BACKGROUND & AIMS
Neck and low back pain are the major musculoskeletal problems effecting people around the globe. Increasing number of researches underpin the effects of cupping in neck and low back pain. However, empirical studies are required to confirm the efficiency of cupping therapy. Therefore, the aim of this review was to examine the efficacy of cupping treatment in non-specific neck and low back pain.
STUDY SELECTION & ELIGIBILITY CRITERIA
This systematic review included Randomised Controlled Trials focused on cupping therapy and its effects on neck and low back pain. Extensive search was performed on Google Scholar, PubMed, MEDLINE and Pedro databases. Studies published from 2009 to 2017 were included.
Eight RCT’s with a 659 sample size were selected for review. Compared to other cupping methods ‘wet cupping’, ‘fire cupping’ and ‘cupping massage’ were superior in reducing pain in neck and low back pain P<0.001. However, a few cupping techniques showed relatively less significant P<0.133, P<0.05, and P<0.037 in comparison to previously mentioned methods.
Cupping therapy can be beneficial in alleviation of non-specific cervicalgia and lumbago in short-term. However, due to weak evidence and a small sample size, the study was restricted from drawing a definite conclusion. Future high-level evidence and research work is required for confirmative and conclusive recommendation of cupping in clinical settings for musculoskeletal pain.
Low back pain, Neck pain, Prevention, Rehabilitation, Spine, Disease, Therapeutic.
[Rasool D.Therapeutic Effect of Cupping on Non-Specific Neck and Low Back Pain-A Systematic Review. Pak. j. rehabil.2020; 9(1): 04-10]
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Low back pain (LBP) and neck pain (NP) are among the most common problems people suffer from in their life throughout the world1. NP is a predominant musculoskeletal condition affecting people of different age groups, including young adult to old age individuals2. Almost 60% to 80% of people suffer from LBP at some stage of their life3. Similarly, higher prevalence of neck pain persists in individuals with an average of nearly 50% in their lifetime4. Besides these worrying figures, the positive aspect is that people usually recover quickly following an episode of LBP and NP. Etiological factors of NP and LBP are many including inflammatory disease, joint disorder, musculoskeletal origin, degenerative diseases, poor posture, working for extended hours, driving for long durations7,8. Tension headache and migraine attacks are considered as risk factors of NP9. Most of the time a generalised term ‘LBP’ and ‘NP’ is used in the diagnosis index for a patient suffering from LBP and NP thus, indicating that mostly diagnosis is given as nonspecific LBP, either acute or chronic10. However, 20% of LBP patients5 and 10% of NP patients6 suffering from acute pain, go into the chronic phase. Due to chronic LBP, quality of life is compromised, which leads to further deterioration of a person’s well-being, social relationship and physical abilities11. Similarly, severe NP attributes to compromised daily activities leading to psychological issues12. There is limited evidence of definitive treatment for non-specific chronic neck pain13. Conventional treatment such as medication and even surgery does not always guarantee the patient will be pain free14. Usually such patients apply home remedies to reduce their pain and discomfort15. In a patient population as such, there is a paradigm shift towards complementary therapy such as acupuncture, manual therapy and cupping therapy. In comparison to other pharmacological treatment, cupping therapy is an inexpensive, non-invasive and low-risk modality16.
Since the last decade, there has been an increase in the trend of using cupping therapy for relieving LBP and NP in Middle East countries and China17. Cupping therapy is increasingly gaining popularity amongst athletes and Hollywood stars18. Since almost a decade there is lot of research being conducted on effects of cupping in different clinical conditions19,20. Cupping therapy is an old Chinese technique used for treating musculoskeletal, neuromuscular and other clinical conditions21. It has originated from Traditional Chinese medicine that prevailed thousands of years ago22. Cupping therapy is extremely helpful in different musculoskeletal conditions, arthritis, inflammatory disorders and other clinical conditions23. It is mostly done for relief from LBP and NP. There are different kinds of cupping methods available including holding, moving, shaking, fire and quick cupping. Two most commonly used techniques are “dry and wet cupping”24. Dry cupping is a method in which a plastic or silicon cup is placed on the skin and blood is drawn via suction method25. On the other hand, blood is drawn from lacerated skin into the cup in ‘wet cupping’
procedure26. Other techniques used are fire cupping, pulsatile cupping, cupping massage and moving cupping. However, basic principle of cupping is to increase blood flow and body energy27. A systematic review conducted on the effects of cupping on chronic back pain in 2018 concluded a positive impact of cupping in the selected population28. Another review was done regarding the outcome of cupping in the neck pain population only. To date, only one review was done back in 2015 which was suggestive of high-level of scientific studies to affirm the claims of published studies. Heterogeneity in studies and low-quality evidence are suggestive of rigorous appraisal of current literature. Therefore, this review will investigate previous and updated available literature about the effectiveness of cupping in nonspecific NP and LBP.
The systematic review has followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
DATA SOURCES AND SEARCHING STRATEGIES
Following databases were searched; Google scholar, PUBMED, Physiotherapy Evidence Database and Pedro. Since there are limited publications therefore, search was conducted from 2009 to 2020 in order to include all valuable research work. Keywords used were “cupping”, “neck pain”, and “low back pain”. Literature was searched related to various kind of cupping including dry, wet and pulsatile cupping. Moreover, cupping therapy itself or in combination with neck and low back pain were also searched.
ELIGIBILITY CRITERIA OF STUDIES
Searched literature was filtered by time frame. Data from 2009 to 2017 was included. Eligibility criteria for the studies to be included was Randomised Controlled Trials (RCT). Single and double blinded RCT’s using any form of control in comparison with cupping were included. Furthermore, cupping therapy of any kind was used including dry cupping; wet cupping; empty cupping; moving cupping; medicinal cupping; needling cupping were examined for its outcome. Studies were excluded if they failed in showing the randomisation process.
Pain was used as the main outcome measure in this study regardless of etiology. It must be assessed by Visual Analogue Scale (VAS), McGill Present Pain Index (PPI), and Oswestry Pain Disability Index (ODI) or by any other validated tool for pain measurement that should be self-reported or physician mentioned pain score. Moreover, additional outcomes were explored including quality of life reported by patient or physician.
Subjects of all age groups with neck and low back pain, either acute or chronic were included to assess the outcome of intervention (cupping) used.
RISK OF BIAS
The quality appraisal of the eligible studies was assessed and risk of bias was measured on six domains comprised of random sequence, allocation concealment, participants blinding, outcome assessment blinding, incomplete outcome data and selective reporting respectively.
|110||group and no|
|Teut et al27 .||Pulsatile||intervention||Twice||p=0.063|
|2018||(49.0± 13.7||cupping on||4 to 12||p=0.133|
|was allowed for|
|Yazdanpanahi et||150||Dry cupping||SF McGill pain||Thrice|
|al . 2017||(25 ± 4.2||LBP||2 weeks|
|Saha et al .||massage on||VAS||weekly||P<0.037|
|2017||(52.6± 10.3||medical care|
|Chi et al14.||60||Fire cupping||Not|
|2016||(43.6± 8.0||on NP||mentioned|
|Albedah et al29.||80||on||No treatment,||Thrice|
|2015||(36.48± 9.3||(Acetaminop||(Acetaminophen)||Rating Scale||weekly||1|
|Lauche et al18.||61||Cupping||Progressive||VAS||Twice||P<0.001|
|2013||massage on||muscle relaxation||weekly|
|(54.1± 12.7||NP||3 months|
|Cramer et al30.||(6.17 ±||Wet cupping||VAS||P<0.001|
|2011||on NP||medical care with||NDI||weekly|
|12.21||GP/Orthopedics||for 2 weeks|
- √ Indicate low-risk of bias
- x Indicate high-risk of bias
- ? Indicate high-risk of bias
Initially when a combination of a search term was used, it showed limited results. When the search term ‘cupping therapy’ was used on databases, it yielded 1200 results on Google scholar whereas, this number dropped down to 673 when the same keywords were used on PubMed. This trend continued and the figures plunged to 69 at Pedro database. Following reading of relevant headings and abstract, full-text article were stratified. As a consequence, eight studies which assessed cupping therapy effects on neck and low back pain are selected for review.
Characteristics of Included Trials
From eight included studies, a total of 659 sample size was included. Among selected studies three are conducted in Germany, two in Iran, one in Taiwan, one in Norway and one in Saudi Arabia. All of this research work is published in English. Female percentage in all the included studies is higher (70%) than that of men.
Among selected studies, four are conducted on effects of cupping on low back pain17,27,29,31. Similar numbers of researches are done in the neck pain population14,18,28,30. Out of eight trials, three studies are done to assess the outcome of wet cupping in NP and LBP9,10,25. Cupping massage effects are examined in NP in two studies18,28. Furthermore, dry cupping, fire cupping and pulsatile cupping techniques are used to investigate the efficacy of cupping in LBP and NP in an individual study14,17,27. No comparison of cupping with sham or other complementary medicine technique were done in two trials14,18. However, only one study had a comparison of cupping with acupressure and control group21. On the other hand, patients were allowed to take medications for pain relief with cupping in a control group in four trials27,29,30,31. In the included studies, the primary outcome (pain) is measured by either VAS, Numeric rating scale (NRS), McGill pain questionnaire, Short form MPQ SF-36, and the Present Pain Index (PPI). The description is depicted in Table-1.
Risk Of Bias In Included Studies
Almost all the trials used concealed the method of sample randomisation apart from one study which did not mention sample randomisation method17. That sample were blinded to the intervention in only two studies27,28. On the other hand, therapists were not blinded in all the included research studies. Similarly, assessors in the studies were also non-blinded. Details mentioned in Table-2.
A variety of cupping techniques are being used in included trials. Wet cupping is used in three research studies29,30,31, whereas two trials were conducted on cupping massage technique18,31. On the other hand, dry, fire and pulsatile cupping methods were used in individual studies. Among all, wet cupping and cupping massage technique appears superior to other methods in terms of reducing pain (p<0.001).
Effects Of Intervention
The effect of cupping therapy was assessed mainly by VAS in multiple studies. It included neck and low back pain. Neck and LBP, both conditions were treated whether it was chronic or acute. Therefore, outcome of cupping was assumed to be gross when assessed by VAS. On the other hand, a couple of trials used different tool such as, short form McGill present pain index to investigate the effects of cupping in patients.
Comparison Of Intervention With Control Group
In the included trials, comparison was done between cupping/treatment group (TG) and control group (CG). Three studies investigated the outcome of wet cupping and compared it with the control group. Firstly, NRS score was found to be statistically significant upon comparison with control group at a 4 weeks’ time 24.4 (19.7–29.1) 56.3 (51.6–60.9) P value 0.000129. Secondly, another study also claimed that the wet-cupping group had significantly lower levels of pain intensity ([95% confidence interval (CI) 1.72—2.60] mean difference = 2.17, p < 0.01)31. Thirdly, not much statistically significant difference between TG and CG was found. Mean intensity was 4.45 ± 2.17, and 4.18 ± 1.90 respectively, group difference at 95% CI was 0.28 (–0.91; 1.46) and p value was 0.6430.
Furthermore, other trials conducted on assessing fire cupping outcome in NP also found a significant difference between TG from 9.7 to 3.6 and CG 9.7 to 9.5, P<0.001 following treatment14. In addition, dry cupping findings were also convincing following 2 weeks of intervention. Baseline readings in TG 31.8 ± 10.8, CG 31.8 ± 9.8, p-value 0.1. This changed dramatically following 2 weeks post intervention in TG 4.1±3.6, CG 14.0 ± 5.2, p value 0.00117.
On the other hand, cupping massage result was not found to be promising when compared baseline figures of TG and CG 49.8 ± 21.8, 45.1 ± 16.3 and following 3 weeks of intervention 29.9 ± 22.9, 42.8 ± 15.8 respectively, –14.3 (–27.7; –1.0), P-value 0.03728. Similar results were obtained in the other study as well. VAS at baseline in TG and CG was 55.86±19.7, 56.36±18.6 respectively. Following 12 weeks of intervention it decreased in TG to 39.86±30.0, CG 45.26±23.5 and estimate group difference at 12 weeks was -0.16 (-13.90;13.55) and p value was 0.9818. Likewise, findings were obtained in the pulsatile cupping technique. Baseline readings of TG and CG were 53.2 ± 7.4 and 59.9 ± 12.8, following 12 weeks, mean adjusted VAS pain intensity was lower for pulsatile cupping vs. control 15.1 (3.1±27.1), p =0.014)27.
Cupping therapy can be a useful tool in adjunct to available treatment options in complementary medicine therapy. Studies conducted on the effects of cupping in other clinical conditions also acknowledged it to be an effective tool to lessen the pain in chronic and acute conditions. Cupping is found to be effective in treating Fibromyalgia16, carpal tunnel syndrome18 and in critical conditions17. Among different cupping techniques, wet cupping procedure was suggested to be an effective tool in reduction of pain9,10,25. In these studies, pain score dropped dramatically following two weeks of cupping treatment. However, the major disadvantage of these studies was the use of pain medication not only in the intervention group, but also in controlled group. This might be the main factor of swift reduction in pain in both groups. Thus, raising questions upon the direct impact of cupping in alleviation of pain. Additionally, none of these trials used placebo for comparison of their intervention. Thus, it is difficult to confirm the conclusion drawn by the authors of these trials. Similar results were obtained in a study which used the fire cupping technique3. This study has many flaws including no blindness of sample, therapist, and no comparability. Lastly, although the pain intensity reduced in a short time, the overall duration of intervention used was not mentioned, which again places doubt in the mind regarding the clarity of the trial.
Furthermore, other studies also ascertain that pain reduced moderately in people treated by cupping massage method23,26. Nevertheless, there is a major difference between the outcomes in both trials in terms of pain relief. Pain intensity went down by more than 50% in three weeks23 only, whereas pain reduced by 25% following three months of treatment in the other trials26 in chronic neck pain patients. Therapists and patients both were not blinded, small sample size and incomparability with other treatment groups are few of the short comings of these research work23,26. In comparison to the above excellent outcome, not much of a significant result was obtained when pulsatile cupping intervention was used for up to 12 weeks19. A similar kind of drawback was found in this study as well as discussed above. In spite of pain medication intake being allowed, the pain score did not decrease much. A whole trial was conducted and concluded by the same therapist involved in cupping. Hence, there is a high chance of bias in the conclusion of the trial. Moreover, various kinds of cupping techniques has been used in the studies. The biggest drawback of wet cupping is that it is not applicable for all people and all age groups13. Due to the sparse technique used, it is extremely difficult to confirm which type of therapy is effective in treating NP and LBP. Paucity of high-level of evidence is lacking in the current available literature.
Additionally, all the studies have a small sample size, weak strength of studies and no comparison of cupping with placebo are the major drawbacks of the current literature. Furthermore, a considerable number of people left the study including the experimental group during research work. This raises doubt on the conduct, transparency and efficiency of the study and its outcome.
Similarly, there is ambiguity in the specific points of cupping for LBP and NP. These findings could be due to the fact that it is still not a widely used treatment method in clinical settings around the world. Additionally, many people do not trust complementary medicine techniques due to its lack of evidence. Thus, the sample size remains the core issue in the available studies. As a consequence, implication of cupping therapy in clinical settings cannot be emphasised due to lack of strong evidence.
Besides the above discussed issues, the number of available scientific research is limited. Only eight studies were found for analysis regarding the efficacy of cupping, which is a very low number. More research work has been done, but it is not in English and has not been included in this review. Hence, the limitation of this review is the unavailability of studies to draw a definitive conclusion.
Cupping therapy can be a useful adjunct to the other available conventional methods for nonspecific NP and LBP. Current research suggests pain reduction with cupping therapy treatment. However, limited studies, low-quality studies, weak evidences and a small sample size in published trials are suggestive of future high-quality studies for affirmative conclusion.
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- Al-Bedah AM, Aboushanab TS, Alqaed MS, Qureshi NA, Suhaibani I, Ibrahim G, Khalil M. Classification of cupping therapy: a tool for modernization and standardization. J Altern Complement Med. 2016 :1-0.
- Moura CD, Chaves ÉD, Cardoso AC, Nogueira DA, Corrêa HP, Chianca TC. Cupping therapy and chronic back pain: systematic review and meta-analysis. Revista latino-americana de enfermagem. 2018;26.
- Cao H, Li X, Yan X, Wang NS, Bensoussan A, Liu J. Cupping therapy for acute and chronic pain management: a systematic review of randomized clinical trials. J Tradit Chin Med. 2014 ;1(1):49-61.
- Tagil SM, Celik HT, Ciftci S, Kazanci FH, Arslan M, Erdamar N, Kesik Y, Erdamar H, Dane S. Wet-cupping removes oxidants and decreas-es oxidative stress. Complementary therapies in medicine. 2014;22(6):1032-6.
- Hanan S, Eman S. Cupping therapy (al-hija-ma): It’s impact on persistent non-specific lower back pain and client disability. Life Sci J. 2013;10(4):631-42.
- Markowski A, Sanford S, Pikowski J, Fauvell D, Cimino D, Caplan S. A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. The J Altern Complement Med. 2014;20(2):113-7.
- Chechet EA, Isaikin AI. Management of patients with headache and cervicalgia in outpatient practice. Neurology, Neuropsychi-atry, Psychosomatics. 2016;7(4):71-7.
- Al-Bedah AM, Elsubai IS, Qureshi NA, Aboushanab TS, Ali GI, El-Olemy AT, Khalil AA, Khalil MK, Alqaed MS. The medical perspective of cupping therapy: Effects and mechanisms of action. Journal of traditional and comple-mentary medicine. 2019;9(2):90-7.
- Al Bedah AM, Khalil MK, Posadzki P, Sohaibani I, Aboushanab TS, AlQaed M, Ali GI. Evaluation of wet cupping therapy: systematic review of randomized clinical trials. J Altern Comple-ment Med. 2016;22(10):768-77.
- Razzaq T, Khan MA, Zehra N. Public awareness towards cupping therapy in Karachi. PJMD. 2013;2(04):18
- Khalil MK, AlSanad S. The Compound Effect of Cupping Therapy: Searching Beyond the Meridians. J Acupunct Meridian Stud. 2018;35(3):101-3.
- Jacobs WC, Rubinstein SM, Willems PC, Moojen WA, Pellisé F, Oner CF, Peul WC, van Tulder MW. The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J 2013;22(9):1936-49. Chi LM, Lin LM, Chen CL, Wang SF, Lai HL, Peng
- The effectiveness of cupping therapy on relieving chronic neck and shoulder pain: a randomized controlled trial. Evidence-Based Complementary and Alternative Medicine. 2016.
- Qureshi NA, Ali GI, Abushanab TS, El-Olemy AT, Alqaed MS, El-Subai IS, Al-Bedah AM. History of cupping (Hijama): a narrative review of litera-ture. Journal of integrative medicine. 2017;15(3):172-81.
- Samadi M, Kave M, Mirghanizadeh S. Study of cupping and its role on the immune system. J Relig Health. 2013;1:59-65.
- Yazdanpanahi Z, Ghaemmaghami M, Akbar-zadeh M, Zare N, Azisi A. Comparison of the effects of dry cupping and acupressure at acupuncture point (BL23) on the women with postpartum low back pain (PLBP) based on Short Form McGill Pain Questionnaires in Iran: a randomized controlled trial. 2017 ; 11(2):82-89.
- Lauche R, Materdey S, Cramer H, Haller H, Stange R, Dobos G, Rampp T. Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain—a randomized controlled trial. PloS one. 2013 7;8(6):653-78.
- El-Olemy AT, Al-Bedah AM, Almosilhi AH, Almu-sailhi JA, Hussein AA, Khalil M, Aboushanab TS, Elsubai IM, Alqaed MS, Ali GI, Al-Eidi S. Cupping Therapy (Al-Hijamah): An Exploratory Study of Healthcare Professionals Controversial Beliefs and Conceptions, Kingdom of Saudi Arabia. Journal of Complementary and Alternative Medical Research. 2017 7:1-1.
- Emerich M, Braeunig M, Clement HW, Lüdtke R, Huber R. Mode of action of cupping—local metabolism and pain thresholds in neck pain patients and healthy subjects. Complementa-ry therapies in medicine. 2014 ;22(1):148-58.
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- Ganesan S., Acharya AS, Chauhan R., Acharya S. Prevalence and risk factors for low back pain in 1,355 young adults: a cross-sectional study. Asian Spine J. 2017;11(4):610–617
- Chen B, Li MY, Liu PD, Guo Y, Chen ZL. Alterna-tive medicine: an update on cupping therapy. QJM:. 2014 ;108(7):523-5.
- Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for treating pain: a systematicreview. Evidence-Based Complementary and Alterna-tive Medicine. 2011.
- Cao H, Li X, Yan X, Wang NS, Bensoussan A, Liu J. Cupping therapy for acute and chronic pain management: a systematic review of randomized clinical trials. J Tradit Chin Med. 2014 ;1(1):49-61.
- Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM. Cupping therapy and chronic back pain: systematic review and meta-analysis. Rev. Latino-Am. Enfermagem. 2018;26: e3094.
- Teut M, Ullmann A, Ortiz M, Rotter G, Binting S, Cree M, Lotz F, Roll S, Brinkhaus B. Pulsatile dry cupping in chronic low back pain–a random-ized three-armed controlled clinical trial. BMC complementary and alternative medicine. 2018 ;18(1):115.
- Saha FJ, Schumann S, Cramer H, Hohmann C, Choi KE, Rolke R, Langhorst J, Rampp T, Dobos G, Lauche R. The effects of cupping massage in patients with chronic neck pain-a randomised controlled trial. Complementary medicine research. 2017;24(1):26-32.
- AlBedah A, Khalil M, Elolemy A, Hussein AA, AlQaed M, Al Mudaiheem A, Abutalib RA, Bazaid FM, Bafail AS, Essa A, Bakrain MY. The use of wet cupping for persistent nonspecific low back pain: randomized controlled clinical trial. The J Altern Complement Med 2015 ;21(8):504-8.
- Cramer H, Lauche R, Hohmann C, Choi KE, Rampp T, Musial F, Langhorst J, Dobos G. Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Complementary Medicine Research. 2011;18(6):327-34.
- Farhadi K, Schwebel DC, Saeb M, Choubsaz M, Mohammadi R, Ahmadi A. The effective-ness of wet-cupping for nonspecific low back pain in Iran: a randomized controlled trial. Complementary therapies in medicine. 2009 ;17(1):9-1