Dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with non-specific chronic low back pain: a randomised trial

Use of cupping therapy in musculoskeletal disorders: A cross-sectional study on the profile, training, and practice of Brazilian physical therapists

INTRODUCTION

Cupping therapy is a widely used technique in Brazilian physical therapy for the treatment of musculoskeletal disorders. However, there is limited scientific evidence to support its effectiveness.

OBJECTIVE

To investigate the profile, training, clinical practice, and scientific updates of Brazilian Physical Therapists who use cupping therapy as a therapeutic resource for musculoskeletal disorders.

METHODS

A cross-sectional study was conducted through an online questionnaire, including 646 Physical Therapists who use cupping therapy in their practice. All data were analysed descriptively.

RESULTS

Cupping therapy is a technique that has been widely adopted in clinical practice by Physical Therapists, particularly among young, female professionals who have recently graduated from private universities. The primary reason for interest in this technique among these Physical Therapists is the high demand from patients. Additionally, it is often used in conjunction with other manual therapeutic techniques. They identified easy access, low cost, and ease of use as the key factors that make cupping therapy an attractive option. However, a lack of high-quality scientific evidence, as described in the literature, was identified as a major barrier to its use.

CONCLUSION

The Physical Therapists included in this study use cupping therapy in their clinical practice, relying heavily on their own experience and the preferences of their patients, rather than utilizing the third pillar of evidence-based practice, which is to rely on the best available evidence. This study suggests that these Physical Therapists are currently implementing a technique without current scientific recommendations for its use in the treatment of musculoskeletal disorders.

The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials

OBJECTIVES

This study aims to investigate the effectiveness of cupping therapy on low back pain (LBP).

METHODS

Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included in this study. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).

RESULTS

Eleven trials involving 921 participants were included. Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p = 0.004). There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p = 0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p = 0.11). Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p = 0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p = 0.008) at the endpoint intervention. There was no evidence indicating the association between pain reduction and different types of cupping (p = 0.2). Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p = 0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p = 0.78) at the endpoint intervention. Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p < 0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p = 0.29). A potential association between pain reduction and different cupping locations (p = 0.05) was found. Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n = 8; d=1.8 [95% CI: 1.22 - 2.39], p < 0.001) and usual care (n = 5; d=1.07 [95% CI: 0.21- 1.93], p = 0.01). Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 h, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p < 0.001). Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p = 0.03). There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p = 0.39). A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).

CONCLUSION

High- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The actual therapeutic effects of cupping could be confirmed by using objective pain assessments. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.

TRIAL REGISTRATION

This systematic review was initially registered on PROSPERO with registration code: CRD42021271245 on 08 September 2021.

Using multi-channel near-infrared spectroscopy to assess the effect of cupping therapy on the spatial hemodynamic response of the biceps muscle: A preliminary study

BACKGROUND

The local hemodynamic response after cupping therapy has been considered as a contributing factor for improving muscle tissue health; however, the effects of cupping pressure and duration on the spatial hemodynamic response have not been investigated.

OBJECTIVE

The objective of this study was to investigate the hemodynamic response inside and outside the cupping cup under various pressures and durations of cupping therapy.

METHODS

A 3-way factorial design with repeated measures was used to investigate the main and interaction effects of the location (areas inside and outside the cup), pressure (-225 and -300 mmHg) and duration (5 and 10 min) on the hemodynamic response of the biceps muscle. A functional near-infrared spectroscopy was used to assess hemodynamic changes in 18 participants.

RESULTS

A significant three-way interaction of the location, pressure, and duration factors was observed in oxyhemoglobin (p= 0.023), deoxy-hemoglobin (p= 0.013), and blood volume (p= 0.013). A significant increase was observed in oxyhemoglobin, blood volume, and oxygenation compared to pre-cupping (p< 0.05) in the area outside the cup.

CONCLUSION

Our findings indicate that an appropriate combination of cupping pressure and duration can effectively affect the spatial hemodynamic response of the biceps.

Efficacy of cupping therapy on pain outcomes: an evidence-mapping study

Objective

Cupping therapy is an ancient technique of healing used to treat a variety of ailments. An evidence-mapping study was conducted to summarize the existing evidence of cupping therapy for pain-related outcomes and indicate the effect and the quality of evidence to provide a comprehensive view of what is known.

Methods

PubMed, Cochrane Library, Embase, and Web of Science were searched to collect the meta-analyses investigating the association between cupping therapy and pain-related outcomes. The methodological quality was assessed by using the AMSTAR 2 tool. Significant outcomes (p < 0.05) were assessed using the GRADE system. The summary of evidence is presented by bubble plots and human evidence mapping.

Results

Fourteen meta-analyses covering five distinct pain-related conditions were identified and assessed for methodological quality using the AMSTAR 2, which categorized the quality as critically low (36%), low (50.0%), moderate (7%), and high (7%). In accordance with the GRADE system, no high-quality evidence was found that demonstrates the efficacy of cupping therapy for pain-related outcomes. Specifically, for neck pain, there were two moderate-quality, four low-quality, and two very low-quality evidence, while only one very low-quality evidence supports its efficacy in treating herpes zoster and one low-quality evidence for chronic back pain. Additionally, for low back pain, there were two moderate-quality, one low-quality, and four very low-quality evidence, and for knee osteoarthritis, three moderate-quality evidence suggest that cupping therapy may alleviate pain score.

Conclusion

The available evidence of very low-to-moderate quality suggests that cupping therapy is effective in managing chronic pain, knee osteoarthritis, low back pain, neck pain, chronic back pain, and herpes zoster. Moreover, it represents a promising, safe, and effective non-pharmacological therapy that warrants wider application and promotion.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255879, identifier: CRD42021255879.

Hemorphin-Based Analgesia: A Mechanism of Cupping Technique?

Background and Objective

Cupping is a time-honoured traditional healing modality for pain management and remains favoured by professionals and lay people across several cultures today. However, the analgesic mechanism of cupping is still poorly understood. In addition, clinical guidelines for standardized applications of cupping are currently lacking. The awareness of cupping marks has provoked curiosity about the connection between skin color changes and their benefit for local pain relief. Computer simulation is a promising approach for numerical modeling the cupping-evoked erythrocyte emigration. Quantitative proteomic profiling of cupping-induced blister fluid exhibited a significant decrease in the abundance of haemoglobin β subunit. This finding provides a critical clue to paint a novel picture of the mechanism behind cupping. The hemorphins are a set of non-classical opioid peptides derived from the proteolysis of haemoglobin β subunit. In the present study, a probable mechanism of hemorphin-based cupping analgesia is proposed. The hemorphin could also act as a potential biomarker for objective and timely quantitative clinical assessment of cupping in the management of pain conditions. A seminal theory may open a new avenue for future translational research on promoting the efficacy and safety of cupping analgesia.

Conclusion

The local analgesic effect of cupping is probable in the context of haemoglobin degradation that bestows the appearance of hemorphins along with engaging opioid receptor signalling. Exploring the potential novel mechanism of cupping analgesia facilitates seeking non-pharmacologic pain interventions.

Anatomical Points of Cupping Therapy for Musculoskeletal Pain: A Systematic Review

Background: The prevalence of musculoskeletal pain is rising and plays a substantial role in disease and disability worldwide. There have been several previous studies on cupping therapy’s effectiveness in reducing musculoskeletal pain. However, studies that specifically review the literature on cupping points to reduce musculoskeletal pain are lacking.Purpose: This study aimed to identify the anatomical points of cupping therapy for musculoskeletal pain.Methods: A systematic review was employed. PubMed, ScienceDirect, and Google Scholar were used for the search process. The screening was performed based on inclusion and exclusion criteria. Crowe Critical Appraisal Tool (CCAT) was used to measure the quality of the articles. Standardized forms were used to extract essential characteristics from articles, including study design, participant and sample, and results. Data were narratively analyzed for thematic synthesis.Results: From a total of 1,045 articles acquired, eight articles were included in data synthesis. All articles were randomized control trials (RCT) design. Seven regions of cupping points were identified, including upper-middle-lower fibres of the trapezius muscles, the inter-scapular area around the 2-4th vertebrae torachalis, the sacrum area, between the lower vertebrae and the coccyx bone, the 1-5th vertebrae lumbalis, the 3-5th vertebrae lumbalis, knee joint, and lower border of the spinous process of the second lumbar vertebra (L2).Conclusion: Seven anatomical points of cupping therapy for musculoskeletal pain were identified by this systematic review based on studies. Single research could not define the whole range of advantages of each point. To support the previously described theories regarding cupping and develop new ones, future novel scientific studies are also required.

Effectiveness of self-management of dry and wet cupping therapy for low back pain: A systematic review and meta-analysis

BACKGROUND

Low back pain (LBP) can significantly affect a person's quality of life. Cupping has been used to treat LBP. However, various cupping methods are typically included in evaluating the efficacy of cupping therapy. Therefore, the objectives of this study were to evaluate the evidence from the literature regarding the effects of dry and wet cupping therapy on LBP in adults. Dry and wet cupping therapy are analyzed categorically in this study.

METHODS

We searched for randomized clinical trials with cupping in LBP published between 2008 and 2022. In dry or wet cupping clinical studies, pain intensity was assessed using the Visual Analogue Scale and present pain intensity, and the quality of life intensity was measured using the Oswestry disability index.

RESULTS

The 656 studies were identified, of which 10 studies for 690 patients with LBP were included in the meta-analysis. There was a significant reduction in the pain intensity score with present pain intensity using wet cupping therapy (P < .01). In addition, both cupping therapy groups displayed significant Oswestry disability index score reduction compared to the control group (both P < .01). The patients with LBP have a substantial reduction by using wet cupping but have not shown a considerable decrease by using dry cupping (P = .19). In addition, only wet cupping therapy groups displayed a significantly improved quality of life compared to the control group. The study had a very high heterogeneity (I2 > 50%). It means there is no standardization in the treatment protocol in randomized clinical trials. In the meta-regression, there was statistically significant evidence that the number of treatment times and intercepts were related (P < .01).

CONCLUSION

The present meta-analysis shows that wet cupping therapy effectively reduces the pain intensity of LBP. Furthermore, both dry wet cupping therapy improved patients with LBP quality of life.

Exploring patient experiences of participating in a real and sham dry cupping intervention for nonspecific low back pain: A qualitative study

Background

The current quality of evidence supporting dry cupping for individuals with chronic low back pain (CLBP) is low and suggests that nonspecific factors impact experiences reported by patients. Therefore, this study assessed the impacts of social and professional support on the experience of individuals with CLBP treated with dry cupping or sham.

Method

This is an observational study with qualitative approach. Twenty-four individuals with CLBP who received dry cupping or sham in a previous clinical trial were invited. Data was collected using a semi-structured interview conducted by a trained researcher. Content analysis was used to analyze experiences, systematic procedures, and description of the content of messages. The dimensions of “pain”, “general perceptions”, and “perceived social and professional support” guided the analysis.

Results

Answers of both groups converged on similar perceptions, especially regarding pain. Physical condition was the most fragile aspect. We also observed an influence of perceived social and professional support on painful symptoms. Thus, the experience of individuals with CLBP treated with dry cupping or sham indicated that factors related to social and professional support impacted results.

Conclusions

We observed that individuals with CLBP reported similar perceptions of the effects of dry cupping or sham treatment, indicating that contextual factors may influence the perception of these individuals regarding the treatment received.