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Musculoskeletal disorders are a leading cause of pain and disability worldwide, affecting over 1.7 billion individuals. Acute musculoskeletal pain (AMP) refers to pain caused by injury to muscles, bones, joints, ligaments, or soft tissues, lasting less than 4 weeks (, ). Common etiologies include sprains, strains, soft tissue injuries, whiplashes, and contusions (, ). Without timely and appropriate management, acute pain may develop into chronic pain syndromes (). Therefore, early and effective interventions are essential. AMP is prevalent across all age groups and is one of the leading complaints in emergency and outpatient clinics. Current treatment mainly relies on opioid and non-opioid analgesics. However, the side effects and dependence risks of opioids have prompted recommendations for multimodal analgesia strategies, emphasizing the need for evidence-based non-pharmacological alternative therapies (, ). Acupuncture is a fundamental component of traditional Chinese medicine (TCM). Based on meridian syndrome differentiation, it involves the insertion of needles into specific acupoints to treat diseases and alleviate symptoms (). As a safe, economical, and evidence-based therapy, acupuncture has gained growing recognition for its potential in managing acute pain ().

Acupuncture prescriptions targeting specific points demonstrate certain feasibility in treating AMP. Shuzhong Gao has discussed this concept, and multiple clinical studies have demonstrated that rapid symptom relief in certain specific conditions, especially pain, can be achieved through the use of single acupoints (–). These studies hold practical relevance in emergency pain management, where rapid efficacy, minimal acupoint usage, and short treatment durations are crucial (). Research indicates that patients treated with emergency acupuncture report not only significant pain relief but also improvements in anxiety, stress, and sleep quality (). At the neurophysiological mechanistic level, acupuncture may induce neuroplastic changes in brain, particularly in modulating connectivity and function in motor-related cortical regions (, ). Different acupoints activate distinct brain regions associated with specific functions, thus enabling targeted therapy efficacy. The primary motor cortex (M1) plays a direct and critical role in motor recovery, motor control, and neuroplastic remodeling (–). The increased excitability of M1 not only promotes the recovery of motor function but also supports the neurocognitive foundation for adapting to new motor pattern (). Despite its widespread use in musculoskeletal pain, there is still a lack of standardization of acupoint selection strategies. Many randomized controlled trials (RCTs) employ combinations of five or more acupoints, complicating the evaluation of specific acupoints efficacy and thus limiting the replicability and clinical applicability. In contrast, the approach of selecting fewer acupoints (typically 1–3) not only facilitates analysis of the mechanism of therapeutic effects but also improve clinical practicality, enabling streamlined therapeutic designs. Moreover, distal acupoints may offer specific advantages for certain pain subtypes, which is worthy of further exploration. Factors such as needling techniques, modes of acupuncture stimulation, and adjunctive exercise modalities (e.g., active exercise, myofascial release, stretching) may also influence therapeutic efficacy (). However, relevant analyses in the literature remain underexplored.

To address these research gaps, this study focused on acupoint selection strategies for AMP and selected RCTs employing 1–3 acupoints as the core dataset for analysis. CiteSpace, developed by Professor Chaomei Chen via Java, is a powerful bibliometric and visualization tool (). Through CiteSpace, research hotspots were identified through multidimensional bibliometric analyses, including keyword clustering, high-frequency term analysis, and burst detection, thereby clarifying the application trends of core acupoint combinations. Through frequency statistics, influential factor screening, and spatial visualization of acupoint distributions, the empirical rationale and theoretical logic behind “core acupoint protocols” are further uncovered. The ultimate goal is to provide clinicians with referable, scientifically grounded and efficient acupoint selection strategies tailored to various subtypes of AMP.

Literature data were retrieved from the China National Knowledge Infrastructure (CNKI), WanFang data, VIP Chinese Science and Technology Periodical Database (VIP), SinoMed, Web of Science (WOS), PubMed, Embase, and Cochrane, from their inception to October 15, 2025. A combination of topic and free word was used. Detailed search strategies are presented in .

To ensure the accuracy and relevance, rigorous eligibility criteria were established. The inclusion criterion encompassed RCTs, observational research, and case reports. The exclusion criteria were as follows: (1) non-original studies, such as conference abstracts, dissertations, announcements, reviews, systematic reviews, or meta-analyses; (2) studies with those focused on chronic pain, identified by terms such as “chronic,” “refractory,” “old injury,” “old strain,” or “degenerative changes,” or those in which the primary symptoms were non-pain-related manifestations (e.g., numbness, weakness); (3) studies with musculoskeletal pain secondary to postoperative or visceral acute pain; (4) studies with incomplete information, such as missing full text, unclear needling protocols, or the use of proprietary treatment formulas; (5) studies in which more than three acupoints were used during the intervention; (6) interventions in which acupuncture was not the primary treatment modality, with dominant therapies, including herbal medicine, Tuina, or physical therapy; (7) secondary musculoskeletal disorders, such as stroke, Parkinson’s disease, etc.

All included Chinese studies were exported in RefWorks format, and English studies in txt formats, and then secondary screened using NoteExpress 3.9.0.9588. The exported documents are saved as “download.txt” and imported into the visualization analysis tool CiteSpace 6.1.R6 to carry out scientific knowledge graph construction and visualization analysis of the keywords. After the database was constructed, all included studies were read in full, and core intervention information was extracted exclusively from the acupuncture treatment groups. For studies with population subgroups or intervention groups that all met the inclusion criteria, each group was treated as a separate analytical unit.

To ensure standardized and consistent data extraction, the following criteria were applied: (1) Modern medical diagnosis. (2) Pain location classification, based on the description in the studies, categorized into neck, shoulder, waist, hip-buttock, thigh, calf, knee, ankle, foot, elbow, wrist and hand. (3) Acupoint selection strategy, classified according to proximal acupoint selection and distal acupoint selection. Distal acupoint selection is defined as involving acupoints separated from the pain site by two or more joints (e.g., wrist, elbow, shoulder, hip-buttock, knee, ankle), while proximal acupoint selection involved fewer than two joints. The division of distal and proximal acupoints selection strategy in this paper is an operational definition employed specifically to facilitate cross-study comparisons, and does not represent an established consensus standard. Cases involving both were included in the analysis. (4) Needle angle, classified as “perpendicular needle insertion,” “oblique needle insertion” and “subcutaneous needle insertion.” (5) Whether exercise is involved, based on whether the study clearly indicates active or passive exercise, training, stretching, or other interventions during acupuncture, divided into “with exercise” and “without exercise.” (6) Type of acupuncture, classified as “body acupuncture,” “scalp acupuncture,” “auricular acupuncture,” “wrist-ankle acupuncture,” “hand acupuncture,” “foot acupuncture,” “eye acupuncture.” (7) Number of acupoints, recording the actual number of acupoints used during treatment, bilateral acupoints of the same name are counted as 1 acupoint. (8) Combined therapies, such as combined massage, TDP irradiation, hot compress, etc., are also recorded. (9) Specific acupoint, based on the WHO International Standard Terminologies On Traditional Chinese Meidicine and National Standards of the People’s Republic of China GB/T 12346-2021 (Meridian Acupoints), GB/T 13734-2008 (Auricular Acupuncture), GB/T 40997-2021 (Extra Acupuncture), GB/T 40997-2021 (Nomenclature and location of extra points in common), GB/T 21709.19-2009 (Wrist-Ankle Acupuncture), GB/T 21709.15-2021 (Ophthalmic Acupuncture), and GB/T 21709.2-2021 (Scalp Acupuncture) (). For non-standard acupoint naming, the above-mentioned acupoints are matched based on the description of acupoint location. Auricular acupoints are represented as AP-X, wrist and ankle acupoints as WAA-X, ophthalmic acupoints as OA-X, and scalp acupoints as SA-X. Acupoints that are not found are described according to the EX-original description name and listed in . Proximal “tender points,” “pain points,” “sensitive points,” etc. are uniformly classified as “Ashi points.” Descriptions of distal Ashi points or sensitive points are uniformly classified as “EX-Ashi points.” If multiple eligible therapeutic strategies are reported in the same study, each strategy shall be included as an independent entry, and a metrological analysis shall be subsequently performed on all included entries. The protocol for this review was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO) platform (Registration number: CRD420251155446).

This study retrieved 2424 studies from CNKI, 2549 from Wanfang, 1764 from VIP, 419 from SinoMed, 568 from WOS, 333 from PubMed, 445 from Cochrane, 1169 from Embase. After applying inclusion and exclusion criteria, 404 Chinese and 34 English studies were included. The annual publication trends of Chinese studies exhibited a fluctuating evolutionary trajectory as “high-low-high”, which can be divided into three phases: an early high-productivity phase (1992–1998), a low-level fluctuation phase (1999-2017), and a subsequent resurgence (2018-present). The number of English studies was almost non-existent or extremely low in the early years but has shown an upward trend since 2010 ().

This study used CiteSpace 6.1.R6 to perform co-occurrence, clustering, and burst detection analysis on keywords in Chinese and English studies. The LLR algorithm was used to identify keywords from cited studies for annotation and clustering analysis to reveal research hotspots and evolutionary trends in the field of acupuncture treatment for AMP. Nodes represent keywords, and the size of the circles represents the frequency of keyword citation. show the keyword co-occurrence and clustering network of Chinese studies, forming a total of 10 clustering modules. The clustering modularity (Q) is 0.69, and the average silhouette coefficient (S) is 0.8608, indicating that the clustering structure has good significance and internal consistency. The identified clusters included “#0 Clinical observation,” “#1 Acute disease,” “#2 Electroacupuncture,” “#3 Treatment Outcomes,” “#4 Acupuncture analgesia,” “#5 Lumbar sprain,” “#6 Pain,” “#7 Ashi point,” “#8 Active exercise,” “#9 Dongqi needle technique.” Keyword timeline plots and burst detection analysis further reveal the dynamic evolution of research hotspots at different stages. reveal that early Chinese studies mainly focus on the selection of acupoints and therapeutic effects. After 2008, motion style acupuncture treatment, single acupoints, and balance acupuncture became prominent hotspots, gradually becoming a research focus in AMP. show the co-occurrence and clustering of keywords in English studies, identify 6 clustering modules with a clustering modularity(Q) is 0.8181 and the average silhouette coefficient(S) is 0.951, indicating high clustering quality. The results of keywords clustering included “#1 Randomized controlled trial,” “#2 Acute disease,” “#3 MSAT,” “#4 Pain management,” “#5 Range of motion” and etc., reflecting current research focus on clinical research of acute disease, pain management, joint mobility, and individualized treatment. The burst detection analysis showed that recent reaches concentrated on acupuncture intervention and pain management of lumbar sprain and low back pain (see for details). Overall, Chinese and English clinical research showed a surge research related to MSAT.

A total of 515 Chinese and 63 English therapeutic strategies were reviewed. In terms of disease spectrum, lumbar soft tissue pain is the most common disease across both language groups, with similar indications reported in each (). Pain localization analysis revealed a predominant focus on lumbar and ankle regions (). Perpendicular needle insertion was the most common needling angle (). In both Chinese and English studies, distal acupoints were selected more frequently than proximal ones (). Regarding acupuncture types, body acupuncture was the prevailing technique, but hand acupuncture predominated in Chinese studies, while English studies used wrist-ankle acupuncture more often (). Acupuncture methods were mainly described in Chinese studies, with Point-toward-point needle insertion being the most used method (). In terms of the number of acupoints, both Chinese and English studies prefer selecting single acupoint (). In a comparison of acupoint selection strategies and the distribution of acupuncture combined with exercise, Chinese research often incorporated exercise therapy, whereas English studies rarely combined acupuncture with exercise ().

Regarding acupoint selection for neck pain, Chinese studies often use SI3, SI6, and Ashi point in conjunction with exercise regimens, and Ashi point, EX-Jingtong, and EX-Zhongping in non-exercise regimens. English studies, however, often use LI10, LI16, and SI15 in conjunction with exercise regimens, and Ashi point and SI3 in non-exercise regimens. For chest and back pain, proximal acupoint selection is frequently used. Chinese studies use Ashi point, PC6, and SJ6 in conjunction with exercise regimens, and Ashi point, GB34, and EX-B2 in non-exercise regimens. English studies use Ashi point, CO14, and PC6 in non-exercise regimens. The lumbar region is the most frequently treated area in this study. Distal acupoint selection is frequently used for lumbar pain. Chinese studies use EX-UE7, SI3, and Ashi point in conjunction with exercise regimens, and Ashi point, EX-B2, and SI3 in non-exercise regimens. English studies use EX-UE7, LI11, and LR2 in conjunction with exercise regimens, and BL57, BL62, and EX-LE7 in non-exercise regimens. Regarding the selection of acupoints for hip-buttock pain, Chinese studies used Ashi point, BL65, and GB41 in combination with exercise regimens, and AP-AH7, Ashi point, and TE5 in non-combined exercise regimens. English studies used Ashi point in combination with exercise programs (see and for details and see for acupoint locations).

Hand pain treatment often prioritizes proximal acupoint selection. Chinese studies using exercise regimens selected SI3, SI6, and Ashi points, while non-exercise regimens selected Ashi points, SP6 Ashi points, and TE5. English studies using non-exercise regimens selected Ashi points, PC6, and WAA-Up 5. For wrist pain, proximal acupoints are often selected. Chinese studies using exercise regimens include Ashi point, GB29, and SA-Yidian, while non-exercise programs use Ashi point, AP-SF2, and EX-Ashi point. English studies with non-exercise regimens use Ashi point, PC6, and WAA-Up 5. For elbow pain, proximal acupoints are often selected. Chinese studies with non-exercise programs use AP-SF3, Ashi point, and WAA-Ashi point. Similarly, English studies with non-exercise programs use Ashi point, LI10, LI11, and WAA-Up 5. The acupoint selection strategy for shoulder pain often focuses on distal acupoints, combining body acupuncture with exercise therapy. Chinese studies use SI3, SI6, and Ashi point in conjunction with exercise regimens, and Ashi point, EX-Zhongping, and AP-SF4,5 in non-compliance exercise regimens. English studies use Ashi point, EX-Zhongping, and LI14 in conjunction with exercise regimens ( and ). Acupoint locations are shown in .

For thigh pain, proximal acupoints are often selected. Chinese studies using exercise regimens include Ashi point, BL57, and EX-Xinmen while non-exercise regimens include Ashi point, BL63, and EX-Jianqian. For knee pain, proximal acupoints are often selected. Chinese studies using exercise programs include Ashi point and TE10 while non-exercise regimens include Ashi point, LI11, and SP8. English studies using exercise programs include Ashi point while non-exercise regimens include Ashi point, WAA-Down 3, and WAA-Down 4. For ankle pain, distal acupoints are often selected. Chinese studies without exercise regimens include EX-Xiaojie, Ashi point, and TE4. Similarly, English studies using without exercise programs include Ashi point, TE5, and WAA-Ashi point. For foot pain, proximal acupoints are often selected. Chinese studies without exercise regimens include Ashi point and English studies without exercise programs include Ashi point, SP6, and ST36 ( and ). Acupoint locations are shown in .

This section explores the selection of distal or proximal acupoints and combination of exercise for pain in different areas. When pain occurs in the waist, ankle, neck, chest-back, shoulder, and hip-buttock, distal acupoints are used more frequently than proximal acupoints, especially in the waist and shoulder. However, for pain in the thigh, knee, and upper limb, proximal acupoints are used significantly more frequently than distal aucpoints. Similarly, English studies support the preference for distal acupoints for trunk pain and proximal acupoints for limb pain (). The spatial distribution of acupoints also supports the distribution of locations and acupoints, as shown in . Similarly, in Chinese studies on the use of exercise for pain in different locations, acupuncture combined with exercise is more frequently used for pain in the waist and ankle, but less frequently for pain in the upper limb and knee. English studies use acupuncture combined with exercise less frequently, as shown in .

Using “whether combined with exercise” as the dependent variable, and selecting “Painful Location,” “Acupoint Location Strategy,” “Needling Manipulation,” “Needling Angle,” “Type of Acupuncture,” and “Number of Acupoints” as independent variables, univariate and multivariate logistic regression analyses were conducted. In Chinese studies, univariate analysis revealed significant associations between factors such as “Painful Location,” “Acupoint Location Strategy,” and “Type of Acupuncture” with exercise compliance. Multivariate regression analysis further indicated that Ankle pain (OR = 3.87, 95% CI: 1.17–12.86, p = 0.027), Lumbar pain (OR = 3.49, 95% CI: 1.20–10.17, p = 0.022), Distal acupoint selection (OR = 5.32, 95% CI: 3.32–8.53, p < 0.001), Hand acupuncture (OR = 1.87, 95% CI: 1.12–3.13, p = 0.017), and Scalp acupuncture (OR = 5.61, 95% CI: 1.18–26.55) were significantly correlated with exercise. Although the sample size of English literature is small, a significant correlation was still observed between distal acupoint selection and combined exercise (OR = 6.76, 95% CI: 1.48–30.87, p = 0.014), as shown in .

This study underscored acupuncture’s potential significance in treating AMP. Acupoint sensitization appears to bridge disease diagnosis and treatment (, ). Under pathological conditions, sensitized acupoints exhibit a neurogenic inflammation, often resulting in the aggregation of mast cells and immune inflammatory cells in the skin and subcutaneous tissues, as well as the release of inflammatory mediators and active substances (, ). This is thought to form a “sensitization pool” or “inflammatory soup” locally or distally, manifesting as hypersensitivity (aches, swelling, pain, itching) or hyposensitivity in the local skin and muscles, changes in temperature and blood flow, or abnormal skin morphology (nodules, cords, pigmentation), etc. Zhu et al. summarized the patterns of acupoint sensitization in more than 20 types of visceral diseases in China, finding that sensitized acupoints are distributed throughout the body, with dynamic changes in acupoint distribution and reduced pain thresholds (). Acupuncture targeting these acupoints can enhance acupoint function and potentially exert a significant effect with minimal stimulation, thus possibly improving clinical efficacy. Other studies have found that sensitized acupoints dynamically shift from a “resting state” to an “activated state,” with the number of sensitized acupoints decreasing as the disease improves (, ). Consequently, acupuncture targeting these points can yield more pronounced clinical outcomes. Core acupoints are might be viewed as a collection of sensitized acupoints, derived from extensive clinical experience. Distal acupoint selection is particularly unique, may exert its effects through somatosensory-autonomic reflex mechanisms (–). These reflexes are believed to begin with the activation of peripheral nerves derived from neurons in the dorsal root ganglion (DRG) and/or trigeminal ganglion, followed by the spinal cord transmitting sensory information to the brain, activating peripheral autonomic pathways, and ultimately regulating various physiological functions of the body.

Acupuncture combined with exercise therapy is considered an important method for treating AMP, often used in conjunction with hand acupuncture, scalp acupuncture, and distal acupoint selection. Acupuncture combined with exercise has emerged as an increasingly recongnized therapeutic modality. In Chinese, it is mainly described as “Dongqi needle technique” or “exercise therapy,” while English studies use the term MSAT. This approach integrates acupuncture with active or passive movement while needles are retained, potentially amplifying the stimulation effect by moving the muscles being needled, which may result in better regulation of central nervous system neurons and thus a better analgesic effect compared to traditional acupuncture (, ). As a rapidly developing integrated approach in recent years, MSAT has demonstrated superior analgesic and functional improvement effects in numerous clinical studies (, ). The core characteristics include: (1) Acupoints are usually located outside the affected area, especially on the distal healthy side, facilitating movement and avoiding increased local burden. (2) Active, passive, or guided movements are performed simultaneously during acupuncture, such as breathing exercises, Daoyin (guiding and stretching), and muscle stretching. (3) Acupoints are selected concisely, often focusing on the Five-Shu points, Yuan-source points, Xi-cleft points, and Dong’s extraordinary points (). Some studies have also shown that applying Ashi points to the injured area and simultaneously inducing local functional activity can also achieve favorable results (, ). MSAT’s advantage appears to lie in its regulatory capacity to modulate the central nervous system. By retaining the needles and guiding the patient to perform active or passive movements, it is suggested to enhance the activation of subcutaneous high-density A and C fibers, inhibits the activity of long-term potentiation (LTP) and wide dynamic range (WDR) neurons in the spinal cord, and depresses the transmission of pain signals (, ). Moreover, acupuncture promotes the release of endogenous opioid peptides and various neurotransmitters (, ). Regarding acupoint selection strategies, a systematic review indicated that both distal and proximal acupoints exert comparable pain-relief effects through synergistic regulation of peripheral and central nervous systems (). Distal acupoints can influence the limbic-paralimbic-neocortical network, producing a broad-based central analgesic effect (). In this study, distal acupoint selection was used as a closely related method of MSAT, forming an intervention model of “sensitization modulation + distal activation” together with hand acupuncture and scalp acupuncture. For example, scalp acupuncture combined with rehabilitation exercises can improve gross motor function and daily living abilities in children with cerebral palsy (). Hand acupuncture with active exercise can significantly relieve pain and movement disorders in patients with acute neck pain (). Collectively, these results suggest that combining distal sensitized acupoints with motor stimulation may be an optimized treatment strategy (, ).

Compared with current consensus guidelines of acupuncture treatment for acute pain, this study aimed to provide a relatively objective and quantitative basis for acupoint selection and proposes, and explores the potential therapeutic advantages of MSAT. Currently, many studies advocate following the consensus on acupuncture intervention for acute pain in the emergency department (, –). This study, through the Delphi consensus process and following the guidance of the STRICTA framework, emphasized a single targeted treatment course. In most cases of acute pain, distal acupoints are used as primary acupoints, with local acupoints as secondary acupoints. The consensus also reflects various acupuncture methods, such as stimulating local trigger points to induce fasciculations, distal contralateral acupoint selection, and joint-corresponding acupoint selection. Our research results were based on bibliometric and data-driven analysis of clinical studies using a “1-3 acupoints” protocol to treat AMP. These results, along with the consensus, emphasized the principle of distal acupoint selection or anatomical correspondence acupoint selection. This study further explores the location of the disease and acupoint selection strategies. Logistic regression analysis underscored the synergistic value of combining distal, scalp, or hand acupoints with exercise-based therapy. These findings may complement existing consensus treatment approaches. This study provides new evidence that low-dose acupuncture combined with targeted neuromuscular activation may offer a potentially effective alternative in certain acute pain situations.

Current research still has certain limitations. (1) Because the specific modalities, intensity, frequency, and duration of the combined exercise interventions varied substantially across the included studies, we dichotomized exercise into a simple binary variable (with or without). Consequently, the inherent heterogeneity of these exercise regimens may compromise the stability, interpretability, and reproducibility of the odds ratio (OR) estimates. We acknowledge this oversimplification as a methodological limitation of the present study. (2) Although spatial acupoint patterns are evident in clinical practice, the absence of three-dimensional imaging or musculoskeletal structure restricts the mechanistic precision between “specific acupoints and specific pain locations.” (3) Given the significant volume disparity between Chinese and English literature, we did not intend a strict equivalent comparison; rather, to comprehensively identify acupoint patterns and hotspots, the English findings should be interpreted primarily as descriptive and exploratory. (4) Considering that this type of disease includes multiple diseases, there are no statistical outcome indicators, which has a certain impact on the credibility of the acupoint selection strategy. (5) The classification method for distal and proximal acupoints may still involve a certain degree of subjectivity, which could potentially affect the robustness and interpretability of the analytical results.

Treatment of AMP using a limited set of core acupoints is clinically feasible, with MSAT being the most representative technique, exhibiting a clear site-specific acupoint selection pattern. Multivariate analysis further reveals that this strategy is often used in conjunction with distal acupoint selection, hand acupuncture, and scalp acupuncture, showing particularly significant potential therapeutic advantages in acute soft tissue injuries of the lumbar and ankle regions.