analysis553654101.62017.93
10Therapy51333331.082017.29
11Knee50255226.72015.76
12Low back pain48279165.772014.27
13Adjunctive therapy38228154.032013.74
14Clinical trial34219176.262013.44
14Arthritis34215231.712014.65
16Prevalence33218326.032017.09
16Recommendations332274108.72016.39
18Efficacy31181430.162016.26
18Systematic review31213451.972015.68
20Chronic pain29188132.662017.31
21Complementary251554642013.24
22Alternative medicine23145436.912013.61
23Exercise22131113.092018.09
23Placebo221431149.642013.64
23Outcomes22138329.092016.64
23WOMAC22144361.552013.77
27Double blind19941254.422010.32
28Analgesic effect18108252.282014.33
29Stimulation17102239.652015.76
29Rheumatoid arthritis1793234.412013.18
31Reliability1685117.752018.62
31Hip osteoarthritis16105163.752017.38
31Health16122312.692019.12
31Safety16834155.622017.69
35Trigger point1478138.142019.5
35Traditional Chinese medicine1488122.792017.57
35Expression1469212.292018.64
35Rat1468229.072016.64
35Mechanism1469261.292013.21
35Guideline1490346.072017.86
35Quality14884207.362013.43
42Myofascial trigger point1371120.312020.38
42Physiotherapy1376157.772014
42Older adult1380144.542013
42Burden1398218.852017.85
42Acupotomy135934.922019.69
42Protocol136332.152019.23
42Sham acupuncture138336.312018.77
49Pharmacological analgesics1292144.082018.5
49Quality of life12801180.832015.25
49Complementary medicine1273120.672013.92
49Electrical nerve-stimulation12801101.832012.67
49Inflammation126026.252020.92
49Risk1266215.672018.5
55Cost effectiveness1167140.552014.18
55Model1142211.642018.55
55Manual acupuncture1172311.822019.64
55Validation1156339.732015.45
55Impact1175413.912018.64
60Tension-type headache10631136.42015.4
60Nonsteroidal anti-inflammatory drug10561276.42012.7
60Moxibustion1054213.32019.4
60Disease1072211.62018.5
60Cartilage1052210.32017.5
60Warm needling acupuncture105731.12019.8
60Care1053480.42013

Count, number of occurrences; TLS, total link score; citation score, average number of citations; publication score, average publication year..


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JAR
Feb 29, 2024 Vol.41 No.1, pp. 1~73

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Journal of Acupuncture Research

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