Jointly published by Akadmiai Kiad, Budapest and Springer, Dordrecht

539551 Scientometrics, Vol. 80, No. 2 (2009) 541553 DOI: 10.1007/s11192-008-2078-8

Publication activity in complementary and alternative medicine

JENNY-ANN BRODIN DANELL, RICKARD DANELL
Department of Sociology, Ume University SE-901 87 Ume, Sweden In this article we analyse how research on complementary and alternative medicine (CAM) break through into one established scientific arena, namely academic journals. With help from bibliometric methods we analyse publication of CAM articles, in the Medline database, during the period 19662007. We also analyse the general content of the articles and in what journals they get published. We conclude that the publication activity of CAM articles increases rapidly, especially in the late 1990s, and that the changing growth rate is not due to the general expansion of Medline. The character of CAM articles has changed towards more clinical oriented research, especially in subfields such as acupuncture and musculoskeletal manipulations. CAM articles are found both in core clinical journals and in specialized CAM journals. Even though a substantial part of the articles are published in CAM journals, we conclude that the increasing publication activity is not restricted to the expansion of these specialized journals.

Introduction Recent research indicates that complementary and alternative medicines (CAM) are increasingly popular and frequently used by the general population. EISENBERG & AL. [1993, 1998] has shown that the use of 16 CAM therapies, such as homeopathy, massage and energy healing, has increased among the general U.S. population from 34 percent in 1993 to 42 percent seven years later, (see also [HARRIS & REES, 2000]). A similar change has also been observed in Australia (cf. [XUE & AL., 2007; MACLENNAN & AL., 1996]). However, the use of CAM varies significantly among western societies [FISHER & WARD, 1994] and within populations. Women, who are relatively well educated, with poorer health status, and with a holistic orientation to health, seem to be overrepresented. Many users are skeptical towards conventional biomedicine (see [ASTIN, 1998; MACLENNAN & AL., 1996; MILLAR, 1997]), even though CAM often seems to serve as a complement rather than an alternative to conventional medicine [DRUSS & ROSENHECK, 1999]. Some of the reasons of using CAM are the perceived effectiveness, a positive inclination towards it, and its relaxing effects [ERNST & WHITE, 2000].

Received May 21, 2008; Published online April 16, 2009 Address for correspondence: JENNY-ANN BRODIN DANELL E-mail: jenny-ann.brodin@soc.umu.se 01389130/US $ 20.00 Copyright 2009 Akadmiai Kiad, Budapest All rights reserved

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The role and status of CAM has changed dramatically over time (e.g. [SALMON, 1984]). During the late nineteenth century, many CAM practitioners, such as homeopaths and herbalists, practiced alongside with medical professionals. Later on, due to the expansion of biomedical research, development of new technologies and diagnostic tools, and medical professionalization, many CAM occupations became marginalized and legally restricted [KELNER & AL., 2004]. During the late-twentieth century, many CAM therapies gained increased societal recognition and acceptance moving from marginal or fringe positions to becoming more integrated into biomedical practices and public health sectors (see [EKLF, 2004; JTTE & AL., 2001]). This is the case of therapies such as psychotherapy, acupuncture, and osteopathy, which in many western societies are treatments available within public health sectors. These therapies can either be performed by medical professionals, such as midwifes and doctors, or by CAM professionals in collaboration with the public health authorities. In some cases, as with psychotherapy, the integration has advanced to a point where the therapies are no longer regarded as complementary or alternative they are fully integrated. However, acceptance and integration are far from simple processes. They can be identified at many levels and from different perspectives. In most countries there are both symbolic and institutional divisions between conventional/regular/scientific/ biomedicine on the one hand and unconventional/fringe/alternative/holistic medicine on the other [WORSLEY, 1982; JTTE, 2001]. One crucial aspect is that most CAM therapies, at least to some extent, rely on spiritual, religious, or magic assumptions, which can be perceived as being in conflict with scientific norms. Many CAM practitioners avoid integration, since it often requires compromises, or even giving up central ideas and/or parts of the practice. As David Hess points out, when CAM do make their way into biomedical research projects, they usually shorn off their nonwestern theoretical frameworks and reinterpreted in terms of current biomedical and psychological knowledge (HESS, 1995: 201). As a consequence, many practitioners protect ideas of alternative rationality, concerning such aspects as tools of diagnoses and modes of treatment (cf. [HESS, 1993]). From that perspective, being alternative is an advantage especially in those cases when conventional medicine is regarded as insufficient to cure illnesses or reduce various sorts of pain. The alternative modes of treatment, or diagnosis, are not restricted to what is accepted knowledge, according to established medical or scientific communities.1 Among CAM practitioners we also find varying attitudes towards the division between science and non-science. While some, such as many parapsychologists and chiropractors, view their own tradition as scientific, albeit not generally accepted by the broader scientific community (e.g. [HESS, 1993; MARTIN, 1994]), others emphasize spiritual or religious roots and engage in
1

It is crucial to recognize that CAM practitioners exercise their occupation under varying circumstances. The degree of regulation varies among countries. As FISHER & WARD [1994] point out, in most western countries only registered health professionals may practice, while in others practice is almost unregulated.

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debates with established medical and scientific communities only to a limited extent [BRODIN, 2001]. The line of division, between science and non-science, is, of course, not only of interest to those who strive for recognition and acceptance but also to the medical and scientific establishment. As GIERYN [1999] points out, to keep the privileges of being a trusted authority it is crucial to set up clear boundaries to other producers of knowledge. Therefore, it is hardly surprising to find hard resistance among medical professionals and various scientists towards clinical studies on effects of CAM practices or collaboration with CAM practitioners. There are many arenas where it is possible to observe so-called boundary work (e.g. [GIERYN, 1999; STAR & GRIESEMER, 1989]) both between CAM and the medical establishment and within each camp. There are several actors engaged (such as CAM and medical professionals, organizations, public authorities, and even states) in varying negotiations, on different boundaries (for example, what is considered as reliable or scientific knowledge, rights to exercise practice, economical subsidies), and/or boundary objects. In this article we will analyze one type of boundary work, how CAM research breaks through into one established scientific arena, namely academic journals. With help from bibliometric methods, we will analyse publication of CAM articles, in the Medline database, during the period 19662007. We will also analyze the general content of CAM research and if/how it has changed over time. Finally, we will analyze in what journals the articles get published.

Data This study is restricted to published items classified as Journal Articles, during the period 19662007, in the Medline database. We have selected the CAM articles as defined by the Medical Subject Headings (MESH) category Complementary 2 Therapies.

This category includes Acupuncture, Anthrosophy, Holistic Health, Homeopathy, Medicine Traditional (African traditional, Arabic, Ayurvedic, Kampo, Oriental traditional, Shamanism), Mind Body Relaxation (Aromatherapy, Biofeedback, Breathing Experience, Hypnosis, Imagery, Laughter Therapy, Meditation, Mental Healing, Mind Body Relations, Psychophysiology, Relaxation, Relaxation Techniques, Tai Ji, Therapeutic Touch, Yoga, Muscloskeletal Manipulations (Applied Kinesiology, Chiropractic, Osteopatic, Spinal, Massage, Myofunctional Therapy, Relaxation Techniques), Naturopathy, Organotherapy (Tissue therapy), Phytotherapy (Aromatherapy, Historical Eclecticism), Reflexotherapy, Rejuvantation, Sensory Art therapies (Acoustic Stimulation, Aromatherapy, Art Therapy, Color Therapy, Dance Therapy, Music Therapy, Play Therapy, Psychodrama), Spiritual Therapies (Faith Healing, Homeopathy, Magic, African Traditional, Meditation, Mental Healing, Occultism, Radiesthesia, Shamanism, Therapeutic Touch, Witchcraft, Yoga).

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CAM a problematic concept In this article we will use the concept Complementary and Alternative Medicine (CAM) to describe the ideas and practices in focus. However, this is not the only or indisputable concept. Among practitioners, academic scholars, and laypersons, we find concepts such as holistic-, nature-, soft-, unconventional- and integrated medicine (e.g. [CANT & SHARMA, 1999; EASTHOPE, 2003; GORSKI, 1996, JTTE, 2001]). It is also possible to distinguish between complementary and alternative medicine. In that case, complementary medicine is often assumed to be more integrated into mainstream medical practices and more accepted in society at large than their alternative counterparts [EKLF, 2004; HESS, 2002]. In addition there are also concepts such as traditional-, ethno- and folk medicine, which usually refer to medical systems relying on distinct cultural foundations (such as Chinese and African medicine). The last category of concepts has the common characteristic of being defined as non-western medicines, which can be regarded as an ethnocentric category (cf. [HESS, 1995; WORSLEY, 1982]). It is also important to recognise the continual changing boundaries of CAM. What is considered as alternative and/or complementary varies over time. Some medical systems are also understood in different ways depending on cultural context. For example, since 1962, Ayurveda is officially recognised in India but regarded as alternative in a western context [WORSLEY, 1982]. Other traditions, such as parapsychology, are understood as more secular in a western context than in other parts of the world [HESS, 1987]. With help from the Medline account of Complementary therapies, we will use CAM as a general concept to describe Therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. They may lack biomedical explanations but as they become better researched some (physical therapy, diet, acupuncture) become widely accepted whereas others (humors, radium therapy) quietly fade away, yet are important historical footnotes. Therapies are termed as Complementary when used in addition to conventional treatments and as Alternative when used instead of conventional treatment.3 Publication activity One common utterance about CAM research, not least among medical professionals, is that there is no such thing as CAM research, at least if we refer to reliable research, conducted in accordance with established scientific procedures, and published in wellreputed academic journals. Therefore, let us begin with a simple overview of the publication activity. Figure 1 shows the number of CAM articles in Medline during the
3

http://mesh.kib.ki.se/swemesh/show.swemeshtree.cfm?Mesh_No=E02.190&tool=karolinska

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period 19662007. The articles are restricted to Major Topic headings, in order to exclude articles that only to a small extent concern CAM.

Figure 1. Articles indexed as complementary therapies in Medline during the period 19662007

The CAM articles grow at a steady rate during the period 19661986, with an average growth rate of 52 articles per year. After that follows a couple of years with decreasing publication activity before a rather dramatic increase takes place. During the period 19962005 the growth rate increases to an average of 313 articles per year. At the end of the period, in 20042005, the publication activity falls again. The numbers of the last year, 2007, should be interpreted with caution, since the database probably was not fully updated at the beginning of 2008. How is it possible to explain this change in publication activity? One answer could be that the numbers are not reflecting a real change, but an increase in the number of journals indexed in Medline. Another answer could be that the increase in publication activity reflects a general increase in research and/or publication activity. To test these questions we have analysed the share of CAM articles in Medline over the time period. The right y-axis in Figure 1 shows the percentage of CAM articles in Medline as a whole. Here can we see that the share of articles grows at steady rate during the period 19661986, to be followed by a short period of decrease. In similarity with the increase

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of actual numbers of CAM articles in Medline, there is a substantial increase of CAM articles in Medline as a whole, from 0.3 percent in 1996 to 0.8 percent in 2005. From that we conclude that the changing growth rate of CAM articles is not due to the general expansion of Medline. At the end of the period there is a similar decrease as identified above. Content of CAM articles In order to grasp the development of content in CAM research we have analyzed the prevalence of clinical oriented research. Clinical trials are, not at least by researchers and clinicians, considered as the most credible way to test different kinds of medical treatments. For example, the U.S. National Institute of Health declares that Carefully conducted clinical trials are the fastest and safest way to find treatments that work in people and ways to improve health.4 From a CAM perspective, accomplishment of clinical trials is crucial (even though not the only way) to gain legitimacy from a broader scientific community. However, in the boundary work over scientific claims, clinical trials are also crucial to the opponents of CAM, as a legitimate way of falsifying CAM theories and practices. In MESH, clinical trials are defined as Pre-planned studies of safety, efficacy, or optimum dosage schedule (of appropriate of one or more diagnostic, therapeutic or prophylactic drug, devices, or techniques selected according to predetermined criteria of eligibility and observed for predefined evidence of favourable and unfavourable effects).5 Furthermore, clinical trials can be divided into treatment, prevention, diagnostic, screening, and quality of life trials. They are also conducted in different phases (IIV). Clinical trials can take place in various locations, such as universities, community clinics, and hospitals, and can be funded by both private and federal agencies. In Figure 2 we can see that the character of CAM articles has changed towards more clinical oriented research. A similar development can be identified in Medline as a whole. The clinical trials expand from about 23 percent, on a three-year moving average, of the published articles in the early 1990s up to double a decade later. Among the CAM articles the share of clinical trials was relatively constant during the 1970s and 1980s, about 34 percent on a three-year moving average. In the early 1990s a dramatic change took place, about 67 percent of the CAM articles included clinical trials. At the end of the period, in 20062007, this is true of 18 percent. The expansion of clinical trials in CAM articles takes place both in general medical journals and in journals classified as Complementary Therapies. An interesting result is that the increase of clinical trials precedes the general increase in publication activity, presented in Figure 1.
4 5

http://clinicaltrials.gov/ct/info/whatis#whatis http://mesh.kib.ki.se/swemesh/show.swemeshtree.cfm?Mesh_No=E05.318.760.535&tool=karolinska

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Figure 2. Percent of articles classified as clinical trials (three year moving average)

The fact that the share of clinical trails in CAM journals increased rapidly in the early 1990s might indicate that new types of journals were being established. It can also reflect a general strive for scientific proof/validity (or from an antagonistic perspective; falsification) and acceptance from the scientific and medical establishment, in order to obtain integration of CAM therapies into public health sectors [cf. HESS, 1993]. Another question that arises from the figure above, is if there is a general increase in clinical trials among CAM therapies or just among a few (for example, among those therapies that are already relatively well integrated such as acupuncture, and osteopathy)? With help from the hierarchical categories in MESH, we have separated four dominating subfields (Mind Body Therapies, Spiritual Therapies, Musculoskeletal Manipulations, and Acupuncture) in the overall CAM category. In Figure 3, we can see that there is a substantial increase of clinical trials in all four subfields. However, the increase is, as expected, most dramatic among Musculoskeletal Manipulations and Acupuncture, therapies that in many western societies are fairly well integrated into public health sectors. In Acupuncture and Musculoskeletal Manipulations the share of articles classified as clinical trials are well above the average of all CAM articles.

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Figure 3. Percent of articles classified as clinical trials in four CAM subfields (three year moving average)

Development of CAM journals As indicated in Figure 2, there is a journal category in Medline labeled as Complementary Therapies. This category dates back to the early 1970s. This can imply that this was the point of time when CAM in general, or CAM research and journals in particular, became well enough established and/or accepted to be included in Medline. This can also imply that some journals were re-indexed, and/or that the journals in this category were fairly new (and therefore not included in Medline before). To find out, we have compared the start of publication of the CAM journals, when they are fully indexed in Medline, and if they were indexed in another Medline category before. In Table 1, we can see that most of the journals in the CAM category are fairly new. Nine of them began publication during the 2000s. Full indexation of the journals is also fairly recent. In 27 of the 34 journals, full indexation began in 1990 or later. Only three of the journals, all on Chinese Medicine, are indexed from the 1970s. A difference between the older and newer journals is that the newer ones are often indexed in Medline from their first issue. Journals that started their publication during the 1960s to 1980s are often delayed, from a few years up to several decades.

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Table 1. Journals indexed as Complementary Therapies in Medline, 19732007

Name of Journal Acupuncture & Electro-Therapeutics Research Acupuncture in Medicine: Journal of the British Medical Acupuncture Society Advances in Mind-body Medicine Alternative Medicine Review: a Journal of Clinical therapeutic Alternative Therapies in Health and Medicine American Journal of Acupuncture The American Journal of Chinese Medicine BMC Complementary and Alternative Medicine Chinese Journal of Integrative Medicine Chinese Medical Journal Chinese Medical Sciences Journal Complementary Therapies in Clinical Practice Complementary Therapies in Medicine Complementary Therapies in Nursing & Midwifery Explore Fitoterapia Forschende Komplementrmedizin Forschende Komplementrmedizin und Klassische Naturheilkunde Homeopathy: the Journal of the Faculty of Homeopathy The Journal of Alternative and Complementary Medicine: Research on Paradigm, Practice, and Policy Journal of Herbal Pharmacotherapy Journal of Music Therapy Journal of Traditional Chinese medicine Phytomedicine : International Journal of Phytotherapy and Phytopharmacology Phytotherapy Research: PTR Zhen ci yan jiu (Acupuncture Research) Zhong xi yi jie he xue bao (Journal of Chinese Integrative Medicine) Zhong xi yi jie he za zhi (Chinese Journal of Modern Developments in Traditional Medicine) Zhong yao cai (Journal of Chinese Medicinal Materials) Zhong yao tong bao (Bulletin of Chinese Materia Medica) Zhongguo zhen jiu (Chinese Acupuncture & Moxibustion) Zhongguo Zhong xi yi jie he za zhi Zhongguo Zhongxiyi jiehe zazhi (Chinese Journal of Integrated Traditional and Western Medicine) Zhongguo Zhong yao za zhi (China Journal of Chinese Materia Medica) Zhonghua yi xue za zhi (Chinese Medical Journal/ National Medical Journal of China)
6 7 8

Start of publication 1981 1983 1998 1996 1995 1973 19726 2001 20037 1975 19918 20049 199310 1995 2005 194712 200613 200014 2002 1995 2001 1964 1981 1994 1987 198017 2003 1981 1978 1981 1981 1992 198918 1960
16

Fully indexed in Medline 1981 2001 1999 1998 1996 1999 1979 2001 2005 1978 1991 2005 1999 2004 2005 2000 2006 2000 2002 1995 2004 2000 1981 1999 1999 1985 2003 1991 1997 1988 2005 1992 1989 1973

End of publication

2005

1999

200411

200515

Continues from Comparative Medicine East and West. Continues from Zhongguo Zhong xi yi jie he za zhi (Chinese Journal of Integrated Traditional and Western Medicine). Continues from Proceedings of the Chinese Academy of Medical Sciences and the Peking Union Medical College. 9 Continues from Complementary Therapies in Nursing & Midwifery. 10 Continues from Complementary Medical Research. 11 Continued by Complementary Therapies in Clinical Practice. 12 Continues from Estratti fluidi titolati. 13 Continues from Forschende Komplementrmedizin und Klassische Naturheilkunde. 14 Continues from Forschende Komplementrmedizin. 15 Continued by Forschende Komplementrmedizin (2006). 16 Continues from British Homoeopathic Journal. 17 Continues from Zhen ci ma zui. 18 Continues from Zhong yao tong bao.

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This could indicate that CAM is now a more established scientific subfield. Another finding is that none of the journals in the CAM category have been reindexed by Medline.19 A relevant question is in what journals the CAM articles appear. Is the observed change in growth rate (see Figure 1) due to the increase of journals indexed as Complementary Therapies? Another question is if any of the CAM articles are published in well-reputed medical journals. In Figure 4 we subtract CAM articles published in journals indexed as Complementary Therapies and Core Clinical Journals.20 In this figure we can see that the expansion of CAM articles is not only due to the increase of journals indexed as Complementary Therapies, even though a substantial part of the articles are published in this category. The first peak, in 19851986, can probably be explained by the increase of journals classified as Complementary therapies (even though only one new journal, Zhen ci yan jiu, appear in the category). For the rest of the period, from 1986, there is a substantial expansion both within and outside the journal category. At its peak in 2005 about 28,5 percent (1,261) of the CAM articles were published in journals indexed as CAM. The expansion of articles in journals classified as Complementary Therapies is also in line with the results of Table 1. From Figure 4 we can conclude that the number of CAM articles published in journals indexed as Core Clinical Journals is relatively stable up to the middle of the 1990s. During the period 19661995 the average is 68 articles per year. After 1996 the average increases to 132 articles per year.21 At its peak in 2005 5,9 percent (258) of the CAM articles were published in Core Clinical Journals. The relatively few number of journals indexed as Complementary Therapies (see Table 1) can probably be explained by the fact that there are few multiple classifications of journals in the database. In this specific category, there are none. If we look at other journal categories, such as Nursing, with a great share of the CAM articles, we find many journals that also could be classified as CAM journals (such as Complementary Therapies in Nursing and Midwifery, Holistic Nursing Practice, Journal of Holistic Nursing, Holistic Nursing, British Homeopathic Journal). Measures of expansion within and outside journal categories, such as Complementary Therapies, therefore seem relatively rough. For that reason we can expect an underestimation of the number of CAM journals and the volume of articles published in these.

19 Several of the journals are continuations of older journals, that were not indexed in Medline. Therefore, the year of first publication may be underestimated. 20 As defined by The Abridged Index Medicus (AIM), which is included in Medline as a subset. 21 The actual numbers of articles should not be confused with the average growth rate, mentioned above.

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Figure 4. Subtracted articles by journal categories

Establishment of specific CAM journals can be interpreted in many ways. First of all, they can be a sign of greater public interest in CAM and/or different CAM subfields. The specialized journals can also be an indication of greater research activity and a scientific need for specialization. However, these journals could also be interpreted as strategies to create separate scientific fields, governed at least in part by, other scientific standards than biomedicine. This, in turn, can also be the result of exclusion from conventional medical forums. These strategies have been observed in the case of parapsychological research, when J. B. Rhine founded a separate journal off campus. As David Hess points out, would the parapsychological interpretation be that Rhine, to a large extent, was forced into a separatist position by the scepticisms by his colleagues [HESS, 1993; MAUSKOPF & MCVAUGH, 1980]. Conclusions Based on our observations we conclude that the publication activity in CAM increases rapidly, especially from 1996, and that the changing growth rate is not due to the general expansion of Medline. The number of CAM articles in Medline grows at steady rate from 19661986, with an average growth rate of 52 articles per year. After a short period of decline, a rather dramatic increase takes place. During the period

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19962005 the growth rate increases to an average of 313 articles per year. At the end of the period, in 20042005, the publication activity is falling. The steady increase from 1996 is in great part due establishment of specialised CAM journals. However, the field displays a rapid growth both within and outside this journal category. The content of CAM articles has changed towards more clinical oriented research, during the studied period of time. The increase takes place both within and outside CAM journals, and in all major CAM subfields. However, the expansion of clinical trials is most dramatic among Musculoskeletal manipulations and Acupuncture, therapies that in many western societies are fairly well integrated in public health sectors. We also conclude that the shift towards clinical trials precedes the general increase in CAM publication activity. However, it is beyond the scope of this article to interpret the causal connection between those two trends. It is important to notice that the trends of publication activity, or the change towards clinical oriented research, tell nothing about the actual results of CAM research. This certainly needs further research. It is also difficult to predict the future of CAM publication activity. The observed decline can have very different explanations. It can be due to changing research funding, but it can also be related to the results of clinical research. If a specific tradition or technique has been proven false or ineffective in several clinical studies, it is reasonable that the research interest is decreasing. Both the question of changes concerning research funding, and the question concerning the reception of CAM research among medical researchers and practitioners needs further investigation. Also the geographical dimension of CAM research is of interest. The geographical distribution of CAM research would be particularly interesting to investigate in connection to the variations among nations concerning research founding and organization of health sectors. References
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