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  • Acupuncture Therapy for Postoperative Pain

    Acupuncture Therapy for Postoperative Pain

    Introduction

    Postoperative pain foremost refers to the acute pain that occurs immediately after surgery and consists mainly of pain from somatic and visceral trauma caused by surgical operations and pain from inflammatory irritation around nerve endings,1 which attributes to injurious pain.2 If it continues to be poorly controlled, pathological remodeling of the central and peripheral nervous system occurs3 and the nature of the pain changes to neuropathic pain or mixed pain, then it progresses to chronic postoperative pain. More than 300 million patients undergo surgery worldwide each year.4 Between 30{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} and up to 80{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of patients report moderate to severe pain in the days following surgery, and approximately 20{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} developing chronic pain.5 Persistent pain not only affects the patient’s recovery and leads to longer hospital stays,6 but also adds to the psychological burden of the patient, causing anxiety and depression.7,8 For families and society, both the direct increase in hospitalization expenses and consumption of medical resources, and the consequent indirect decline of individual labor force and even unemployment,9 are issues that should not be underestimated.

    Currently, pharmacological analgesia remains the dominant modality for the treatment of postoperative pain. Analgesics can meet the requirements of short-term and rapid analgesia, however, their side effects such as the addiction of opioids,10 the gastrointestinal harm and possible cardiovascular risks of non-steroidal anti-inflammatory drugs (NSAIDs),11,12 are also evident. Furthermore, although numerous postoperative pain management recommendations have been available over the years, the drugs recommended are generalized for all procedures.13 The efficacy of pain medication may vary depending on the type of surgical procedure,14 so it is difficult for specialists to find an effective solution for a particular procedure, and many patients report unsatisfactory results in terms of postoperative pain control.15 This all indicates to the fact that pharmacological analgesia is not a long-term solution. Searching for green, safe, low adverse effects and targeted analgesia gradually becomes one of the most important concerns of clinicians.

    Acupuncture therapy, a series of traditional Chinese medical treatment internationally accepted and applied for its undeniable effectiveness of therapeutic effects in the treatment of various pain-related conditions and nerve disorders,16,17 is one of the ideal non-pharmacological treatments to control post-operative pain. Studies have found that acupuncture therapy can intervene in pain through mechanisms such as increasing endogenous opioid peptides in the brain,18,19 modulating abnormal neurological function,20 and influencing intracellular signaling pathways.21 A randomized controlled trial (RCT) showed that acupuncture was effective in relieving postoperative pain in patients undergoing hemorrhoidectomy.22 Another RCT also found that acupuncture therapy was safe and effective in the management of post-cesarean pain.23

    Bibliometric analysis is a method for evaluating and quantifying literature information using mathematical and statistical methods,24 which can help to recognize the research advances in a specific field of science comprehensively.25 This analytical method has been applied to many areas with a large body of research accumulated, including pain management. In one of these studies, Gao et al26 analyzed the field of acupuncture for analgesia, and it can be seen in this study that acupuncture therapy for postoperative pain has also received considerable attention. However, despite the heat in the clinical and research area, no studies have yet explored current research trends in the treatment of postoperative pain with acupuncture therapy and continued in-depth study of this field using bibliometric analysis is highly warranted.

    The approach of bibliometric was applied in this study to analyze the literatures about acupuncture therapy for postoperative pain over the last 20 years, through multiple perspectives such as journals, authors, institutions, countries, keywords, and references. And the results were presented in the form of scientific knowledge maps by using the CiteSpace software, then the maps were further interpreted and analyzed, to gain an intuitive and comprehensive understanding of the research in the field, identify research hotspots and provide new research ideas.

    Methods

    Data Sources and Search Strategy

    All data for this study were obtained from the Web of Science (WoS) core collection database on 1 March 2022. The data search strategy included the topics “postoperative pain” and “acupuncture therapy”, with the publications period of the literatures ranging from 2001–01-01 to 2022–02-28. Only English-language papers were included, the country and category of the study were not restricted. Duplicates and articles without full text were excluded. Secondary search for references and relevant reviews in the literatures was conducted in order to avoid omissions. The specific search strategies and results were shown in Table 1. Eventually, 840 articles were obtained.

    Table 1 The Topic Search Query

    Analysis Tool

    This research applies CiteSpace (V5.8.R3 64-bits) combined with Excel to organize and visualize data for analysis, including: (1) statistical and descriptive analysis: for parameters such as annual publication volume, authors, countries, institutions and journals; (2) collaborative network analysis: mainly for the three dimensions of countries (regions), institutions and authors;(3) co-occurrence analysis: for keywords; (4) co-citation analysis: for authors, journals and references; (5) citation burst analysis: mainly for keywords and references; (6) cluster analysis.

    The specific parameters for the visualization analysis were set as follows. The threshold of “Top N{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} per slice” was 50 for all calculations. The time span was from January 2001 to February 2022, and the time slice setting for all analyses conducted with CiteSpace was “1 year per slice”. Clustering labels were extracted by using the LLR algorithm.

    Charts Interpretation

    The nodes in the maps generated by CiteSpace represent the objects being analyzed (such as different authors, institutions, or keywords); the size of the diameter of the nodes reflects the frequency (such as the output or citation frequency.); different colors correspond to different years (such as the year of publication); the lines between the nodes indicate the collaboration or co-occurrence relationship between the two, the color of the line indicates the time of the first collaboration and the thickness of the line reflects the strength of the relationship between the two.

    Results

    Annual Publications and Trends

    The retrieval of database found that a total of 860 articles have been published in the field of acupuncture therapy for postoperative pain in the past 20 years, and the number and trend of annual articles are shown in Figure 1. 2001 to 2014 could be seen as one phase. During this period, the annual number of articles published showed a fluctuating and slow growth trend, with an annual average of about 24 articles. There were four small peaks of growth successively, but all of them were quickly followed by a fall back. 2015 to the present is another phase. The number of publications in 2015 surged to 60, and after a small rebound, 2016 to 2019 saw a sustained and significantly accelerated increase in the number of publications, with the heat of attention increasing and stabilizing at an average of over 80 publications per year for the period 2019 to 2021, which was the highest record over the past 20 years. Only two months of data are currently available for 2022, but based on the above, it can be deduced that the number of publications this year will also be considerable and the research fever in the field of acupuncture for postoperative pain will continue.

    Figure 1 The number of annual publications on acupuncture treatment for postoperative pain.

    Note: In this figure, the number of articles published in 2022 is marked with an “*” and indicated by a dashed line, since only two months of data are available for this year.

    Analysis of Journals and Cited Journals

    Journals

    The total number of journals that published these 860 articles on acupuncture treatment for postoperative pain was 344 and the top 10 journals with the highest cumulative number of publications were listed in Table 2. The most published journals, accounting for about 14{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of the total number of articles published, were Evidence-Based Complementary and Alternative Medicine (40 articles), Acupuncture in Medicine (39 articles), and Medicine (38 articles). Anesthesia and Analgesia had the highest impact factor (IF) of 5.178, with 21 articles published, ranking 5th.

    Table 2 The Top 10 Journals with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Cited Journals

    In conjunction with centrality, CiteSpace was used to generate a map of cited journals with 645 nodes and 5770 links (Figure 2), reflecting the co-citation relationships between journals. A node represented a journal, which gave a total of 645 journals involved in co-citation in the field of acupuncture therapy for postoperative pain. Shown in Table 3, the top five contributing journals as cited are Pain, Anesthesia and Analgesia, Anesthesiology, British Journal of Anaesthesia, and Acupuncture in Medicine. In the cited journal map, the purple ring outside the node reflected the size of the centrality of the journal it represented. Table 4 listed the journals with the highest centrality in the field of acupuncture therapy for postoperative pain, with Clinical Journal of Pain and European Journal of Anaesthesiology being the top, both at 0.07.

    Table 3 Top 5 Cited Journals with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Table 4 Top 7 Cited Journals with the Highest Centrality on Acupuncture Treatment for Postoperative Pain

    Figure 2 Co-citation map of journals on acupuncture treatment for postoperative pain.

    Analysis of Countries

    Statistically, articles on acupuncture therapy for postoperative pain mainly came from 53 countries. The five countries with the highest contribution to the number of articles and the highest centrality were shown in Table 5 respectively, and a map of country cooperation networks was generated accordingly (Figure 3). As seen from it, China, the top publisher, has a weak chain of partnerships with other countries and need more international cooperation to enhance the global promotion of acupuncture therapy for postoperative pain. As the first of the pivot nodes, the US published a large amount of relevant literature and established collaborative relationships with quite a few countries. In addition, several countries forming a salient hexagonal circle of cooperation were visible in the upper right of the map. The mutual cooperation between these countries was developed early and closely. Meanwhile, they also maintained a certain cooperative relationship with Germany, one of the pivot nodes.

    Table 5 Top 5 Countries with the Highest Frequency and Centrality on Acupuncture Treatment for Postoperative Pain

    Figure 3 Map of countries cooperation network on acupuncture treatment for postoperative pain.

    Analysis of Institutions

    The top five institutions in terms of volume and centrality were listed in Table 6. China Medical Univ and Kyung Hee Univ both ranked first with 25 articles, followed by Korea Inst Oriental Med, Chinese Acad Sci and Shanghai Univ Tradit Chinese Med. China Med Univ, which had the highest number of articles, had the the highest centrality meanwhile, and Shanghai Univ Tradit Chinese Med was also tied. The inter-institutional collaboration network was generated accordingly, as shown in Figure 4. During this process, it was found that there were many instances where the names of institutions were not written normally, causing CiteSpace to identify the same institution as a different node. Such cases were all merged manually.

    Table 6 Top 5 Institutions with the Highest Frequency and Centrality on Acupuncture Treatment for Postoperative Pain

    Figure 4 Map of inter-institutional collaboration network on acupuncture treatment for postoperative pain.

    Analysis of Authors and Cited Authors

    Authors

    A total of 623 authors contributed to these 840 articles in the field of acupuncture therapy for postoperative pain and a map was generated using CiteSpace to show the collaborative relationships between the different authors (Figure 5). The nodes marked with names in the graph were the authors with three or more publications. And the authors with more than five publications, seven in total, were the core authors in this field. The most prolific author was Inhyunk Ha, with 10 publications. With him at the center, the graph presented a collaborative block linking up highly productive authors such as Byungcheul Shin (8 publications) and Meriong Kim (6 publications). Man Zheng was also active, with 6 publications, and he was part of the same team as Zhen Zheng, who had 5 publications. Lianbo Xiao and Di Sessler also had 5 publications. The map also manifested some loosely linked teams, most of which were multiple authors of the same paper. The collaborations between the different teams were less. Other relevant information about core authors were listed in Table 7. The “Year” column in the table manifested when the author first published, reflecting how early the author had been interested in the field. The “Nationality” column showed that the core authors were mainly from Korea and China. Moreover, the “Author” and “Country” modules were overlaid to obtain a new graph (Figure 6), where the distribution of authors by nationality can also be observed.

    Table 7 Top 7 Authors with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Figure 5 Map of authors cooperation network on acupuncture therapy for postoperative pain.

    Figure 6 Authors-countries collaboration map on acupuncture therapy for postoperative pain.

    Cited Authors

    In combination with centrality and applying “pathfinder” and “pruning sliced networks”, CiteSpace was used to generate a co-citation map of authors from the field of acupuncture therapy for postoperative pain with 745 nodes and 2824 connected lines (Figure 7). The five most frequently co-cited authors whose articles had the highest impact were Han JS, Sun Y, Lee A, Lin JG and Wang SM, listed in Table 8. The seven authors with the highest centrality were demonstrated in Table 9, with four of them, Han JS, Vickers AJ, Wang SM and Ernst E, having centrality greater than or equal to 0.1.

    Table 8 Top 5 Cited Authors with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Table 9 Top 6 Cited Authors with the Highest Centrality on Acupuncture Treatment for Postoperative Pain

    Figure 7 Co-citation Map of Authors on Acupuncture Therapy for Postoperative Pain.

    Keywords Co-Occurrence Analysis

    The 840 articles of acupuncture therapy for postoperative pain brought together a total of 517 keywords. “Pathfinder” and “pruning sliced networks” applied, a co-occurrence map of keywords, Figure 8, was generated. The 10 most frequently occurring words have been listed in Table 10, and 6 keywords occurred more than 100 times. Of interest were the “electroacupuncture” ranked 4th and “auricular acupuncture” ranked 8th. The frequency of these two keywords about therapeutic techniques was particularly high. Meanwhile, the keyword “auricular acupuncture” and two keywords related to electroacupuncture research, “electrical stimulation” and “electrical nerve stimulation”, had a high centrality (Table 11).

    Table 10 Top 10 Keywords with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Table 11 Top 11 Keywords with the Highest Centrality on Acupuncture Treatment for Postoperative Pain

    Figure 8 Co-occurrence map of keywords on acupuncture therapy for postoperative pain.

    Further clustering based on the co-occurrence map resulted in a total of 12 clusters presented in Figure 9. The five largest clusters were “#0 postoperative nausea”, “#1 spinal nerve ligation”, “#2 systematic review”, “#3 postoperative ileus”, “#4 gi endoscopy”, “#5 undergoing autologous hematopoietic stem cell transplantation”. These were the most talked about topic in this area. Transforming the map into a Timeline view (Figure 10) allowed to observe the evolution of hot spots in the field of acupuncture therapy for postoperative pain research over the last 20 years.

    Figure 9 Cluster map of keywords co-occurrence on acupuncture therapy for postoperative pain.

    Figure 10 Timeline map of keywords co-occurrence on acupuncture therapy for postoperative pain.

    References Co-Citation Analysis

    A total of 855 references were extracted from the 840 articles of acupuncture therapy for postoperative pain to analyze cited references. The earliest cited literature was published in 1996 and the most recent reference was published in 2020. The five most frequently cited publications were listed in Table 12. Three of these were systematic reviews, one clinical randomized controlled trial, and one review. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis by Wu MS et al,27 published in 2016 topped the list with 44 citations. Table 13 demonstrated the top 5 papers ranked according to centrality. Three of these were clinical randomized controlled trials, one was a systematic review, and one was a review article. Written by Sun Y et al, Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials,28 published in 2008 had the highest centrality of 0.22.

    Table 12 Top 5 Cited References with the Highest Frequency on Acupuncture Treatment for Postoperative Pain

    Table 13 Top 5 Cited References with the Highest Centrality on Acupuncture Treatment for Postoperative Pain

    As shown in Figure 11, there was a co-citation map of references generated by CiteSpace. All references marked on the graph were those with more than 8 citations, and it can be seen that a large number of highly cited literatures were published in the last 10 years. Based on this, 19 valid clusters were obtained (Figure 12). The five largest clusters were #0 acupuncture analgesia, #1 evidence-based nonpharmacologic strategies, #2 postoperative complication, #3 randomized controlled trail, #4 ambulatory anesthesia, #5 capsicum plaster.

    Figure 11 Co-citation map of references on acupuncture therapy for postoperative pain.

    Figure 12 Cluster map of references co-citation on acupuncture therapy for postoperative pain.

    Citation Burst Analysis

    Burst keywords refer to keywords that have seen a spike in citations over a period and represent the research hotspot for the corresponding time. The 840 included articles were measured via CiteSpace and a total of 16 burst keywords were extracted, as shown in Figure 13. These keywords first appeared in 2001 or before, but the burstness began and ended at different times (shown as the red bars). Among them, “postoperative nausea” had the highest value of burst intensity, with a “Strength” of 8.36. Keywords having the longest duration of the burstness were “acupuncture analgesia” and “trial”, both beginning in 2008 and ending in 2016. The three latest burst keywords, “pain relief” from 2018, “systematic review” from 2019 and “osteoarthritis” from 2020, have been still ongoing.

    Figure 13 Top 16 keywords with the strongest citation bursts.

    A reference citation burst is a surge in the frequency of the reference being cited over a period, which can help to identify areas at the forefront of current research. A total of 15 references of citation burst were extracted for this study and were displayed in Figure 14. Four references with the latest burstness were identified. An article by Zhang RX published in 201429 and an article by Lee A published in 201530 both began bursting in 2017, with the former ending bursting in 2019 and the latter in 2020. The next burst reference was the same as the most frequently cited article (Wu MS, 2016),27 and meanwhile it had the highest value of burst intensity (15.32). This reference and another one by Chou R were both published in 2016,31 with their citation bursts beginning in 2018 and continuing until now.

    Figure 14 Top 15 references with the strongest citation bursts.

    Discussion

    General Information on Publications

    The 840 publications included spanned the period from January 2001 to February 2022. Analysis of the annual volume of literature published revealed that the volume of publications in the field of acupuncture for postoperative pain had increased to varying degrees each year. This increase was relatively steady in the early stage, more prominent after 2015, and stabilized at its highest level during the latest 3 years. This indicates that the field is in a period of rapid development and has great scope for exploration and research value. From the analysis of journals, the impact factors (IF) of the top ten journals with the highest cumulative number of publications are generally low. This indicates that the influence of acupuncture techniques for postoperative pain control in international applications is still relatively limited, and the quality of relevant publications needs to be improved. The highly cited journals mainly reflect the sources of journals that are the knowledge base of the relevant literatures. Most of them are comprehensive medical journals that serve as a bridge of knowledge between conventional and complementary alternative therapies, and they are more influential, with having a higher impact factor.

    In terms of the number of national publications, the contributions of China and USA are the most prominent. The parameters of the cooperation map show that the density of national collaborative networks is not low, which means that to some extent an international environment for collaborative research in the field of acupuncture for postoperative pain has been formed, with European and American countries such as the USA, UK and Germany playing a larger role, while Asian countries, represented by China and Korea, have more fragmented links. Institutions in Chinese and Korean are the main locations for research in this field. Medical schools and their affiliated medical institutions are the main institutional form. None of the top five institutions in the centrality ranking has a value above 0.10, suggesting that even the representative institutions are only collaborating on a small scale.

    In terms of authors, Inhyuk Ha and his partners have published the most articles, focusing on the application of acupuncture therapy for postoperative pain in the low back, with the most influential article being cited 42 times. This meta-analysis has provided evidence to support the use of acupuncture for acute pain occurring within one week of back surgery.32 From China, Man Zheng is member of a research team investigating the role of acupuncture therapy in perioperative pain prevention, particularly in thoracic and abdominal surgery. A randomized controlled trial conducted by the team demonstrated that in patients undergoing gynecological laparoscopy surgeries, a single electroacupuncture session within 24 hours before surgery was effective in preventing postoperative pain.33 The author who has the highest frequency of being cited and centrality is Han JS, whose most cited paper is a review published in Pain in 2011,34 which focuses on the consensus and controversy surrounding the research on the efficacy and mechanisms of acupuncture-related therapy, including the selection of acupoints, stimulation methods and intensity, and neurological effects, providing a reference for both clinical application and trial protocols.

    Research Hotspots and Frontiers

    Keywords and references reflect the content of the research from different aspects. Observed in the spatial dimension, the level of their frequency, centrality and burst intensity, and clustering distribution can suggest research hotspots. And in the temporal dimension, the dynamic changes of them can reflect research trends and help identify research frontiers.

    Highly Concerned Treatment Techniques and Types of Surgery

    Based on the frequency and centrality of the keywords, it can be determined that electroacupuncture and auricular acupuncture are probably the therapeutic techniques that have received the most attention from researchers in this field. A multicenter randomized controlled trial demonstrated that electroacupuncture combined with conventional care was superior to conventional care alone for the relief of non-acute pain following back surgery.35 Another randomized controlled trial also showed that auricular acupuncture could provide postoperative analgesia and reduce the application of analgesic medication and was safe to perform.36

    Studies on the control of postoperative pain with acupuncture have covered a variety of surgical types, including low back surgery, osteoarthritis surgery, lung cancer surgery, cardiac surgery, brain surgery, laparoscopic surgery, tonsillectomy, hysterectomy, total knee replacement, hip replacement, caesarean section, oral surgery, spinal surgery, shoulder and neck surgery, gastric cancer surgery, and anorectal surgery. The studies on chronic lower back pain due to the aftermath of low back surgery are the most, with 58 occurrences of related keywords.

    Hot Research Topics and Directions

    The results of clustering and burstness of keywords revealed a consistently high level of concern for postoperative nausea. The largest cluster was “postoperative nausea”. Of the 16 burst keywords, “postoperative nausea” was the keyword with the earliest occurrence (beginning in 2002) and the greatest intensity of burstness. Moreover, the keyword “nausea” had a second citation burst in 2014. Both nausea and pain are the most common complications after surgery. Meanwhile, there is also a degree of causality between the two. Opioid analgesics have been found to be one of the main causes of postoperative nausea and vomiting.37,38 The problem of nausea can be addressed to a great extent if postoperative pain can be relived with minimal use of such medications. Acupuncture therapy has attracted the attention of researchers as an excellent complementary and alternative therapy. A systematic review by Pouy S et al showed that acupuncture therapy can prevent and reduce the occurrence of post-tonsillectomy pain and nausea in pediatric patients.39 A popular direction of research derived from this research hotspot is PC6 acupoint stimulation. The acupoint of Neiguan (PC6), located on the pericardium meridian, is a specific point for the treatment of nausea and vomiting.40 Studies on the relief of postoperative complications of pain and nausea have been conducted as early as 1996 by applying pressure to the Neiguan point.41 A systematic review and meta-analysis by Cheong KB et al demonstrated the safety and effectiveness of acupuncture stimulation of the PC6 acupoint or with the combination of other acupuncture points to alleviate postoperative vomiting associated with anesthetic analgesia.42

    In addition, transcutaneous electrical nerve stimulation (TENS) is another hot direction of research in this field, as reflected in the keyword clustering and burstness. This technique is also combined with auricular acupuncture techniques.43 A similar technique arising from the disciplinary crossover is transcutaneous electrical acupoint stimulation (TEAS).44–46

    Research Trends and Forefront

    From an overall perspective, keywords whose burstness occurred in the first decade mainly reflected a concentrated discussion of postoperative pain management and acupuncture analgesic techniques, with the main form of research being mostly RCTs. In the recent decade the main focus has been on pain symptom relief and postoperative quality of life, with a gradual increase in the number of systematic reviews. Moreover, animal experiments, as well as mechanism-related studies, also have a place, as evidenced by the burst keyword “rat” and the second largest cluster “#1 spinal nerve ligation” (a kind of rat modelling technique). Looking at the three newest burst keywords, “pain relief” shows the constant attention received by the topic of postoperative pain management. The rise in heat of “systematic review” reflects the development of evidence-based medicine in this field. 2020 saw the burstness of the term “osteoarthritis”, indicating that in the last two years acupuncture analgesic techniques have started to be used in osteoarthritis surgery more often and intensive research has been conducted.47,48

    The citation status of the references also manifests a distinctly evidence-based medical color. The most influential literatures in this field are of a variety which is dominated by RCTs and systematic reviews of clinical studies. In the results of clusters, both “#1 evidence-based nonpharmacologic strategies” and “#3 randomized controlled trail” have a relatively large size. The most frequently cited reference suggested that certain modes of acupuncture did have implications for alleviating postoperative pain and reducing opioid use.27 That acupuncture could control acute postoperative pain and reduce the side effects of pharmacological analgesia was supported by the reference with the highest centrality.28

    According to the newest burst references, electroacupuncture could alleviate pain by activating a range of bioactive substances including opioids, N/OFQ, 5-hydroxytryptamine, norepinephrine and others.29 Lee A et al evaluate the preventive effect of several methods of stimulating the PC6 acupoint on nausea and vomiting resulted from surgical analgesia and anesthesia.30 This fits in with the direction of research embodied in the keywords. The last is a guideline on postoperative pain management published in 2016.31 In this guideline, TENS is supported by moderate quality evidence and is recommended as a complementary therapy. In contrast, the effectiveness of other acupuncture therapies remains controversial, although there is adequate evidence for their safety. However, most of their citations and evidence are of results published before 2005 and their evidence needs to be updated. This suggests that the current focus in the field of acupuncture therapy for postoperative pain is still on proving the effectiveness of acupuncture therapy and that there is a long way to go in terms of conducting high quality clinical research.

    Conclusion

    In this study, the analysis of annual volume of publications and journals suggests that the field of acupuncture therapy for postoperative pain relief is currently in a period of rapid development. The analysis from country to institution to author shows a progressively more microscopic perspective of observation and consistency is evident among them: there may be more localized individual collaborations, but the overall collaborative network is not yet mature. In terms of keywords and references, electroacupuncture and auricular acupuncture (therapeutic techniques), low back surgery (types of surgery), “postoperative pain, nausea and vomiting” and their derivatives are research hotspots in this field. Improvement of postoperative life quality, proof of clinical efficacy and evidence-based evaluation are the current research trends and frontiers. Overall, the field of acupuncture for postoperative pain has great potential for development, and more international exchanges and collaborations as well as high-quality research results are needed in the future.

    Strength and Limitation

    The strength of this study is that literatures on acupuncture therapy for postoperative pain were analyzed by applying bibliometrics and visualization for the first time, and the results were interpreted from multiple perspectives, with the information presented in the macroscopic perspective sufficiently explored, revealing the research hotspots and trends in the field. The limitation of this study is that only literature from the Web of Science was analyzed. This is because CiteSpace cannot combine and analyze data from multiple sources at the same time, and other databases cannot export the corresponding citation formats for citation analysis.

    Abbreviations

    NSAIDs, non-steroidal anti-inflammatory drugs; RCT, randomized controlled trial; WoS, Web of Science; IF, impact factor; TENS, transcutaneous electrical nerve stimulation; TEAS, transcutaneous electrical acupoint stimulation.

    Data Sharing Statement

    The raw data of this article was collected from the online database WoS, which can be obtained directly by logging in or contacting the authors.

    Ethics Approval and Informed Consent

    This study did not contain any human or animal test subjects. Thus, the requirement for ethics approval was waived.

    Acknowledgments

    The authors would like to express their appreciation to Prof. Chaomei Chen for developing CiteSpace and opening its access.

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    This study was supported by the National Natural Science Foundation of China (U21A20404); the Innovation Team and Talents Cultivation Program of National Administration of Traditional Chinese Medicine (ZYYCXTD-D-202003).

    Disclosure

    The authors report no potential conflicts of interest in this work.

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    19. Gao YH, Wang JY, Tan LH, et al. [High mobility group box 1/ CD 24 receptor/β-EP signaling in “Zusanli” (ST 36) region contributes to electroacupuncture analgesia in rats with neuropathic pain]. Zhen Ci Yan Jiu. 2018;43(9):537–542. Chinese. doi:10.13702/j.1000-0607.170450

    20. Tu WZ, Cheng RD, Cheng B, et al. Analgesic effect of electroacupuncture on chronic neuropathic pain mediated by P2X3 receptors in rat dorsal root ganglion neurons. Neurochem Int. 2012;60(4):379–386. doi:10.1016/j.neuint.2012.01.006

    21. Tu WZ, Li SS, Jiang X, et al. Effect of electro-acupuncture on the BDNF-TrkB pathway in the spinal cord of CCI rats. Int J Mol Med. 2018;41(6):3307–3315. doi:10.3892/ijmm.2018.3563

    22. Wu J, Chen B, Yin X, Yin P, Lao L, Xu S. Effect of acupuncture on post-hemorrhoidectomy pain: a randomized controlled trial. J Pain Res. 2018;11:1489–1496. doi:10.2147/JPR.S166953

    23. Usichenko TI, Henkel BJ, Klausenitz C, et al. Effectiveness of acupuncture for pain control after cesarean delivery: a randomized clinical trial. JAMA Netw Open. 2022;5(2):e220517. doi:10.1001/jamanetworkopen.2022.0517

    24. Zhang J, Zhang Y, Hu L, et al. Global trends and performances of magnetic resonance imaging studies on acupuncture: a bibliometric analysis. Front Neurosci. 2020;14:620555. doi:10.3389/fnins.2020.620555

    25. Pan H, Xi Z, Yu X, Sun X, Wei X, Wang K. Knowledge mapping analysis of international research on acupuncture for low back pain using bibliometrics. J Pain Res. 2021;14:3733–3746. doi:10.2147/JPR.S340992

    26. Gao Z, Zhang J, Liu GF, Ji LX. Research trends from 2010 to 2020 for pain treatment with acupuncture: a bibliometric analysis. J Pain Res. 2021;14:941–952. doi:10.2147/JPR.S300911

    27. Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367. doi:10.1371/journal.pone.0150367

    28. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008;101(2):151–160. doi:10.1093/bja/aen146

    29. Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology. 2014;120(2):482–503. doi:10.1097/ALN.0000000000000101

    30. Lee A, Chan SK, Fan LT. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2015;2015(11):Cd003281.

    31. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–157. doi:10.1016/j.jpain.2015.12.008

    32. Cho YH, Kim CK, Heo KH, et al. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Practice. 2015;15(3):279–291. doi:10.1111/papr.12208

    33. Li S, Zheng M, Wu W, Guo J, Ji F, Zheng Z. Effects of electroacupuncture administered 24 hours prior to surgery on postoperative nausea and vomiting and pain in patients undergoing gynecologic laparoscopic surgery: a feasibility study. Explore. 2017;13(5):313–318. doi:10.1016/j.explore.2017.06.002

    34. Han JS. Acupuncture analgesia: areas of consensus and controversy. Pain. 2011;152(3 Suppl):S41–s48. doi:10.1016/j.pain.2010.10.012

    35. Heo I, Shin BC, Cho JH, et al. Multicentre randomised controlled clinical trial of electroacupuncture with usual care for patients with non-acute pain after back surgery. Br J Anaesth. 2021;126(3):692–699. doi:10.1016/j.bja.2020.10.038

    36. Hendawy HA, Abuelnaga ME. Postoperative analgesic efficacy of ear acupuncture in patients undergoing abdominal hysterectomy: a randomized controlled trial. BMC Anesthesiol. 2020;20(1):279. doi:10.1186/s12871-020-01187-4

    37. Tan HS, Habib AS. The optimum management of nausea and vomiting during and after cesarean delivery. Best Pract Res Clin Anaesthesiol. 2020;34(4):735–747. doi:10.1016/j.bpa.2020.04.012

    38. Viderman D, Aubakirova M, Abdildin YG. Transversus abdominis plane block in colorectal surgery: a meta-Analysis. Front Med. 2021;8:802039. doi:10.3389/fmed.2021.802039

    39. Pouy S, Etebarian A, Azizi-Qadikolaee A, Saeidi S. The effect of acupuncture on postoperative pain, nausea and vomiting after pediatric tonsillectomy: a systematic review. Int J Adolesc Med Health. 2019;33:5.

    40. Apfel CC, Kinjo S. Acustimulation of P6: an antiemetic alternative with no risk of drug-induced side-effects. Br J Anaesth. 2009;102(5):585–587. doi:10.1093/bja/aep080

    41. Ho CM, Hseu SS, Tsai SK, Lee TY. Effect of P-6 acupressure on prevention of nausea and vomiting after epidural morphine for post-cesarean section pain relief. Acta Anaesthesiol Scand. 1996;40(3):372–375. doi:10.1111/j.1399-6576.1996.tb04448.x

    42. Cheong KB, Zhang JP, Huang Y, Zhang ZJ. The effectiveness of acupuncture in prevention and treatment of postoperative nausea and vomiting–a systematic review and meta-analysis. PLoS One. 2013;8(12):e82474. doi:10.1371/journal.pone.0082474

    43. Li JZ, Li XZ, Wang MS, Li JP, Shi F, Yu HF. [Effects of transcutaneous electrical stimulation of auricular Shenmen point on postoperative nausea and vomiting and patient-controlled epidural analgesia in cesarean section]. Zhonghua Yi Xue Za Zhi. 2012;92(27):1892–1895. Chinese.

    44. Yu X, Zhang F, Chen B. The effect of TEAS on the quality of early recovery in patients undergoing gynecological laparoscopic surgery: a prospective, randomized, placebo-controlled trial. Trials. 2020;21(1):43. doi:10.1186/s13063-019-3892-4

    45. Lan F, Ma YH, Xue JX, Wang TL, Ma DQ. Transcutaneous electrical nerve stimulation on acupoints reduces fentanyl requirement for postoperative pain relief after total Hip arthroplasty in elderly patients. Minerva Anestesiol. 2012;78(8):887–895.

    46. Huang S, Peng W, Tian X, et al. Effects of transcutaneous electrical acupoint stimulation at different frequencies on perioperative anesthetic dosage, recovery, complications, and prognosis in video-assisted thoracic surgical lobectomy: a randomized, double-blinded, placebo-controlled trial. J Anesth. 2017;31(1):58–65. doi:10.1007/s00540-015-2057-1

    47. Lee YJ, Han CH, Jeon JH, et al. Effectiveness and safety of polydioxanone thread-embedding acupuncture (TEA) and electroacupuncture (EA) treatment for knee osteoarthritis (KOA) patients with postoperative pain: an assessor-blinded, randomized, controlled pilot trial. Medicine. 2020;99(30):e21184. doi:10.1097/MD.0000000000021184

    48. Park TY, Kim HJ, Lee JH, et al. Efficacy and safety of acupuncture treatment as an adjunctive therapy after knee replacement: single-center, pragmatic, randomized, assessor blinded, pilot study. Medicine. 2021;100(10):e24941. doi:10.1097/MD.0000000000024941

    49. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444–1453. doi:10.1001/archinternmed.2012.3654

    50. Wang H, Xie Y, Zhang Q, et al. Transcutaneous electric acupoint stimulation reduces intra-operative remifentanil consumption and alleviates postoperative side-effects in patients undergoing sinusotomy: a prospective, randomized, placebo-controlled trial. Br J Anaesth. 2014;112(6):1075–1082. doi:10.1093/bja/aeu001

    51. Usichenko TI, Dinse M, Hermsen M, Witstruck T, Pavlovic D, Lehmann C. Auricular acupuncture for pain relief after total Hip arthroplasty – a randomized controlled study. Pain. 2005;114(3):320–327. doi:10.1016/j.pain.2004.08.021

    52. Usichenko TI, Kuchling S, Witstruck T, et al. Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial. CMAJ. 2007;176(2):179–183. doi:10.1503/cmaj.060875

    53. Affas F, Nygårds EB, Stiller CO, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthopaedica. 2011;82(4):441–447. doi:10.3109/17453674.2011.581264

  • What Is Acupuncture? A Complete Beginner’s Guide

    What Is Acupuncture? A Complete Beginner’s Guide

    Acupuncture solutions can be completed in clinics, hospitals, healthcare spas, chiropractic offices, and wellness centers. “The bodily setting may be a conventional clinic or resemble a spa,” Chu suggests. The treatment room is ordinarily a peaceful, non-public area, and sufferers are generally specified a indicates of communicating with the practitioner by means of a bell or get in touch with gadget, he adds.

    New individuals must expect to entire a health care historical past consumption sort upon arrival, just like at any other healthcare pay a visit to. You’ll also expend time, from a couple of minutes to lengthier, speaking about with the supplier your worries, similar to a medical medical professional getting a heritage. “There’s a small back again-and-forth of questioning and diagnosing,” Sheinberg suggests. This helps the company have an understanding of any health considerations you’re hoping to tackle as a result of acupuncture, so they can produce the best therapy strategy for you, usually in a collaborative way.

    From there, you could undress, lie on the treatment table, and protect you with the sheets, as you would prepare for a conventional therapeutic massage. Or, the practitioner may perhaps provide you with a robe to don in excess of your undergarments.

    The moment you are on the desk, the practitioner will insert the acupuncture needles. Acupuncture needles usually range from .5 to 2.5 inches in length, and are normally little more than enough that people today refer to them as “painless needles.”

    You may feel very little or you may perhaps truly feel a gentle soreness when the needles are placed in the skin, but there shouldn’t be any pain after the needles are in position. “If there is persistent discomfort, notify the practitioner,” Chu states.

    When you should not really feel ache, you should really feel a deep ache or stress in the areas exactly where the needles were being inserted. That deep ache signifies that the needles have been inserted at just the proper stage in the fascia to encourage the acupoint. “Sometimes, I request patients for feedback since I want to be certain I’m in the proper position,” Sheinberg claims.

    Acupuncture sessions can last for a several minutes of up to an hour, dependent on the intent of your stop by and the provider’s model of apply. Forty-five to 60 minutes is very normal, Sheinberg states.

    According to Johns Hopkins Medicine, some individuals report that acupuncture helps make them really feel energized, whilst other people say they feel comfortable.

    What is far more, you could truly feel sleepy, drowsy, or gentle-headed following your acupuncture session. “Drinking warm h2o or tea afterward is inspired,” Chu says.

    Right before leaving the clinic, check your system to make certain all acupuncture needles were removed. “It’s unusual, but acupuncture needles are in some cases unintentionally still left in,” Chu states. Really do not be alarmed if you locate a needle simply just notify the practitioner and they’ll remove it.

    The effects of acupuncture typically are not fast. It can acquire many months of weekly solutions to see long lasting changes, dependent on your sought after outcome. Some short-term outcomes may possibly point out that the acupuncture classes are doing work. One sign is you detect slight enhancements in your signs and symptoms. Curiously, the other is a worsening of signs and symptoms. “It’s basically not a lousy signal if you sense even worse just after acupuncture,” Sheinberg says. “It means we’ve stirred issues up.”

    On the other hand, if you really don’t see any improvements subsequent acupuncture, that may show that you haven’t landed on the ideal acupoints but. “Just like anything in drugs, there is a little bit of experimenting to uncover what is effective greatest for any a person individual,” says Sheinberg. Consider discover of how you truly feel after your acupuncture periods and share that details with the practitioner at the following appointment. This will aid the practitioner high-quality-tune your cure.

  • Wai Acupuncture and Integrative Medicine Expands in Central Florida and Hires Anna Small | News

    Wai Acupuncture and Integrative Medicine Expands in Central Florida and Hires Anna Small | News

    LONGWOOD, Fla., Jan. 10, 2022 /PRNewswire/ — The stresses of the Covid-19 pandemic have taken a toll on the Central Florida group, primary some citizens of the Longwood and Wekiva Springs area to look for a more holistic strategy to address their strain and wellbeing wants.

    As acceptance for acupuncture and alternative medication grows in the Central Florida area, Wai Acupuncture’s mission is to assistance the Longwood and encompassing communities this sort of as Altamonte Springs to achieve holistic wellbeing making use of acupuncture and Frequency Unique Microcurrent treatment.

    “People today should really consider natural and holistic methods to recover rather than ordinarily relying on plenty of prescribed medication for their illnesses.” said Dr. Nancy Chau, the lead physician at Wai Acupuncture. “Current investigation from 2019 infers that medicine and prescription errors are the 3rd main lead to of death, whereas holistic healing possesses no aspect effects.“

    The increasing demand for holistic therapeutic in Central Florida had introduced Wai Acupuncture and Integrative Medication to broaden their clinic workforce, not too long ago introducing Anna Modest to the Wai Acupuncture crew. Anna Small is a pupil intern at Wai Acupuncture subsequent her enthusiasm to help other folks heal holistically and attain a stability of wellbeing in their day by day life.

    Originally from Buffalo New York, Anna’s journey into holistic therapeutic began when she seasoned a pivotal minute of healing from acupuncture throughout her young many years. The holistic therapeutic encounter experienced turned into a passion for Anna when she attended Buffalo Seminary and finished her undergraduate training at the University of Pittsburgh.

    Anna can take terrific desire in studying herbology and enjoys discovering about Chinese and Eastern philosophies and cultures. The Wai Acupuncture staff is dedicated to aid purchasers holistically recover by way of Acupuncture and Oriental Medication and introducing Anna Tiny to the workforce designed the clinic’s mission to grow holistic healing even much better.

    For the forthcoming calendar year of 2022, Wai Acupuncture and Integrative medication is energized to announce approaching more products and services to enrich the wellbeing of the Central Florida community. Just one of the approaching products and services involves: Tai-Chi / Qigong applications for people who are intrigued in nourishing the mind through the martial-arts influenced fashion of training. Additionally, Wai Acupuncture is proud to announce that Cookie, our clinic canine, is scheduled to acquire a therapy doggy certification in February. Following her certification, Cookie will be capable to take part much more in therapy relevant courses to dietary supplement holistic healing.

    Media call:

    Alex Chau

    [email protected]

    407-335-4688

    Cision Watch authentic content material to down load multimedia:https://www.prnewswire.com/information-releases/wai-acupuncture-and-integrative-medicine-expands-in-central-florida-and-hires-anna-tiny-301456393.html

    Source Wai Acupuncture and Integrative Medication

  • Acupuncture Therapy for Postoperative Pain

    Bibliometric analysis of research on acupuncture: 20 years

    Introduction

    Neck pain, which is caused by neck damage, stiff neck, or cervical disease, refers to pain and movement disorders in the neck area. It can be induced by trauma, invasion of external pathogens (eg, wind-cold dampness), weakness, or multiple causes. Consequently, neck pain can cause tension, movement disorders, stiffness, radiating pain, and other forms of pain.1 It is a common musculoskeletal disease, and according to the 2017 statistics on the leading cause of global years lived with disability, it ranked 9th in women and 11th in men.2 Almost half of adults experience neck pain at least once in their lifetime,3 and more than 50{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of acute neck pain cases last longer than 1 year from onset.4 Although neck pain does not adversely influence an individual’s life itself, it affects the quality of life.5

    Conventional treatments, including drugs, injections, and surgeries, are known to reduce neck pain;6,7 however, these interventions can also induce adverse events, such as gastrointestinal, cardiovascular, and renal complications; nerve damage; hemorrhage; and readmission.8–10 Thus, an increasing number of patients seek complementary and alternative medicine (CAM) for effective and safe treatment of neck pain.

    Acupuncture therapy, which originated from ancient China,11 is one of the most popular CAM therapies in the world and widely used to effectively manage neck pain.12 Numerous studies have shown the benefits of acupuncture on neck pain, including pain relief,13–17 improved quality of life,18 reduced rate of cervical surgery,19 and cost-effectiveness.20 One of the reasons patients seek acupuncture therapy is because of its safety and effectiveness. However, notwithstanding the popularity in clinics and research areas, no studies have yet analyzed the publication trends on acupuncture for neck pain treatment via visual analyses.

    Bibliometric methods are quantitative methods that analyze large volumes of literature in a specific field using mathematical and statistical tools. By measuring the cooccurrence of information—authors, organizations, countries, keywords, and number of citations—in the literature, we can possibly understand various network relationships.21 This analytical method has been applied in many areas with large numbers of studies accumulated, including those on CAM. Jeon et al,22 Park et al,23 Moon et al,24 and Chen et al25 employed a bibliometric method to explore the general prescription of acupuncture, moxibustion, bee venom, and traditional Chinese medicine formula. In addition, Lee et al26 analyzed articles on acupuncture for pain treatment. Liang et al27 also evaluated the research trends on acupuncture for low back pain, while Li et al28 reviewed acupuncture therapy for knee osteoarthritis.

    In this study, we aimed to (a) analyze a large number of studies on acupuncture for neck pain treatment from a macroscopic perspective using a bibliometric method, (b) understand the characteristics of network data among the studies, and (c) discuss future research directions and specific tasks that may be undertaken in related research areas.

    Materials and Methods

    Data Sources, Search Strategies, and Coding

    A systematic literature search was conducted using the Web of Science database to identify relevant papers. The following search string was used to generate the initial search results: “(acupuncture OR electroacupuncture) AND (cervical pain OR neck pain).” This yielded 658 papers, which were further analyzed using the following inclusion criteria: (a) published from January 1, 2000 to December 4, 2020, (b) classified as an “article” or “review,” (c) written in English, and (d) had an abstract. The papers were manually selected on the basis of their titles and abstracts. Specifically, studies on acupuncture with needle insertion, ear acupuncture, and electroacupuncture were included, whereas those on pharmacopuncture, injection, acupressure, laser acupuncture, and transcutaneous electrical nerve stimulation were excluded. Using these systematic criteria, we finally included 325 articles. The authors were processed on the basis of their full names.

    Data Analysis

    The papers were coded in terms of publication year, research area, journal, country, organization, authors, and keywords. The results were analyzed and visualized using VOSviewer (v1.6.15; The Center for Science and Technology Studies, Leiden University, Leiden, The Netherlands), a program that maps bibliometric network data.29

    In the visualization using the VOSviewer program, the attraction/repulsion values in the layout items were set differently to yield clear representations of each of the organization, author, and keyword items (organization: attraction, 4/repulsion, −2; author: attraction, 5/repulsion, −4; keywords: attraction, 3/repulsion, −1).

    Results

    Distribution by Year

    The frequency of publication gradually increased from 5 publications in 2000 to 25 in 2018. Throughout the steady increase observed every year, 44 papers were published in 2019, which was the highest recorded number of publications in a year (Figure 1).

    Figure 1 Distribution of publications by year.

    Figure 2 Continue.

    Figure 2 Continue.

    Figure 2 (A) Network map of the six clusters of organizations. (B) Network map of the organizations according to the average publication year. (C) A network map of organizations according to the average citations.

    Distribution by Research Area

    In terms of research area, the area of integrative and complementary medicine (38.2{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) yielded the most papers, followed by the areas of neuroscience and neurology (21.2{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), general and internal medicine (15.7{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), rehabilitation (13.2{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), and anesthesiology (10.8{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) (Table 1).

    Table 1 Distribution of the Publications by Research Area

    Distribution by Journal Title

    In terms of journals, Evidence-based Complementary and Alternative Medicine (5.8{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) was the most frequently publishing journal, followed by the Journal of Alternative and Complementary Medicine (5.2{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), Acupuncture in Medicine (3.7{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), Complementary Therapies in Medicine (3.7{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), and Pain (3.4{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) (Table 2).

    Table 2 Distribution of the Publications by Journal Title

    Distribution by Country

    In terms of publishing countries, the US (30.5{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) had the most publications, followed by China (21.8{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), England (12.0{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), the Republic of Korea (10.2{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), and Germany (7.4{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) (Table 3).

    Table 3 Distribution of the Publications by Country

    Distribution by Organization

    In terms of research organizations, the University of York, UK, (5.5{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) and Kyung Hee University (4.3{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) published the most papers, followed by Jaseng Hospital of Korean Medicine and Memorial Sloan Kettering Cancer Center, with 11 articles (3.4{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) each. The University of Southampton ranked fifth, with 10 papers (3.1{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) published (Table 4).

    Table 4 Distribution of the Publications by Organization

    The organizations were analyzed using VOSviewer. First, the organizations that published more than three papers were identified. Of 73 organizations, 59 were divided into six clusters (Figure 2A). Cluster 1 consisted of 15 organizations, including the University of Alberta, University of Toronto, and Canadian Memorial Chiropractic College. Cluster 2 consisted of 14 organizations, including the University of York, UK, Memorial Sloan Kettering Cancer Center, and the University of Southampton. Cluster 3 consisted of 10 organizations, including the China Academy of Chinese Medical Sciences, Harvard University, and Beijing University of Chinese Medicine. Cluster 4 consisted of nine organizations, including the University of California, Los Angeles; Karolinska Institute; and Stanford University. Cluster 5 consisted of seven organizations, including Kyung Hee University, Jaseng Hospital of Korean Medicine, and the Korea Institute of Oriental Medicine. Cluster 6 consisted of four organizations, including China Medical University Taiwan, China Medical University Hospital, Taiwan City Hospital, and Taipei City Hospital.

    Second, the results were classified according to the average publication year by organization (Figure 2B). The yellow color in Figure 2B indicates that the organizations had published papers in recent years, and the blue color indicates otherwise. The University of Munich in Germany had the oldest average publication year (2007.0). The Icahn School of Medicine at Mount Sinai and Oregon Health & Science University in the US had the most recent average publication year (2019.0).

    Third, the publications from every organization were classified according to their average number of citations (Figure 2C). The yellow color in Figure 2C indicates more citations, and the blue color indicates otherwise. The network map of the average number of citations revealed that Keele University in England had the highest average number of citations (238.0), while Daejeon University had the lowest average number of citations (1.7).

    Distribution by Author

    In terms of authors, Hugh MacPherson of the University of York, UK, (5.5{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) had published the most papers, followed by Claudia Witt of the University Hospital Zurich (4.0{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), In-Hyuk Ha of Jaseng Hospital of Korean Medicine (3.4{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), Andrew Vickers of Memorial Sloan Kettering Cancer Center (3.1{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}), and Pierre Cote of Ontario Tech University (2.8{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}) (Table 5).

    Table 5 Distribution of the Publications by Author

    The authors were analyzed using the VOSviewer program. First, 60 of the 81 authors who had published more than three papers were classified into six clusters (Figure 3A). Cluster 1 consisted of 13 authors, including Kristi Randhawa, Yu Hainan, and Carlo Ammendolia. Cluster 2 consisted of 13 authors, including Hugh MacPherson, Kathleen Ballard, and Julia Woodman. Cluster 3 consisted of 12 authors, including Claudia Witt, Andrew Vickers, and Dominik Irnich. Cluster 4 consisted of 11 authors, including Pierre Cote, Margareta Nordin, and Linda Carroll. Cluster 5 consisted of seven authors, including In-Hyuk Ha, Me-riong Kim, and Yoon Jae Lee. Cluster 6 consisted of four authors, including Cesar Amorim, Daniela Aparecida Biasotto-Gonzalez, and Nivea Cristina De Melo.

    Figure 3 Continue.

    Figure 3 Continue.

    Figure 3 (A) Network map of the six clusters of authors. (B) Network map of the authors according to the average publication year. (C) Network map of the authors according to the average number of citations.

    Second, the author results were analyzed according to the average publication year (Figure 3B). The yellow color indicates the authors who had published in recent years, and the blue color indicates otherwise. According to the analysis, Benno Brinkhaus of Germany, Jaime Guzman of the US, Sheilah Hogg-Johnson of Canada, and Lena Holm of Sweden had the oldest average publication year (2008.0), while Yoon Jae Lee had published the most recent papers (2018.5).

    Third, the author results were classified according to the average number of citations (Figure 3C). The yellow color indicates more citations, and the blue color indicates otherwise. The analysis showed that Nadine Foster of England had the highest average number of citations (238.0), while In-Hyuk Ha had the lowest average number of citations (3.1).

    Analysis of Keywords

    The keywords used in the 325 papers were analyzed using VOSviewer. Among the 7483 keywords extracted from the article titles and abstracts, 41 keywords that were mentioned more than 25 times were analyzed; the keywords were classified into three clusters (Figure 4A). The top keywords in Cluster 1 were “group” (149 times), “week” (87 times), “score” (75 times), and “session” (75 times). The top keywords in Cluster 2 were “therapy” (123 times), “evidence” (109 times), “data” (85 times), and “condition” (70 times). The top keyword in Cluster 3 was “case” (37 times).

    Figure 4 Continue.

    Figure 4 Continue.

    Figure 4 (A) Analysis of the three clusters of keywords. (B) Analysis of the keywords according to the average publication year. (C) Analysis of the keywords according to the average number of citations.

    The keyword results were then classified according to the average publication year (Figure 4B). The yellow color indicates the keywords that were used in recent publications, and the blue color indicates otherwise.

    Afterward, the keyword results were classified according to the average number of citations of the papers that contained them (Figure 4C). The yellow color indicates more citations, and the blue color indicates otherwise.

    The analysis of the average publication year by cluster showed that Cluster 2 (2013.9) published earlier than did Clusters 1 and 3. In addition, the average number of citations in Cluster 2 was 30.8, which was higher than that in Clusters 1 and 3 (Table 6).

    Table 6 Clusters of the Keywords by the Average Publication Year and Number of Citations

    Discussion

    The main finding of this study with a total of 325 selected papers is that we were able to identify the research trends on acupuncture for neck pain treatment using visual methods, including tables and figures. The number of research studies on this treatment method has gradually increased over the last two decades, indicating that acupuncture is becoming more popular among researchers, clinicians, and patients.

    The area of the top publishing journal was integrated and complementary medicine. This indicates that papers on acupuncture for neck pain treatment are more favored in CAM journals that are focused on the intervention of traditional Chinese medicine than in other department-specific medical journals. Researchers need to broaden their choice of journal to journals of other areas to better disseminate information on the excellence of acupuncture among medical professionals who only have a keen interest in Western medicine.

    In terms of publishing countries, the US, China, England, the Republic of Korea, and Germany were the top five countries researching on this topic. If the database was not limited to the English-based Web of Science database, Asian countries would have more published records because acupuncture is widely accepted in East Asian countries.

    In terms of authors, Hugh MacPherson, Claudia Witt, and In-Hyuk Ha were the top three authors with the highest number of published papers. Cluster 1 mainly included Canadian authors from Ontario Tech University, while Cluster 2 had the most English authors from the University of York, UK. European authors were primarily included in Cluster 3, with authors from Charite Medical University of Berlin forming the largest group of researchers. The highest average number of citations in Cluster 3 was 113.2. Nadine Foster of England, who had the highest average number of citations, was also included in Cluster 3. The average publication year was 2011.4, which was the second oldest. The authors in Cluster 4 were from different organizations, but with most of them hailing from the US and Canada. The average publication year was 2010.6, which was the oldest. Cluster 5 included researchers from the Republic of Korea, specifically Jaseng Hospital of Korean Medicine, Kyung Hee University, and Pusan National University. The average publication year was 2017.7, which was the most recent among the clusters. Among the authors in Cluster 5, Yoon Jae Lee had an average publication year of 2018.5, which indicates that he had published several articles in recent years. In Cluster 6, there were numerous authors from Universidade Nove de Julho, all of whom were from Brazil. Our analysis revealed that the average number of citations of the papers published by European authors was generally high.

    Organizations in the Republic of Korea had recently published a large number of research studies on acupuncture, ranking fourth in terms of the number of publications by country. It appears that organizations the Republic of Korea have made significant progress in a short period compared to older and more established organizations in Europe. However, the average number of citations of the publishing authors in the Republic of Korea (6.0) was the second lowest. The gap between the two types of ranking lists indicates that many studies are published but less cited in other studies; this finding needs to be pointed out to the researchers in the country.

    The top ranking authors were also analyzed according to the contents of the studies. First, we determined that some authors, including Hugh MacPherson of Cluster 2 and Claudia Witt, Andrew Vickers, Dominik Irnich, George Lewith, Karen Sherman, Stefan Willich, and Nadine Foster of Cluster 3, were members of Acupuncture Trialists. They studied chronic pain treated with acupuncture.30,31 This group disclosed that among several patient characteristics, the pain severity at baseline was related to the effect of acupuncture on chronic pain.32 However, the application of this criterion in clinical situations is limited because of lack of clinical applicability. Second, Pierre Cote, Margareta Nordin, Linda Carroll, and Gabrielle van der Velde of Cluster 4 are often involved in the same studies. They were included in the task force on neck pain and usually conducted studies according to clinical practice guidelines.33 Among the authors from the Republic of Korea in Cluster 5, In-Hyuk Ha, Me-riong Kim, Yoon Jae Lee, and Jinho Lee from Jaseng Hospital of Korean Medicine co-authored several articles. This group usually conducted studies on the effect of acupuncture and electroacupuncture on neck pain.19,34

    In terms of keywords, those in Cluster 1 were commonly used terms in clinical trials, including “group,” “week,” “score,” “session,” and “acupuncture treatment.” The keywords in Cluster 2 were terms related to research methodology, including “therapy,” “evidence,” “data,” “condition,” “systematic review,” and “meta-analysis”. The keywords in Cluster 3 were insufficient for analysis, as only one keyword (“case”) was retrieved. Cluster 2 had an earlier average publication year and a higher average number of citations than the other clusters. There appeared to be diverse opportunities for these papers to be cited, as they had the earliest average publication year.

    This study has some limitations. Only papers written in English in the Web of Science database were retrieved in this study. Limiting the database to only one source can yield lopsided results but also has an advantage of providing information on clear and lucid research trends in a highly trusted database. Second, this study included various studies of different quality with the same emphasis on each article. Without relation to the type and the quality of studies, bibliometric analysis only explores on the distribution and the number of conducted studies. However, this is a characteristic of the analysis and it targets the quantitative research trend.

    Our results suggest several important directions for further research on acupuncture for neck pain treatment. First, we suggest the construction of a more detailed and precise search string that includes relevant keywords not only on neck pain but also on other diseases. The keywords used in this research were “acupuncture” and “neck pain” but these might not be enough to encompass all the diseases that can cause neck pain. Second, considering that this research was conducted on the basis of papers written only in English, further analyses of papers written in other languages would illustrate more accurate research trends on acupuncture for neck pain treatment. Third, as this study broadly reviewed different types of papers, focusing on clinical trials would better capture clinical research trends. Finally, the results of this study could contribute to future research on thoracic spine, pelvic girdle, and joint diseases.

    Conclusion

    This study analyzed 325 papers on acupuncture for neck pain treatment to analyze research trends over the last two decades using a bibliometric approach. First, our analysis showed that the number of publications increased from 2000 to 2020. Specifically, the number of studies had steadily increased since 2015, demonstrating that research had been actively conducted. Second, in terms of research area and journals, a number of papers had been published in the fields of CAM and pain. Third, in terms of countries, the largest number of papers had been published in the US and in Northeast Asian countries, such as China, Republic of Korea, Taiwan, and Japan. Fourth, in terms of organizations, the University of York, UK, had published the most papers, followed by Kyung Hee University and Jaseng Hospital of Korean Medicine. Fifth, in terms of authors, the publishing authors from Europe had the highest average number of citations, while more authors from the Republic of Korea had recently published more studies. In addition, the top three groups that published co-authored papers were also identified. Sixth, our analysis revealed two major topics: (a) topics used in clinical trials on acupuncture and (b) topics related to research methodology.

    Data Sharing Statement

    Data may be provided through the corresponding author’s email.

    Ethics Approval and Informed Consent

    This study did not include any patient information. Thus, the requirement for ethics approval was waived.

    Acknowledgments

    This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF-2017R1A2B4011707).

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF-2017R1A2B4011707).

    Disclosure

    JP and HK are the co-first authors. The authors report no conflicts of interest related to this work.

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