Research status of traditional & complementary medicine systems across the world

Abstract

Background

Despite strong presence of biomedicine, traditional and complementary medicine (T & CM) systems have sustained with their multidimensional connect with people. However, their scientific acceptance and mainstreaming falls short due to inadequacies in research. Also, available reports in this regard scarcely focus on their individuality and present them as a consolidated entity.

Objectives

The present study was carried out to elucidate individual research status of certain WHO- acknowledged T & CM systems in a customized framework of indirect indicators.

Material and methods

The research status of selected systems was assessed on basis of quantitative indicators viz., research dissemination outcomes concerned with scientific documents and researchers, contribution in COVID-19 prevention and management, and patents profile.

Results

Systems such as Traditional Chinese Medicine and Acupuncture fare better than most others. The number of documents in multidisciplinary SCOPUS database was larger than those in PubMed, a healthcare database for almost all systems. Out of 28 lead authors, half belonged to developed countries, viz., USA and Germany. Highest citation count was recorded for TCM (n = 2238). Of the 105 journals analyzed, 40 were not dedicated to specific T & CM system. Most number of discretely dedicated journals (n = 20) mentioned TCM as primary scope. Cochrane systematic reviews (n = 142) and protocols (n = 33) were highest for Acupuncture, while many systems had zero presence. Maximum COVID-19 related clinical studies were registered for TCM (n = 335), followed by Ayurveda (n = 112). TCM related patents were also highest among all.

Conclusion

There is a huge variation in the research status of different T & CM systems. The stakeholders of these systems need to establish a strong evidence base at par with biomedicine. United efforts at global level through organizations such as WHO-Global Traditional Medicine Centre (GTMC) might be helpful in this regard.

1. Introduction

Due to various reasons, ‘health’ remains an elusive target to achieve for developed as well as developing nations. When health-related issues cripple people, their journey toward economic, educational, and industrial excellence is hampered. The recent COVID-19 pandemic underlined this fact specifically. During the pandemic, even the biomedicine system was put to use with inconclusive evidence [1], as were other ‘complementary,’ ‘traditional,’ and ‘alternative’ systems of medicine.

The co-existence of biomedicine and other different systems of medicine is observed in almost all nations. Much before the COVID-19 catastrophe, the World Health Organization (WHO) acknowledged the potential and importance of these traditional and complementary (T & CM) systems of medicine in healthcare as per ‘WHO traditional medicine strategy: 2014–2023.’ [2]. The primary aim of this strategy was to increase comprehensiveness of healthcare services by systematic integration and mainstreaming of these underrated medical systems. It also acknowledged the emphasis on quality enhancement of available healthcare and respect towards autonomy of patients in choosing from options.

Most of the T & CM systems have a strong foothold among people owing to their prolonged popular use. A strong connect of these systems towards cultural, geographical, even religious aspects of people's lives have sustained them in overpowering presence of biomedicine. Overall, the diversity of our existence is represented by this heritage. The WHO target of ‘better health and well-being’ of the famed ‘Triple-Billion Targets’ will be difficult to achieve if this potential remains underexplored. In line of this, WHO recently founded the ambitious - ‘WHO Global Traditional Medicine Centre’ (GTMC) in Jamnagar, Gujarat, India [3]. This centre will focus on transforming the traditional knowledge into contemporary science with the help of cutting-edge technology. Such sustainable and futuristic efforts are needed to present these systems of medicine on a comparable platform with biomedicine.

The major challenge in acceptance and subsequent mainstreaming of T & CM systems is the paucity of valid and robust research data [4]. Research in healthcare systems basically helps in translation of knowledge into application potential. The dissemination of research outcomes through various scientifically valid platforms is the final and most crucial part of this process. The availability of scientifically acclaimed evidences is an explicit asset for biomedicine. Though issue of lack of evidence is acknowledged by WHO or other entities, many times it is addressed for all T & CM systems in general. However, in the present work we have explicitly provided a differential research status for various T & CM systems.

Numerous T & CM systems are practiced around the world. We referred to the most recent benchmark document, “WHO Global Report on Traditional and Complementary Medicine- 2019”, for selecting the systems for present review [5]. This report presents their status on various levels, but majorly as an undifferentiated entity. We identified the need of presenting their individual research status. The appraisal of research practices involves multiple component evaluation, with no universal set standards. Martensson et al. have described certain ‘proxy variables’ commonly used for objective evaluation of quality of research practices, such as publication measures, quality of researchers, size of scientific networks, etc. [6] On similar base, we designed a framework of certain indicators suggestive of research status of a medicinal system, where data could be obtained from credible sources. We do not assume this as an exhaustive review of available evidences. However, various unique aspects considered in this global review will be modest yet leading effort towards harnessing evidence potential for T & CM systems. It will also provide crucial leads for qualitative evaluation for future researchers, to illustrate the accomplishments of these systems.

2. Methodology

The medicine systems acknowledged in the aforementioned report as ‘Types of T&CM practices used in Member States’ viz. Acupuncture, Ayurveda, Chiropractic, Homeopathy, Naturopathy, Osteopathy, Traditional Chinese medicine (TCM), Unani medicine, Prayer, Spiritualism, Traditional Midwives, Therapeutic Massage, Hypnotherapy, Reiki, Reflexology, Hands-On Healing, Hydrotherapy, Feldenkrais, Biofeedback, Rolfing, Bach flower remedies, Anthroposophic Medicine, Neural Therapy, gSoba Rig-pa (traditional Bhutanese medicine), Siddha medicine, Iranian TM, and Cupping and Ozone Therapy were included for the present study. Although included in original report, ‘Herbal Medicine’ was excluded due to its equivocal nature and overarching presence in many other medicine systems such as TCM, Ayurveda, Naturopathy etc.

2.1. Overview of various aspects of research

The research status of individual systems was assessed on the basis of various outcomes in form of research dissemination. The components of this framework and their retrieval methodology were as follows-

2.1.1. Availability of scientific documents in public domain

The documents such as articles, patents, books, conference papers, etc. present a diversified view of research. Thus, the documents available on PubMed, a biomedical database, and SCOPUS, a multidisciplinary database, were searched by VB & VN independently. The differences such as duplication or omission of data due to its manual retrieval were faced. These were settled by cross examination of data and discussion between all authors. The senior authors, PG and SB approved and finalized the final data for assessment. The availability of documents (excluding retractions, errata and undefined) was searched within “article title, abstract, keywords” with the name of medicine system as a search term. No other filters were applied.

2.1.2. Strength of researchers in their research performance

For each medicine system, highest cited researchers were identified to understand its geographical reach as well as citation strength. During SCOPUS document search, the author profile (name, country, and h-index) of the leading author in each system was retrieved. Potential biases such as self-citation count was not considered.

2.1.3. Scientific popularity of documents

Document citations are the commonest predictors of scientific popularity [7][]. They indicate extent of readership as well as credit identification for a work. Thus, minimum ten top-cited documents for each medicine system were retrieved from SCOPUS database. These were assessed on basis of their metadata, especially title and abstract. It was identified whether the document was actually relevant to the concerned system or was the system just referred therein. The most relevant documents identified by this exclusion strategy with highest citation were noted. Their details such as, type of document, authors, year of publication, source, and total citations were documented.

2.1.4. Availability of dedicated, system-specific journals

Availability of dedicated journal indicates the potential impact and sizable volume of ongoing research work of a particular system. In SCOPUS database, journals categories under predefined subject areas, viz., Complementary And Manual Therapy; Complementary And Alternative Medicine are present. We explored these categories further for each listed system. Only those journals indexed SCOPUS till December 2023 and/or with CiteScore 2022, were retrieved. The scope of each journal was checked manually on their respective websites. They were categorized as dedicated journals for different medicine system accordingly. Where such clear categorization was not possible, they were included in ‘undefined’ category and further grouped according to best applicable scope description. CiteScore metrics of all journals were also noted. CiteScore metrics, powered by SCOPUS provide an outlook to measure citation impact of journals published by various well-known publishers. These were considered as they are freely accessible and transparently calculated.

2.1.5. Availability of systematic reviews and study protocols

The Cochrane library is considered as a vital resource of high-quality evidence in healthcare research. The Cochrane protocols and reviews constitute key aspects of proposed and completed approaches towards evidence generation for a specific field. The availability of systematic reviews and study protocols for each medicine system in Cochrane Database of Systematic Reviews from Cochrane library was searched in “Title, Abstract, Keyword” search with name of medicine system as keyword. No other filters were applied.

2.2. Contribution in COVID-19 prevention and management

The chaotic COVID-19 situation provided an opportunity for all medicine systems to contribute in various manners. The unavailability of definite medicines, provided a wide scope for utilization in its prevention, symptomatic management, and even mitigation of other consequences. Thus, the contribution of each medicine system in COVID-19 situation on basis of various aspects was studied, for gauging their preparedness in accepting challenges and providing out-of-box solutions.

2.2.1. Registered clinical trials and research publications COVID-19

The efforts taken by each medicine system in preventing or managing COVID-19 and its associated issues such as long COVID, psychological trauma etc. were assessed, in terms of registered clinical studies. The clinical trials registered in WHO-International Clinical Trials Registry Platform (ICTRP) were searched by adding the ‘Restricted to COVID-19’ filter and using name of medicine system as search term. For retrieving data of research publications in WHO COVID-19 research database, the search strategy, db:(“MEDLINE” OR “Web of Science” OR “EMBASE” OR “ProQuest Central” OR “PREPRINT-MEDRXIV” OR “EuropePMC” OR “PREPRINT-RESEARCHSQUARE” OR “Academic Search Complete”) AND covidwho_topics: (“traditional_medicine”) was used with addition of name of each medicine system in “Title/Abstract/Subject” fields of document.

2.2.2. Registered systematic reviews of clinical studies for COVID-19

Systematic reviews of well-designed clinical studies are considered to provide best evidence due to their methodical and rational nature. The systematic reviews for COVID-19 were searched in PROSPERO database with search strategy- (coronavirus or corona-virus) AND (wuhan or beijing or shanghai or Italy or South-Korea or Korea or China or Chinese or 2019-nCoV or nCoV or COVID-19 or Covid19 or SARS-CoV∗ or SARSCov2 or ncov) OR (pneumonia AND Wuhan) or “COVID-19″ or “2019-nCoV” or “SARS-CoV” or SARSCOV2 or 2019-nCov or “2019 coronavirus” or “2019 corona virus” or covid19 or ncov OR “novel corona virus” or “new corona virus” or “nouveau corona virus” or “2019 corona virus” OR “novel coronavirus” or “new coronavirus” or “nouveau coronavirus” or “2019 coronavirus” or “Long Covid”). The name of each medicine system was added at the end of search strategy for each search. The search was restricted to human studies and usage of particular medicine system as intervention.

2.3. Patents profile

Patents ensure preservation of intellectual property rights. The patenting process involves various technical considerations to assert novelty and innovative aspects of the work. We searched for availability of published and granted patents for individual T & CM systems to understand this aspect. The database of published international patents by World Intellectual Property Organization (WIPO), i.e., ‘Patentscope,’ was searched as it includes patent data from 193 nations. In the search strategy, search term as “Name of medicine system”, was searched in Field “Front Page”. The filters, viz., English language, stemming activated, single family member were applied.

The data retrieved for all above indicators was organized in spreadsheets using MS Excel. The data characteristics were analyzed and presented as tables and figures.

3. Results

Of the various medicine systems included in the present review, a few such as Acupuncture, TCM etc., have a distinct presence, while most others have limited presence in the research arena. The results obtained from extensive literature searches are mentioned in this section.

3.1. Overview of various aspects of research

3.1.1. Availability of scientific documents in the public domain

In PubMed database, the number of documents included under the system ‘Osteopathy’ was highest, followed by ‘Acupuncture.’ There were no documents listed for ‘Cupping and ozone therapy.’ However, in the SCOPUS database, the highest number of documents were obtained under ‘TCM,’ again followed by ‘Acupuncture.’ Least number of documents were attributed to ‘Cupping and ozone therapy.,’ yet again. The number of documents in SCOPUS database was larger than those in PubMed for all systems, except Osteopathy, Hypnotherapy, Reflexology, and Rolfing. For systems, such as Therapeutic massage, Hands-on Healing, gSoba Rigpa, Spiritualism etc., SCOPUS enlisted documents were considerably more than those in PubMed. The documents retrieved in PubMed and SCOPUS databases are presented in Table 1.

Table 1.

Documents available for medicine systems in PubMed and SCOPUS databases.

Medicine System	No. of Documents (PubMed)	No. of Documents (SCOPUS)
Acupuncture	12675	53712
Ayurveda	929	9132
Chiropractic	1156	10022
Homeopathy	1140	13738
Naturopathy	186	1964
Osteopathy	89248	4269
TCM	9024	75691
Unani	231	1737
Prayer	6520	15137
Spiritualism	46	1876
Traditional Midwives	153	2354
Therapeutic Message	4	3263
Hypnotherapy	2325	2179
Reiki	378	715
Reflexology	6613	1396
Hands-on healing	9	159
Hydrotherapy	3845	5952
Feldenkrais	36	277
Biofeedback	5186	18215
Rolfing	6526	62
Bach flower therapy	14	61
Anthroposophic medicine	59	431
Neural therapy	11417	44614
gSoba Rig-pa	84	2030
Siddha Medicine	492	1320
Iranian TM	127	1730
Cupping and ozone therapy	0	18

3.1.2. Strength of researchers in their research performance

For each medicine system, top cited author data was retrieved from SCOPUS database. The individual author profile was reviewed for obtaining their country and research performance in term of citations and h-index. A single author, ‘Ernst E.’ was top cited for multiple systems, viz., Acupuncture, Chiropractic, Homeopathy, Bach flower therapy and Reflexology. As the author had broad approach, rather than system-specific one, second-most top cited author profiles were included for these aforementioned systems. Out of 28 authors, nine belonged to USA, followed by five authors from Germany. Neurath, Markus Friedrich (highest cited for Traditional Massage), with more than sixty-six thousand SCOPUS citations, lead the overall list. He was closely followed by Okano, Hideyuki (Neural Therapy) with more than sixty-three thousand SCOPUS citations. The data of leading authors is presented in Table 2.

Table 2.

Medicine system-wise leading author according to SCOPUS database.

Medicine System	Leading Author Details
	Author	Country	SCOPUS Citations	h-index
Acupuncture	Lee, Myeong Soo	South Korea	12491	55
Ayurveda	Patwardhan B	India	7134	44
Chiropractic	Leboeuf-Yde, Charlotte	Denmark	10610	54
Homeopathy	Fisher, Peter A.G.	UK	4359	28
Naturopathy	Beer, Andrel Michael	Germany	812	17
Osteopathy	Vaughan, Brett R.	Australia	682	14
TCM	Xie, Yanming	China	1696	18
Unani	Ahmad, Sayeed	India	4389	34
Prayer	Koenig, Harold George	USA	33316	90
Spiritualism	Alvarado, Carlos S.	USA	440	10
Traditional Midwives	Hamer, Davidson Howes	USA	11039	53
Therapeutic Message	Neurath, Markus Friedrich	Germany	66868	129
Hypnotherapy	Whorwell, Peter James	UK	19862	72
Reiki	Baldwin, Ann Linda	USA	1831	25
Reflexology	Sikorskii, Alla Yu	USA	4078	32
Hands-on healing	Bengston, William F.	USA	56	4
Hydrotherapy	Beer, André Michael	Germany	812	17
Feldenkrais	Hannon, John Charles	USA	163	5
Biofeedback	Blanchard, Edward B.	USA	21006	74
Rolfing	James, Helen	USA	26	1
Bach flower therapy	Carpio, Marcia Hortensia Corona	Cuba	8	2
Anthroposophic medicine	Kiene, Helmut	Germany	4428	27
Neural therapy	Okano, Hideyuki	Japan	63771	127
gSoba Rig-pa	Zhang, Yi	China	1805	22
Siddha Medicine	Brindha, Pemaiah S.	India	1964	21
Iranian TM	Kamalinejad, Mohammad	Iran	5502	40
Cupping and ozone therapy	Miehle, Wolfgang	Germany	85	5

3.1.3. Scientific popularity of documents-

The top cited documents retrieved for each listed system were from varied sources, such as journals and books. For gSoba Rigpa, the term ‘Traditional Bhutanese Medicine’ yielded the results. When relevance checking was done, many of the documents were excluded. Thus, data for systems viz., Acupuncture, Chiropractic, Naturopathy, Unani Medicine, Therapeutic Massage, Reflexology, Hands-on healing, Hydrotherapy, Feldenkrais, Biofeedback, Neural therapy, Siddha medicine, and Cupping and ozone therapy, was excluded. All the included documents were research articles published in journals. Highest citation count was recorded for document from TCM (n = 2238). Two research articles were published in highly coveted journal, the Lancet. The overview of top-cited documents in each system is presented in Table 3.

Table 3.

Relevant top-cited documents in SCOPUS database.

Medicine System	Document Title	Authors	Source	Year	Total Citations
Ayurveda	Medicinal plants of India with anti-diabetic potential	Grover J.K.; Yadav S.; Vats V.	Journal of Ethnopharmacology	2002	1374
Homeopathy	Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials	Linde K.; Clausius N.; Ramirez G.; Melchart D.; Eitel F.; Hedges L.V.; Jonas W.B.	Lancet	1997	807
Osteopathy	Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis	Bronfort G.; Haas M.; Evans R.L.; Bouter L.M.	Spine Journal	2004	424
Traditional Chinese medicine	Antioxidant activity and phenolic compounds of 112 traditional Chinese medicinal plants associated with anticancer	Cai Y.; Luo Q.; Sun M.; Corke H.	Life Sciences	2004	2238
Prayer	The many methods of religious coping: Development and initial validation of the RCOPE	Pargament K.I.; Koenig H.G.; Perez L.M.	Journal of Clinical Psychology	2000	1519
Spiritualism	Effects of mindfulness-based stress reduction on medical and premedical students	Shapiro S.L.; Schwartz G.E.; Bonner G.	Journal of Behavioral Medicine	1998	979
Traditional Midwives	Cosmopolitical obstetrics: Some insights from the training of traditional midwives	Jordan B.	Social Science and Medicine	1989	220
Hypnotherapy	Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome	Whorwell P.J.; Prior A.; Faragher E.B.	Lancet	1984	437
Reiki	Biological correlates of reiki touch (Service mark) healing	Wardell D.W.; Engebretson J.	Journal of Advanced Nursing	2001	128
Rolfing	Shifts in pelvic inclination angle and parasympathetic tone produced by Rolfing soft tissue manipulation	Cottingham J.T.; Porges S.W.; Richmond K.	Physical Therapy	1988	41
Bach flower therapy	Efficacy of Bach-flower remedies in test anxiety: A double-blind, placebo-controlled, randomized trial with partial crossover	Walach H.; Rilling C.; Engelke U.	Journal of Anxiety Disorders	2001	35
Anthroposophic medicine	Complementary cancer therapy: A systematic review of prospective clinical trials on anthroposophic mistletoe extracts	Kienle G.S.; Kiene H.	European Journal of Medical Research	2007	110
gSoba Rig-pa	Psychological Adjustment and Sleep Quality in a Randomized Trial of the Effects of a Tibetan Yoga Intervention in Patients with Lymphoma	Cohen L.; Warneke C.; Fouladi R.T.; Rodriguez M.A.; Chaoul-Reich A.	Cancer	2004	348
Iranian TM	Chemical characterization of basil (Ocimum basilicum L.) found in local accessions and used in traditional medicines in Iran	Javanmardi J.; Khalighi A.; Kashi A.; Bais H.P.; Vivanco J.M.	Journal of Agricultural and Food Chemistry	2002	253

3.1.4. Availability of dedicated, system-specific journals

A total of 105 journals were retrieved according to the search strategy. Of them, two journals, viz., Phytotherapie and Revue d'Homeopathie, actually had discontinued publishing. They were still included based on their eligibility according to strategy. The majority of the journals, even for traditional medicine systems like TCM, were in the English language. More than one-third of the journals (n = 40) were broadly scoped and were not dedicated to specific medicine system. Most of them (n = 17) mentioned complete T&CM systems as their scope. Of the discretely dedicated journals, most (n = 20) stated TCM as the primary scope, followed by 17 journals for acupuncture. Journals such as, ‘Journal of Integrative Medicine’ clearly enlisted almost all medicine systems in their scope. Two journals, viz., ‘Journal of Evidence-Based Integrative Medicine’ and ‘Evidence-based Complementary and Alternative Medicine,’ clearly mentioned homeopathy as an exclusion in their scope. No dedicated journals were obtained for systems, such as Prayer, Traditional Midwives, Hands-on healing, Hydrotherapy, Rolfing, Bach flower therapy, Neural therapy, and Iranian TM. Highest CiteScore (n = 10.4) was noted for the journal ‘Phytomedicine’, closely followed by ‘Journal of Ginseng Research’ (n = 10.0). The categorized list of journals is presented in Table 4. The complete journal list is attached in appendix A.

Table 4.

Availability of dedicated journals in SCOPUS database.

Medicine System	Number of dedicated journals	Range of CiteScore (Max-Min)	Journal with highest CiteScore
Acupuncture	17	7.5–0.2	Journal of Integrative Medicine
Ayurveda	8	7.5–0.9	Journal of Integrative Medicine
Chiropractic	5	7.5–1.4	Journal of Integrative Medicine
Homeopathy	8	7.5–0.3	Journal of Integrative Medicine
Naturopathy	6	4.2–0.2	Journal of Integrative and Complementary Medicine
Osteopathy	5	2.5–0.2	Journal of Bodywork and Movement Therapies
Traditional Chinese medicine	20	7.5–0.2	Journal of Integrative Medicine
Unani	3	1.7–0.9	Indian Journal of Traditional Knowledge
Spiritualism	3	2.7–1.6	Explore: The Journal of Science and Healing
Therapeutic Message	4	5.4–1.6	Journal of Evidence-Based Integrative Medicine
Hypnotherapy	3	3.4–1.2	International Journal of Clinical and Experimental Hypnosis
Reiki	1	1.6	Alternative Therapies in Health and Medicine
Reflexology	1	1.6	Alternative Therapies in Health and Medicine
Feldenkrais	1	2.5	Journal of Bodywork and Movement Therapies
Biofeedback	1	1.6	Alternative Therapies in Health and Medicine
Anthroposophic medicine	1	2.5	Journal of Bodywork and Movement Therapies
gSoba Rig-pa	1	1.6	Alternative Therapies in Health and Medicine
Siddha Medicine	1	1.7	Indian Journal of Traditional Knowledge
Cupping and ozone therapy	1	1.2	World Journal of Acupuncture - Moxibustion
Undefined	41 {Traditional Complementary Alternative Medicine (n = 17), Herbal research (n = 10), Specific herb research (Cannabis-n = 3 and Ginseng-n = 1), Natural products research (n = 7), Ageing related research (n = 1), Physiology (n = 1), Not receiving articles (n = 1)}	10.4–0.5	Phytomedicine

3.1.5. Availability of systematic reviews and study protocols

The Cochrane reviews and protocols are considered as gold standard due to their clarity in methodology and reporting. In comparison with biomedicine reviews and protocols, very few reviews were available for listed medicine systems. Among these, maximum systematic reviews (n = 142) as well as protocols (n = 33) included Acupuncture. Many of these systems even had no systematic reviews and or study protocols. Table 5 summarizes the number of available Cochrane reviews and protocols for each medicine system.

Table 5.

Systematic reviews and study protocols in Cochrane Library.

Medicine System	No. of Reviews	No. of Protocols
Acupuncture	142	33
Ayurveda	4	2
Chiropractic	18	0
Homeopathy	16	2
Naturopathy	1	0
Osteopathy	5	0
Traditional Chinese medicine	61	3
Prayer	3	0
Spiritualism	24	1
Traditional Midwives	10	0
Therapeutic Message	33	0
Hypnotherapy	12	0
Reiki	3	0
Reflexology	11	1
Hydrotherapy	11	0
Biofeedback	59	1
Neural therapy	18	0
gSoba Rig-pa	2	0
Unani, Hands-on healing, Feldenkrais, Rolfing, Bach flower therapy, Anthroposophic medicine, Siddha Medicine, Iranian TM, Cupping and ozone therapy	0	0

3.2. Contribution to COVID-19 prevention and management

3.2.1. Registered clinical trials and research publications for COVID-19

Around 13,000 clinical trials related to COVID-19 management were registered on the WHO managed portal, International Clinical Trials Registry Platform (IRCTP). A major portion of them was related to biomedicine interventions. However, most of the listed medicine systems also contributed as seen from the obtained results. Maximum studies were registered for TCM interventions (n = 335), followed by Ayurveda (n = 112). Also, there were no COVID-19 studies registered for some systems, such as spiritualism.

On the other hand, a notable number of COVID-19-related research publications were obtained in the WHO database. Of over five thousand publications, around two thousand were related to listed medicine systems. Almost half of these publications were from TCM (n = 1103), followed by Ayurveda (n = 250). There were no such publications from certain medicine systems. The WHO database search data is presented in Table 6.

Table 6.

Registered clinical trials and research publications in WHO databases for COVID-19.

Medicine System	No. of Registered trials	No. of Publications
Acupuncture	44	222
Ayurveda	112	250
Chiropractic	4	7
Homeopathy	18	102
Naturopathy	12	29
Osteopathy	1	1
Traditional Chinese medicine	335	1103
Unani	13	52
Prayer	7	18
Spiritualism	0	1
Traditional Midwives	0	3
Therapeutic Message	0	4
Reiki	1	2
Reflexology	1	1
Hands-on healing	0	1
Hydrotherapy	0	2
Biofeedback	11	7
Anthroposophic medicine	0	2
Neural therapy	1	10
gSoba Rig-pa	1	3
Siddha Medicine	49	113
Iranian TM	7	15
Hypnotherapy, Feldenkrais, Rolfing, Bach flower therapy, Cupping and ozone therapy	0	0

3.2.2. Registered systematic reviews of clinical studies for COVID-19

According to the PROSPERO database search, over ten thousand systematic reviews of clinical studies were registered for studying all aspects of COVID-19 management. The listed systems contributed to a small section of this. Most of the systems did not have any registered systematic reviews for COVID-19 clinical studies. The data is presented in Table 7.

Table 7.

PROSPERO- registered systematic reviews of clinical studies for COVID-19.

Medicine System	No. of registered reviews
Acupuncture	25
Ayurveda	14
Traditional Chinese medicine	16
Reflexology	11
Chiropractic, Homeopathy, Prayer, Reiki, Hydrotherapy	Each 1
Naturopathy, Osteopathy, Unani, Spiritualism, Traditional Midwives, Therapeutic Message, Hypnotherapy, Hands-on healing, Feldenkrais, Biofeedback, Rolfing, Bach flower therapy, Anthroposophic medicine, Neural therapy, gSoba Rig-pa, Siddha Medicine, Iranian TM, Cupping and ozone therapy	0

3.3. Patents profile

The patents data obtained from WIPO indicates that TCM has by far the highest number of patents (n = 240,743), followed by Neural therapy (n = 81,423). On the other hand, systems like Iranian TM and gSoba Rig-pa have very low or no patent activity. The results obtained for ‘Hands-on healing’ system were not included due to their ambiguous nature. It is also interesting to note that some systems like Chiropractic, Homeopathy, and Naturopathy have moderate patent activity, indicating some level of interest and innovation in these areas as well.

When observed the country wise patent distribution, China and the USA are prominent in several categories, with India featuring in a few areas. Also, the Patent Cooperation Treaty (PCT) is observed to play a significant role in documenting intellectual property protection for traditional systems of medicines. Table 8 presents the patent information for listed T & CM systems.

Table 8.

Patents profile of selected T & CM systems.

Medicine System	No. of Patents	Country with highest patents	No. of patents in country
Acupuncture	28,702	China	19,880
Ayurveda	194	India	144
Chiropractic	2401	USA	1507
Homeopathy	977	USA	326
Naturopathy	247	USA	112
Osteopathy	320	China	137
TCM	240,743	China	221,024
Unani	583	India	398
Prayer	589	USA	302
Spiritualism	2543	USA	1192
Traditional Midwives	302	USA	179
Therapeutic Message	29868	USA	12829
Hypnotherapy	171	PCT	80
Reiki	539	Japan	415
Reflexology	674	USA	327
Hydrotherapy	2246	USA	798
Feldenkrais	29	USA	13
Biofeedback	6810	USA	3249
Rolfing	3646	PCT	1390
Bach flower therapy	511	PCT	262
Anthroposophic medicine	21	PCT	8
Neural therapy	81,423	PCT	50,072
gSoba Rig-pa	3	India	1
Siddha Medicine	506	India	328
Iranian TM	0	NIL	0
Cupping and ozone therapy	95	USA	46

4. Discussion

The overview of multiple dimensions of research in various T & CM systems based on multiple outcome measures provided a picture of contrasts. Research dissemination for medicinal systems such as TCM, Acupuncture and Osteopathy were much greater than certain systems like Iranian TM and Traditional midwives, etc. Despite availability of system-specific anecdotal data, many of them still fail to generate robust and acceptable scientific evidences. Thus, establishment of facilities such as GTMC are justified to support and steer their efforts.

The present analysis was carried out considering the selected T & CM systems in an individualized manner. Previously, they were considered generically by the policy makers. For instance, the recently released ‘Report of Task Force on Evidence-Based Traditional Medicine for Health Care in India,’ 2023 also presented them as undifferentiated entities [8]. Bibliometric analysis of research publications in Ayurveda was carried out by Peter et al. [9], Thrigulla et al. [10] and Nedungadi et al. [11] In the present work, we have tried to respect individual stature of multiple medicine systems, irrespective of their codified or non-codified nature. Also, various methods are utilized to present variety of aspects of research.

We included biomedical and multidisciplinary databases providing authentic and trusted information to get a comprehensive idea for T & CM research. The inclusion of scientific publications such as patents, books, conference papers, etc., along with research articles provided a broad view of research dissemination. Most scientific documents were available for Osteopathy in PubMed and Acupuncture in SCOPUS databases. Here, it should be noted that PubMed only retrieves healthcare-related data, while SCOPUS along with health, include social sciences, arts, and humanities too. It can be inferred that; the dissemination of Acupuncture-related research is in these multiple disciplines. As most of the T & CM are rooted in local cultures, such propagation should also be considered important.

Instead of presenting the search data from SCOPUS database search as it is, we tried to critically acknowledge the eligible ones only. The relevance of many documents could not be comprehended due to lack of clarity for relevance in their metadata and limited expertise of authors in the different T & CM systems. As a result, documents from many systems were not included. It would be an interesting exercise to correctly understand such relevance for each system and present proper citation impact for them. Analysis of available documents suggests that most of these were published in high quality journals focused on biosciences or mainstream medicine. This is a positive factor and should be highlighted. There is also possibility of transdisciplinary collaborations resulting in increased citations. A similar approach can be employed by researchers from other systems too.

Most of the included T & CM systems have originated/practiced in specific, especially underdeveloped and developing areas. Yet, their lead authors belonged to developed nations. Interestingly, for some systems highest cited authors even did not belong to their core geographical region too. For instance, the top-cited author for ‘Reiki,’ a Japanese healing technique, is from the USA. In fact, most of the top-cited authors belonged to the USA, indicating progressive awareness about variety of T & CM systems in a nation with remarkable biomedicine research. The readily available research support from the Government and research policies in the USA might have also contributed to this.

Access and competency to publish in high-quality journals is identified as a barrier in complementary medicine research [12]. This was corroborated by availability of only small section of SCOPUS-indexed journals specifying this category in their subject area. The tendency to consider these systems under a common umbrella was reestablished with most journals not mentioning names of specific systems in their scope. Among the rest, TCM was mentioned in the scope of most journals. Interestingly, many of them were academic publications. It would be a good policy to establish more such dedicated journals with stringent quality norms to publish high-quality work for individual systems. Notably, Homeopathy was distinctly excluded from the scope by two journals otherwise endorsing other T &CM. Cukaki et al. have enlisted some reasons for probable resistance against homeopathy despite its high popularity [13]. It would be wiser to understand such aspects by researchers from other systems too. There is a great scope to establish more journals, as many of the systems do not make it to the cut, but otherwise have a good presence in published documents. CiteScore by SCOPUS measures citation impact of a journal. The highest CiteScore −2022 was available for the journal, “Ca-A Cancer Journal for Clinicians”, which was 642.9. Compared to this, the highest CiteScore of 10.4 for a T & CM system journal is very primitive and shows the long way to attain sizable impact.

Apart from published research documents, we also analyzed the availability of Cochrane reviews and study protocols. Among the small data available, Acupuncture had the largest share. On the other hand, many systems did not have even a single review or protocol attributed to them. Enhancing the quality of research in a focused manner may help to overcome such predicaments and facilitate the mainstreaming of T & CM systems.

A general perception is that T & CM therapies are useful only in chronic and non-fatal conditions. This was challenged to a great extent during the COVID-19 situation. The amount of work undertaken in fields of fundamental research, drug research, and clinical research was tremendous for most of these systems. For Instance, in India, 113 clinical studies were registered in Clinical Trials Registry-India (CTRI), between February to August 2020 only from Ayurveda [14]. To understand a similar global perspective, clinical studies registered on IRCTP were analyzed. Although their numbers were quite low compared to biomedicine studies, their existence was a positive phenomenon. Among them, TCM studies topped the list, followed by Ayurveda. The policy initiatives by the government might be the key reason behind this. Integration of traditional medicine principles in the preventive and therapeutic management of COVID-19 was at the crux of all initiatives. For many systems, no studies were registered, irrespective of coexistent opportunities such as post-COVID health issues, psychological stress, etc. A similar situation was observed for PROSPERO-registered systematic review protocols. There could have been better efforts to seize such chance and leave a considerable impact of all these systems. On the other side, the number of COVID-19-related publications from these systems was far better. However, almost half of them were from TCM. The WHO database captured all types of research and not just clinical studies. It would have been more, if the dissemination of results of clinical studies was practiced diligently and responsibly [15].

While most of the listed T & CM systems are in practice since a very long time, the concept of patenting their remedies is relatively recent and remains a subject of debate. The issue arises from the tension between protecting indigenous knowledge and facilitating innovation and commercialization. Despite this, there was quite good number of patents for systems like, TCM. However, this data needs to be checked qualitatively to understand the extent of novelty in it along with alignment with principles of specific T & CM system.

The present analysis revealed that each medicinal system was at a different level when research status was concerned. Some of them like TCM and Acupuncture are faring better than most of the listed T & CM systems. Thus, it would be better to address issues of these other systems and provide suggestions without keeping them under one umbrella at all times. These systems can be broadly categorized as, holistic (E.g., TCM, Ayurveda), manual (E.g., Osteopathy, Rolfing), and Theological (E.g., prayer, spiritualism) [16]. There is also an aspect of legal status, as some of them are not formally acknowledged in many countries. Despite this, they might be regrouped and integrated either with other T & CM systems or with biomedicine on a need-based scenario for people's benefit.

The ‘Gujarat Declaration’ released by WHO-Traditional Medicine Global Summit 2023, has advocated ‘evidence-based’ integration of T & CM systems around the world in national health policies [17]. However, rigorous, and high-quality research would be mandatory for this. There are various policies released by WHO for certain medicine systems. International standard terminologies and benchmarks for training and for practice have been published for Acupuncture, TCM (Tuina), Ayurveda, and Unani medicine. Additionally, benchmarks for practice are published for Osteopathy and Nuad Thai medicine. Such standard documents for all T & CM systems would be a welcome step towards creating and nurturing a research atmosphere among their stakeholders. WHO ICD-11 recently added a module for Ayurveda, Siddha, and Unani medicine-specific morbidity codes. It already includes a module for morbidity codes from TCM. This surely will help in creating standard data and help their mainstreaming with biomedicine.

The existence and prevalence of T & CM systems across the globe itself is a dynamic phenomenon. For instance, Sowa Rigpa, although originated and mentioned as Bhutanese medicine, is also prevalent in other regions such as Tibet, Mongolia, Nepal, etc. It has been included under the recognized Ayush systems of medicine in India, too. Such equations regarding regulatory status might impact its research status in the forthcoming time. The multifaceted research construct shall be consistently analyzed in such light to clearly perceive the current research status of T & CM systems.

5. Limitations and future scope

The research status of a total of 27 medicine systems was studied for the present work. Even though mentioned in the report, ‘Herbal medicine’ was excluded from analysis owing to certain complexities. It would be a notable work to present the research status of this system by addressing its unique nature. Apart from these WHO-acknowledged systems, many other traditional and indigenous medicine systems, such as Thai Medicine, Korean Medicine, etc. are practiced around the world. These were not included in the present study due to non-inclusion in the aforementioned WHO document. It would be an interesting task to enlist and study this heritage to get a truly comprehensive T & CM picture.

The presented data is a snapshot of bibliometrics retrieved from various data sources. Hence, the outcomes may differ with different timeline, changes in user interface, etc.

Although research status is a multi-faceted construct, we focused on certain indirect indicators which are primarily quantitative. There might be more indicators for evaluation of research status other than those considered here. The qualitative indicators like positive or negative outcomes and impact of research on the popularity of the system, social aspects, etc. could be a remarkable scope for such studies in the future.

6. Conclusion

The United Nations-sustainable development goals (SDG) aim towards endowing a peaceful and prosperous world for all. Strengthening the health systems for providing universal health coverage is a key aspect in accomplishing this mammoth task. The stakeholders of T & CM systems need to embrace this opportunity by establishing a strong evidence base at par with biomedicine, without deviating from their core principles. We believe, that would be the real amalgamation of ‘alternate’ medicines in the ‘conventional’ patient care.

Sources of funding

The authors declare that no funding was received for the present work.

Author contributions

VB: Methodology, Data curation, Writing- Original draft preparation VN.: Data curation, original draft review. PG: Original draft review and editing SB: Conceptualization, Methodology, Original draft Reviewing and Editing.

Declaration of generative AI in scientific writing

None.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Although the corresponding author (SB) is a member of J-AIM Editorial Board, she was not involved in peer review process and editorial decisions related to this paper. Other authors, declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article: