Bibliometrics and visual analysis for clinical research on intervention of tradi

Ling TANG, Jianni QU, Hong GUO,Mei WANG, Nini XU, Xiaoyan BAI, Xueyan FAN,Zhixuan XU, Yihui TIAN, Fen ZHOU

1Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 2School of Nursing, Beijing University of Chinese Medicine, Beijing, China; 3School of Nursing and Rehabilitation, Shandong University, Shandong, China

ABSTRACT

Objective:The objective of this study is to explore the current situation, clinical research hot spots, and trends of traditional Chinese medicine (TCM) nursing technology in rheumatoid arthritis (RA), to draw a panorama of clinical research, to provide the basis and clues for subsequent high-level evidence integration and further in-depth research.

Materials and Methods:Seven databases including China National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP),Wanfang Database, Chinese Biomedical Literature Database (Sino-Med), PubMed, Embase, and the Cochrane Library were searched.The bibliometric method and visualization software CiteSpace were used to conduct a multi-dimensional analysis of the included literature.

Results:A total of 805 pieces of literature were included (of them, one was written in German and four in English), and the number of published literature showed an increasing trend year by year.There were only 30 (3.73%) pieces of literature published in nursing journals.The hot spots of the co-occurrence map were concentrated in:(1) the nursing of fumigation in RA; (2) the efficacy evaluation of TCM nursing technology on pain, joint malformation, and joint dysfunction caused by RA.The included literature themes focused on five TCM technologies:fumigation,moxibustion, acupoint patching, acupoint injection, and Chinese herbal soaking.The beginning year and strength in TCM fumigation were 2012 and 5.2, and those in moxibustion were 2011 and 3.38.

Conclusion:The related studies are on the rise.It has entered the field of international readers with clear research hot spots.However, there are still shortcomings such as little literature published in Chinese nursing core journals, few non-Chinese-related documents, and a lack of international exchanges and cooperation.The current research hot spots in this field are TCM fumigation, and the cutting-edge trend of future research may be fumigation and moxibustion technology.It is suggested that further research can focus on evidence integration and original research on the self-optimization of these two techniques.

Keywords:Literature metrology, rheumatoid arthritis,traditional Chinese medicine nursing technology, visual analysis, Wangbi

INTRODUCTION

Rheumatoid arthritis (RA) is a common inflammatory disease characterized by progressive bone and cartilage destruction that results in severe functional limitations and increases mortality rates.[1]It affects 0.5%-1% of the global population,[2]with women being affected 2-3 times more than men.[3]RA belongs to the category of “Bi syndrome” in traditional chinese medicine (TCM) theory, which is named“Wangbi” in TCM.[4]The clinical manifestations are mainly muscle pain, numbness, limited flexion and extension, joint swelling, etc.[5]

Currently, nonsteroidal anti-inflammatory drugs and glucocorticoids are mainly used to control symptoms in Western medicine, but patients are prone to obvious adverse reactions after long term.[6]With the promotion of TCM in China,[7]more and more TCM nursing technology has been applied in the clinic, which can significantly relieve pain,swelling, and other symptoms of patients.

After a preliminary search of China National Knowledge Infrastructure (CNKI), it was shown that there was more than 1000 literature on the intervention of TCM nursing technology in RA.However, there is no research on the current situation,hot spots and trends in this field which will provide valuable clues and a basis for further research.With the advent of the era of data, mapping knowledge has emerged.The diversified and dynamic analysis of CiteSpace can detect the development of TCM nursing technology in RA and its research hot spots and trend.[8]Therefore, this study adopted bibliometrics and CiteSpace (version:5.8.R3) to analyze the clinical research on the intervention of TCM nursing technology in RA, to understand the current situation, hot spots and trends, and to provide references and new research direction for future studies.

MATERIALS AND METHODS

Identification and selection of studies

We searched four Chinese and three English language electronic databases CNKI, Chinese Scientific Journal Database (VIP), Wanfang Database, Chinese Biomedical Literature Database (Sino-Med), PubMed, Embase and the Cochrane Library from inception to March 25, 2021, and May 25, 2021.

TCM Nursing Program for Wangbi (RA)[9]and Dominant Diseases in TCM[10]were issued by the National Administration of TCM.There were 10 common TCM nursing technologies:Moxibustion, acupoint patching,Chinese herbal soaking, Chinese herbal wet and hot compress, TCM iontophoresis, TCM fumigation, Chinese herbal cold compress, Chinese herbal hot ironing, massage,and acupoint injection.

Both Chinese and English used a combination of subject words and free words for retrieval.The titles or themes were “rheumatoid arthritis, rheumatoid, arthritis, lijie, and wangbi,” involving “TCM Nursing” and the above ten related names of TCM nursing technology were searched.

Inclusion and exclusion criteria

The inclusion criteria were as follows:(1) Clinical studies on patients with RA, with the severity and duration of the disease unlimited.(2) Interventions included TCM nursing technologies.(3) Publication languages included Chinese and foreign languages.(4) The type of research design and publication were not limited.

The exclusion criteria were as follows:(1) Pharmacological studies; (2) mechanism-based studies; (3) literature related to Tibetan, Miao, and Mongolian medicine; (4) The full text was not available.For duplicate publications, retain the one with the previous date.

Parameter settings

There were some specific parameter settings used in CiteSpace, as follows:The time-slicing was set to 1983-2021;the number of years per slice was set to 1; the selected term sources used were title, abstract, author, keyword,and keywords plus; for the node type, only one option was selected at a time from author, institution, country, reference,cited journal, and keyword; the default option in CiteSpace was used for the selection criteria; for the pruning parameter,“pathfinder” and “pruning the merged network” were selected.We combined the keywords with the same meaning.

RESULTS

General description of overall studies

A total of 6309 literature were obtained by preliminary retrieval,including 1442 non-Chinese literature.Moreover, 1990 literature was obtained after checking by NoteExpress3.2.Literature that met the inclusion criteria was selected by browsing the title and abstract, and if not, the full text was downloaded and read for screening.A total of 805 pieces of literature were included,containing one in German and four in English.

Statistical analysis was performed on the annual publication status of 805 included literature, as shown in Figure 1.The annual number of publications was increasing year by year.Before 1999, it was only in single digits, and then slowly raised until 2008.The number of publications increased by up to 19 from 2010 to 2011 and reached the current maximum of 70 in 2020.A total of 7 literature in Chinese were published by March 25, 2021, and no related literature in other languages was retrieved by May 25, 2021.

Figure 1:Annual publication trend chart of literature on the intervention of rheumatoid arthritis by traditional Chinese medicine nursing technology

Of 805 included literature, 729 (90.56%) pieces of literature were published in journals (All non-Chinese literature was published in journals); 46 (5.71%) were dissertations, and 30 (3.72%) were conference literature.

Journal distribution

Included literature was published in 269 journals.Among them,there were only 30 pieces of literature in nursing journals,accounting for 3.73%.The nursing literature journals were classified according to the catalog of Chinese Core Journals of Science and Technology[11]published by the Institute of Scientific and Technical Information of China in 2020.The results showed that there were only two core journals among the top seven journals in terms of published articles (They wereJournalofNursingScienceandJournalofNursesTraining).

Publication institutions and regional distribution

According to the statistics of the first author’s affiliation,the 662 (82.24%) literature was published by hospitals,117 (14.53%) by medical colleges, 9 (1.12%) by health centers,and 17 (2.11%) by other institutions.The top five institutions that contributed literature were:21 (2.61%, including 4 were in English) from the Chengdu University of TCM,11 (1.37%) from Wuhan Hospital of TCM, 10 (1.24%) from Hubei University of TCM, 9 (1.12%) from General Hospital of Southern Theatre Command, 7 (0.87%) from Shanghai Pudong New Area Hospital of TCM.

The top five provinces in terms of regional distribution were:72 (8.94%) in Guangdong Province, 59 (7.33%) in Hubei Province, 59 (7.33%) in Henan Province, 53 (6.58%) in Sichuan Province, and 45 (5.59%) in Jiangsu Province.

Distribution of funds

The proportion of funding reflects the current national health administrative departments to the intervention of TCM nursing technology in RA treatment, as well as the level of the scientific research ability of TCM nursing staff.[12]In this study,a total of 57 pieces of literature were funded, accounting for only 7.10%, including 12 funded by national funds, 31 funded by provincial funds, 7 by municipal, 2 by district, 3 by college fund, and 2 by other types.Funded literature was mainly distributed in Guangdong Province (7), Anhui Province (5),Jiangxi Province (5), and Sichuan Province (5).

Keyword analysis with co-occurrence and focused traditional Chinese medicine nursing technology

Keywords co-occurrence mapping is a kind of content analysis method, which can be used to reveal the development and changes of scientific structure, and then used for frontier hot spots analysis.[13]Keywords analysis was not done because of the small amount of English and German literature.The Chinese literature was counted and a total of 14 keywords with a frequency of more than 30 were obtained, as shown in Table 1.The top five keywords were “rheumatoid arthritis”“ fumigation” “moxibustion” “nursing” and “TCM therapy.”

Table 1:Top 14 keywords related to traditional Chinese medicine nursing technology in rheumatoid arthritis

To visualize the relationship between keywords and the main areas of research, the keywords co-occurrence mapping was further developed.In Figure 2 (As the 800 literature included were Chinese, keywords were artificially translated into English in Figures 2 and 3), each node represents a label.The larger the size of the nodes, the more keywords frequency.The connection line between the nodes represents the strength, and the thicker the line, the closer the cooperation between keywords.It can be seen that the hot spots of TCM nursing technology intervention in RA are:(1) the nursing of TCM fumigation in RA; (2) therapeutic effect assessment of TCM nursing technology on RA; (3) effect of TCM nursing technology on pain, joint deformity and joint dysfunction caused by RA; (4) treatments used in the clinic for RA.

Figure 2:Map of co-occurring keywords related to traditional Chinese medicine nursing technology in RA

Research hot spots could be detected from the burst of keywords.The keywords with the sudden and large increase in the research within a certain period are the burst of keywords.It can vividly show the changes of hot spots in the research field over time.[14]In Figure 3, the timeline was depicted as the blue line.The burst period was shown as the red segment on the blue timeline, indicating the duration of the outbreak is the period that the occurrence of a particular keyword increased rapidly.[15]

Figure 3:Top 30 keywords with the strongest citation bursts

The top 5 TCM nursing technology in terms of literature number were TCM fumigation (310 literature), moxibustion (248 literature), acupoint patching (104 literature), acupoint injection (94 literature), and Chinese herbal soaking (52 literature), accounting for 89.69% of the total.

DISCUSSION

The number of publications is increasing year by year, but the overall literature of nursing journals is relatively small.There is a large difference in the number of documents issued by institutions, with uneven geographical distribution and less cooperation.We find that the funds support ratio is low.TCM fumigation, moxibustion, and acupoint patching have been the research hot spots in recent years.

Our data shows that there is a significant upward trend since 2013 and reach the highest number of 70 literature in 2020, which may be related to the fact that with the promotion of TCM in China in recent years, more and more hospitals have begun to attach importance to the role of TCM nursing technology in the treatment of diseases.There is less literature published in nursing journals and even fewer published in nursing core periodicals.It is worth noting that there is no clear boundary between TCM nursing technology and TCM technology, so most clinical trials published in the medical journal may be dominated by clinicians.In addition,the number of non-Chinese publications in related fields was small, and the five included non-Chinese publications were not published by nursing researchers, reflecting that the research level and English expression of nursing staff need to be improved.[16]Furthermore, although the overall education of nurses is gradually increasing, most of the nurses have not undergone systematic and standardized scientific training.[17]The busy clinical workload makes them lack of a strong research climate in the department where they work,and the inadequate hospital or social support system are all possible reasons for these situations.[18]

In China, except for Tibet and Hainan, relevant literature has been published in 29 other provinces in the mainland,indicating a wide distribution of research.There was no literature published from Hong Kong, Macao, and Taiwan regions, which may be related to the fact that the literature from databases in these regions was not searched in this study.The application of TCM nursing technology covers all medical institutions, suggesting that TCM nursing technology has a wide application range.A total of 662 pieces of literature were published with hospitals as affiliations of the first authors,which may be related to the hospitals having sufficient cases as data sources and corresponding encouragement policies.There are 4 western medicine hospitals in the top-ranked institutions, which suggest that western medicine hospital also attaches great importance to the study.Medical colleges published 117 literature.Compared with medical institutions,they have a better research environment to train researchers and in such environment researchers have abundant time for relevant research.[19]The top five areas are distributed in southeast China, whose economy is more developed than that in the west of China, with better hospital conditions and richer resources.[20]In recent years, a large number of outstanding researchers seek employment in economically developed regions for better development.It is suggested that researchers in western China should actively explore and make full use of national poverty alleviation policies to develop the medical and health industry.[21]Meanwhile,strengthening academic exchanges between the eastern and western regions is necessary.Institutions and researchers should adapt to the era of data, break the barriers of scientific research and deepen cooperation, to promote the development of TCM nursing in RA.

One of the objective indicators to evaluate literature quality and academic level is the proportion of the literature fund.[22]Only 57 pieces of literature were supported by funds, which indicates that the country does not pay enough attention to the related research or the research in this field is not deep enough.With the improvement of medical conditions and the advancement of medicine,only we should improve the research level of medical staff and explore better treatment plans can we minimize the suffering of patients.Therefore, the researchers should develop their sense of innovation to think and design based on previous studies,[23]so that they can seek more funds and conduct more valuable research.

Before 1992, the treatment of RA was mainly based on Western medicine, with less implementation of TCM nursing technology and little attention to nursing by researchers.The number of literature and the frequency of keywords show that fumigation is a hot topic in clinical research, and the other technology used more often are moxibustion, acupoint patching, acupoint injection, and Chinese herbal soaking.It suggests that the hot spots of TCM nursing are very clear and concentrated, and also indicates that these technologies may represent new research directions in future.Furthermore,nursing has been a hot topic since 2013, indicating that researchers have begun to appreciate the important role nursing plays in the treatment of RA.As a young field to be explored, TCM nursing of RA is looking forward to exploring deeply by more researchers.

Among the included non-Chinese literature, four literature (in English) focused on moxibustion which was published by Chinese researchers and one literature (in German) on Chinese herbal soaking.The only German-language literature was published by the University of Duisburg Essen, Germany,but the study site was still in China.It suggests that there is still a lack of international exchange and cooperation in this field and a lack of practical application of TCM nursing technology abroad.On the other hand, it is suggested that scholars need to actively carry out international academic activities and cooperate deeply.[24]

CONCLUSION

This study adopted bibliometrics and CiteSpace to analyze the clinical research on the intervention of TCM nursing technology in RA.The results show that the overall trend of studies in China is on the rise, with a wide distribution of published journals and geographical areas and the research hot spots are clear.However, there are still shortcomings,such as less literature published in Chinese core nursing journals, lack of international cooperation and uneven regional development, etc.The current research hot spot is fumigation and the trend of future research may be acupoint injection, fumigation, and moxibustion.

It is recommended that academic exchanges should be strengthened between regions to promote balanced regional development and researchers should intensify their research efforts, learn new scientific research technology to improve capabilities, then provide higher-quality researches to promote the development of TCM nursing technology in this field and provide a higher level of evidence to support clinical practice.

Financial support and sponsorship

This work was supported by the Research Project on Medical Education launched by the Medical Education Branch of the Chinese Medical Association and the Medical Education Professional Committee of the Chinese Society of Higher Education in 2018 (2018B-N18075), the Education Science Research Project of Beijing University of Chinese Medicine (XJYB2029), and the Fundamental Research Funds for the Central Universities (2020-JYB-ZDGG-082).

Conflicts of interest

There are conflicts of interest.