Cupping therapy and chronic back pain: systematic review and meta

Review Article

Rev. Latino-Am. Enfermagem

2018;26:e3094

DOI: 10.1590/1518-8345.2888.3094

www.eerp.usp.br/rlae

Universidade Federal de Minas Gerais, Escola de Enfermagem, Belo Horizonte, MG, Brazil.

Universidade Federal de Alfenas, Escola de Enfermagem, Alfenas, MG, Brazil.

Universidade Federal de Alfenas, Instituto de Ciências Exatas, Alfenas, MG, Brazil.

Cupping therapy and chronic back pain: systematic review

and meta-analysis

Caroline de Castro Moura

Érika de Cássia Lopes Chaves

Ana Carolina Lima Ramos Cardoso

Denismar Alves Nogueira

Hérica Pinheiro Corrêa

Tânia Couto Machado Chianca

Objectives: to evaluate the evidence from the literature regarding the eects of cupping therapy

on chronic back pain in adults, the most used outcomes to evaluate this condition, the protocol

used to apply the intervention and to investigate the eectiveness of cupping therapy on the

intensity of chronic back pain. Method: systematic review and meta-analysis carried out by two

independent researchers in national and international databases. Reference lists of systematic

reviews were also explored. The quality of evidence was assessed according to the Jadad scale.

Results: 611 studies were identied, of which 16 were included in the qualitative analysis and 10

in the quantitative analysis. Cupping therapy has shown positive results on chronic back pain.

There is no standardization in the treatment protocol. The main assessed outcomes were pain

intensity, physical incapacity, quality of life and nociceptive threshold before the mechanical

stimulus. There was a signicant reduction in the pain intensity score through the use of cupping

therapy (p = 0.001). Conclusion: cupping therapy is a promising method for the treatment of

chronic back pain in adults. There is the need to establish standardized application protocols for

this intervention.

Descriptors: Review; Chronic Pain; Back Pain; Cupping Therapy; Meta-Analysis; Nursing.

How to cite this article

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. [Access ___ __ ____];

Available in: ___________________ . DOI: http://dx.doi.org/10.1590/1518-8345.2888.3094.

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Rev. Latino-Am. Enfermagem 2018;26:e3094.

Introduction

Chronic back pain causes physical, emotional and

socioeconomic changes

(1-3)

and, consequently, high use

of medicines and health resources

(4)

. The search for

demedicalization leads to an increasing use of integrative

and complementary practices, such as Traditional

Chinese Medicine (TCM) resources, to complement

pain-related allopathic care

(5)

. Cupping therapy is one

of the recommended TCM therapies for chronic pain

reduction

(6)

. It involves the application of cups of dierent

materials

(7)

in an acupoint or area of pain by means of

heat or vacuum apparatus

(8)

The eect on pain reduction has not yet been

fully elucidated

(9)

, but dierent mechanisms of action,

based on several assumptions

(10)

, are attributed to

cupping therapy, such as the metabolic, neuronal

hypotheses

(9,11)

and TCM

(12)

. Evidence of the ecacy of

this intervention is limited because of the lack of high

quality, well-delineated randomized controlled trials

(RCTs)

(6)

that result in validated and ecient protocols

for the treatment of chronic back pain. Therefore, this

study aims to evaluate the literature evidence regarding

the eects of cupping therapy on chronic back pain in

adults compared to sham, active treatment, waiting list,

standard medical treatment or no treatment, outcomes

most commonly used to assess this condition, the

protocol used to apply the intervention and subsequently

investigate the eectiveness of cupping therapy on the

intensity of chronic back pain.

Method

A systematic review of the literature was performed,

followed by meta-analysis, used to determine the

intensity of back pain in adult clients. The study was

based on the criteria of the Preferred Reporting Items

for Systematic Reviews and Meta-Analyzes (PRISMA

Statement)

(13)

The PICO (P - population; I - intervention; C -

comparison; O - outcomes)

(14)

guided the elaboration of

the guiding question: “What are the eects of cupping

therapy on adults with chronic back pain?”

The search strategy, carried out by two independent

reviewers from June 2017 to May 2018 was based on

the following databases: Medical Literature Analysis

and Retrieval System Online (MEDLINE) via the US

National Library of Medicine National Institutes of

Health (PUBMED), Web of Science, The Cumulative

Index to Nursing and Allied Health Literature (CINAHL),

Physiotherapy Evidence Database (PEDro), Embase,

Scopus, as well as databases indexed in the Virtual

Health Library (VHL), such as Latin American &

Caribbean Health Sciences Literature (LILACS) and

the National Information Center of Medical Sciences of

Cuba (CUMED). Reference lists of systematic reviews

were also explored in the search for relevant studies

related to the guiding question.

The terms, controlled and free, were combined by

means of the Boolean operators OR and AND as follows:

(“Back Pain” OR “Low Back Pain” OR “Sciatica” OR “Chronic

Pain” OR “Musculoskeletal Pain” OR Myalgia OR “Neck

Pain” OR “Low Back Pains” OR “Musculoskeletal Pains”

OR “Muscle Pain” OR “Neck Pains” OR “Cervical Pain” OR

“Cervical Pains” OR Lumbago OR “lumbar pain”) AND

(“cupping therapy” OR cupping OR cups).

The eligibility criteria for the selection of articles were:

RCT with adults (18 years or older); chronic pain (for three

months or more)

(15)

in at least one of the segments of the

spine (cervical, thoracic and/or lumbar); use of cupping

therapy (dry, wet, massage, ash)

(7)

compared to one or

more of the following groups: sham, active treatment,

waiting list, standard medical treatment, or no treatment.

We excluded studies that did not present online abstract

in full for analysis, those that were not located by any

means and studies with pregnant women.

In order to collect the information from the

selected studies, we used an adapted form

(16)

accordance with the recommendations of the Revised

Standards for Reporting Interventions in Clinical Trials

of Acupuncture (STRICTA)

(17)

and the classications of

cupping therapy

(7,18)

The following data were extracted: article identication

(title, author (s)/training area, journal, year of publication,

study country/language); objectives; methodological

characteristics (design, sample size and loss of follow-up;

inclusion and exclusion criteria); clinical data (number

of patients by sex, mean age, diagnosis, duration of

symptoms); description of interventions in the follow-up

groups (number of sessions, duration of treatment, type

of technique applied (dry, wet, ash or massage cupping),

application device, time of stay of the device, suction

method (manual, re, automatic-electric)/suction strength

(light, medium, strong or pulsating)

(18)

; peculiarities of

the intervention; application points; training area of

the professional who carried out the intervention; years

of experience in the area); outcomes and methods of

evaluation (number of evaluations, intervals between

them, measurement tools); data analysis; main results;

and study ndings.

The methodological quality of eligible studies was

assessed using the Jadad scale

(19)

, which is centered on

internal validity. The questions have a yes/no answer

option with a total score of ve points: three times one

point for the yes responses and two additional points for

appropriate randomization and concealment of allocation

www.eerp.usp.br/rlae

Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM.

methods. Two independent reviewers conducted the

evaluation, and a third investigator was consulted to

solve possible disagreements.

Data analyzes were performed using Stata SE/12.0

statistical software. The absolute dierence between

means with 95% condence intervals was selected to

describe the mean dierences between the treated and

control groups in the evaluation performed shortly after

treatment. P-value <0.05 was considered as statistically

signicant. Potential heterogeneity among the studies

was examined using Cochran Q

(20)

and I

2(21)

statistics.

Since there was statistical signicance in the test for

heterogeneity of the results (p <0.05) and the calculated

value of I

suggested a moderate to high heterogeneity

(67.7%)

(21)

, the random eects model was adopted for

the analysis.

Results

A total of 614 studies were found in electronic and

manual searches. Of these, 296 were removed from the

list because they were duplicates. After reviewing titles

and abstracts, 265 studies were excluded and 53 remained

for analysis of the full text. Of these, 11 studies were not

found (online, via bibliographic switching or direct contact

with authors) and 26 articles were excluded. Finally, 16

articles remained in the review for the synthesis of the

qualitative analysis and 10 articles entered the quantitative

analysis (Figure 1).

*n – Number of articles; †MEDLINE - Medical Literature Analysis and Retrieval System Online; ‡PUDMED - US National Library of Medicine National Institutes

of Health; §PEDRO - Physiotherapy Evidence Database; ||CINAHL - The Cumulative Index to Nursing and Allied Health Literature; ¶LILACS - Latin American

and Caribbean Health Sciences Literature; **VHL – Virtual Health Library; ††CUMED - National Information Center of Medical Sciences of Cuba; ‡‡RCT –

Randomized Clinical Trial

Figure 1 - Flowchart of literature search and selection process. Belo Horizonte, MG, Brazil, 2018

www.eerp.usp.br/rlae

Rev. Latino-Am. Enfermagem 2018;26:e3094.

Study

identication

Objective

Intervention in the

experimental group

Intervention in the

control group

Main ndings

Teut M et al.

(2018)

(22)

To investigate the eectiveness of

Dry Pulsatile Cupping in reducing

pain and improving back function

and quality of life in patients

with chronic nonspecic low

back pain.

Pulsatile cupping with

strong negative pressure

and paracetamol on

demand (n * = 37)

Pulsatile cupping with

weak negative pressure

and paracetamol on

demand (minimal

cupping) (n=36)

Paracetamol (maximum

dose of 4 times, 500

milligrams per day) on

demand (n*=37)

Both suction cup forms were eective

in chronic nonspecic low back pain,

without showing signicant dierences

in the direct comparison after four

weeks. Only pulsatile suction cups

showed eects compared to controls

after 12 weeks.

Saha FJ et al.

(2017)

(23)

To test the eectiveness of

Cupping Massage in patients with

neck pain.

Cupping massage (n*=25)

Waiting list (patients

were asked to

continue medical

care, but refrain from

invasive treatments,

such as injections or

acupuncture) (n*=25)

Cupping massage appears to

be eective in reducing pain and

increasing function and quality of life

in patients with chronic nonspecic

cervical pain.

Lin ML et al.

(2017)

(28)

To evaluate the eectiveness of

laser acupuncture associated

with Chinese cupping therapy in

the treatment of low back pain.

Laser acupuncture and

Chinese cupping (n*=25)

Sham Laser and

Chinese cupping

(n*=23)

Laser acupuncture combined with

Chinese cupping therapy at the

acupuncture points B

†

40 and Ashi

eectively reduces low back pain.

Changes in plasma cortisol levels

have indicated that laser acupuncture

combined with Chinese cupping

therapy is an eective treatment for

pain relief.

Yazdanpanahi

Z et al. (2017)

(31)

To evaluate the eects of

acupuncture approaches on the

severity of postpartum low back

pain among primiparous women

visiting selected educational

centers aliated with the

University of Medical Sciences of

Shiraz, Shiraz, Iran.

Cupping therapy (n*=50)

Acupressure (n*=50)

Control group without

intervention (n*=50)

Although pain intensity decreased

in both groups, this reduction was

signicant in the cupping therapy

group. Therefore, both cupping

therapy and acupressure may be

eective in reducing postpartum low

back pain in primiparous women.

Chi LM et al.

(2016)

(29)

To investigate the ecacy of

cupping therapy in relieving chronic

neck and shoulder pain among

community residents and changes

in skin surface temperature.

Cupping therapy (n*=30)

Control group without

intervention (n*=30)

Cupping therapy increased the surface

temperature of the skin and reduced

systemic blood pressure. The subjective

experience of pain intensity also

reduced. Cupping therapy resembles

an analgesic eect that has no known

negative side eects and can be

considered safe.

AlBedah A et al.

(2015)

(36)

To assess the eectiveness

and safety of Wet Cupping as

a treatment for persistent and

nonspecic low back pain.

Wet cupping and analgesic

drug (maximum of three

500mg acetaminophen

tablets per day) (n*=40)

Analgesic drug

(maximum of three

500mg acetaminophen

tablets milligrams per

day) (n*=40)

Wet cupping works to reduce pain

and improve disability associated with

nonspecic and persistent low back

pain for at least 2 weeks after the end of

the intervention.

Emerich M et al.

(2014)

(9)

To measure, in parallel, the

metabolic changes in the tissue

under the glass cups and the

pressure pain threshold.

Dry cupping (n*=12)

Comparison between the

side on which cupping

therapy was performed

with the contralateral

side, which did not

receive the intervention

(n*=12)

Cupping therapy promotes anaerobic

metabolism lasting 280 minutes in the

subcutaneous tissue and increases the

immediate pressure pain thresholds in

some areas.

Akbarzadeh M

et al. (2014)

(32)

To investigate the eect of Dry

Cupping at point B

†

23 on the

intensity of low back pain in

primiparous women.

Dry Cupping (n*=50)

Routine care and referral

to a specialist in case of

severe pain (n*=50)

Dry cupping in acupoint B

†

23 had a

desirable eect on reducing pain in

patients. The VAS

‡

scores agreed with

those of the McGill short questionnaire.

Lauche R et al.

(2013)

(24)

To test the eectiveness of

12 weeks of Cupping Massage

performed at home, compared to

the same period of progressive

muscle relaxation in patients with

chronic nonspecic neck pain.

Cupping massage (n*=30)

Instructions and training

to perform progressive

muscle relaxation at

home twice a week, 20

minutes per session, and

to record this practice in

a journal (n*=31)

Cupping massage is no more eective

than progressive muscle relaxation

in reducing chronic nonspecic neck

pain. Both therapies can be easily

used at home and can reduce pain to

a clinically relevant minimum extent.

However, cupping massage is better

than progressive muscle relaxation in

improving well-being and decreasing

sensitivity to pressure pain.

Kim TH et al.

(2012)

(34)

To compare the eects of cupping

therapy and the “heated pad” on

neck pain, functional disability

and quality of life in video display

terminal workers.

Cupping therapy (n*=20)

Heated hot water pads

applied to the neck and

upper trapezius muscle

for 10 minutes, 3 times

a week, for 2 weeks

(n*=20)

2 weeks of cupping therapy associated

with an exercise program may be

eective in reducing pain and improving

neck function in workers at Video

Display Terminal.

(the Figure 2 continue in the next page...)

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Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM.

Study

identication

Objective

Intervention in the

experimental group

Intervention in the

control group

Main ndings

Lauche R et al.

(2012)

(25)

To test the ecacy of a single

traditional cupping therapy

treatment in patients with chronic

nonspecic chronic neck pain.

Cupping therapy and

non-steroid medication for

pain and physical therapy

(n*=22)

Non-steroid medication

for pain and physical

therapy (in both groups)

(n*=23)

A single application of cupping therapy

may be eective in the treatment of

chronic nonspecic cervical pain.

Lin ML et al.

(2012)

(30)

To evaluate the eect of laser

acupuncture and soft cupping on

low back pain.

Laser acupuncture and soft

cupping (n*=28)

Soft cupping and laser

without radiation (n*=29)

Laser acupuncture and mild cupping

therapy may be a suitable treatment for

patients with low back pain.

Cramer H et al.

(2011)

(26)

To compare the eects of a series

of 5 sessions of Pulsating Cupping

with standard medical care in

relieving chronic nonspecic

cervical pain.

Pulsating Cupping (n*=24)

Self-directed standard

medical care (physical

therapy, exercises and

analgesic drugs as

needed) (n*=24)

Pneumatic pulsation therapy appears

to be a safe and eective method to

relieve pain and improve function and

quality of life in patients with chronic

neck pain.

Kim JI et al.

(2011)

(35)

To determine the ecacy and

safety of Wet Cupping treatment

for persistent nonspecic low

back pain.

Wet-cupping (n*=21)

Usual care (booklets for

exercise, general advice

for nonspecic and

persistent low back pain,

and acetaminophen) in

both groups (n*=11)

Wet cupping may have a potential

eect on reducing pain associated

with nonspecic and persistent low

back pain.

Lauche R et al.

(2011)

(27)

To determine whether a number

of cupping treatments eectively

relieves chronic nonspecic

cervical pain. In addition, the

subjects’ mechanical thresholds

were measured to determine

whether cupping therapy has an

eect on mechanical hyperalgesia

in patients with chronic neck pain.

Cupping therapy and

non-steroid medication for

pain and physical therapy

(n*=22)

Non-steroid medication

for pain and physical

therapy (n*=24)

Five dry cupping sessions appear to be

safe and eective in the treatment of

chronic nonspecic cervical pain.

Farhadi K et al.

(2009)

(33)

To determine the eectiveness

of Wet Cupping for the treatment

of persistent and nonspecic low

back pain.

Wet cupping (*n=48)

Usual care, combination

of medication and

exercises (n*=50)

Wet cupping is associated with greater

short-term clinical benet compared to

usual care.

*n – Number of participants; †B – Bladder; ‡VAS – Visual Analogue Scale.

Figure 2 - Characterization of the studies regarding the applied intervention, Belo Horizonte, MG, Brazil, 2018 (n=16)

All articles selected were published in English

language and were conducted in Germany

(9,22-27)

Taiwan

(28-30)

, Iran

(31-33)

, South Korea

(34-35)

and in Saudi

Arabia

(36)

. Participants were a total of 1049 people, aged

between 18 and 79 years, of whom 519 were in the

groups receiving the experimental therapy and 530 in

the control groups (sham, waiting list, standard medical

treatment/active treatment or no treatment). Of these,

all had chronic pain conditions

(15)

, being the cervical

spine/neck the most aected area

(9,23-27,29,34)

, followed by

the lumbar region

(22,28,30-33,35-36)

. Two other studies

(31,33)

although they did not make clear the temporality of the

pain, were selected because this information could be

inferred with great accuracy.

The characterization of the studies regarding the

objective, the interventions applied in the experimental

and control groups, and the main ndings are presented

in Figure 2.

Regarding the methodological quality of the RCTs,

all reported the random sequence generation method

and in only one study

(9)

this process was not appropriate.

In another study

(30)

there is not enough information to

infer this information. Only in four RCTs

(22,24,28-29)

there

was a description of masking and in only two

(22,28)

this

was considered appropriate. Loss of follow-up was not

described in only one RCT

(29)

Therefore, 6.25% (n = 1) of the studies

(9)

scored

one on the Jadad score; 12.5% (n = 2)

(29-30)

scored two;

62.5% (n=10)

(23,25-27,31-36)

scored three; 12.5% (n=2)

(22,24)

score four; and 6.25% (n=1)

(28)

scored ve points.

The studied outcomes, the measurement tools, the

number of evaluations and the interval between them

are described in Figure 3.

The most evaluated outcomes were pain intensity

(100%; n=16)

(9,22-36)

, followed by Physical disability

(62.5%; n=10)

(9,23-27,33-36)

, quality of life (37.5%; n=6)

(22-27)

and nociceptive threshold before the mechanical

stimulus, by means of an algometer (37.5%; n=6)

(9,23-27)

The number of evaluations ranged from two (baseline

and after treatment) to 18. Three studies performed

evaluations between sessions

(9,28-29)

; and 13 studies

performed follow-up evaluations after the end of the

treatment, ranging from two days to three months

(9,22-

23,25-27,30-36)

(Figure 3).

The characteristics of the intervention protocol

were based on the recommendations of the Revised

Standards for Reporting Interventions in Clinical Trials

of Acupuncture (STRICTA)

(17)

and in the classications

of cupping therapy

(7,18)

, which are described in Figure 4.

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Rev. Latino-Am. Enfermagem 2018;26:e3094.

Study

identication

Outcomes Measurement Tools

Number of evaluations/

Interval between them

Teut M et al.

(2018)

(22)

1-Pain intensity

2- Measure of back function

3-Quality of life

1- VAS* (0-100)

2-Funktionsfragebogen Hannover Rücken

3- SF-36

†

03 (Baseline, after 4 and 12 weeks)

Saha FJ et al.

(2017)

(23)

1- Pain intensity

2- Pain to the movement

3-Physical disability

4-Quality of life

5- Nociceptive threshold

6- Mechanical detection threshold

7- Vibration detection threshold

8- 2-point discrimination threshold

1- VAS* (0-100)

2-Pain on Movement Questionnaire

3-NDI

‡

4-SF-36

†

5- Algometer

6- Von Frey laments

7-Diapason

8- Pair of compasses with blunt ends

02 (Baseline, 3 weeks after randomization)

Lin ML et al.

(2017)

(28)

1- Pain intensity

2- Plasma cortisol level

1-VAS* (0-100) 2- Biological sample (blood)

02 for cortisol (Baseline and after the

session) / 06 for VAS* (Baseline and

during session)

Yazdanpanahi Z et

al. (2017)

(31)

1- Pain intensity 1-Short-form McGill Pain Questionnaire

04 (Baseline, immediately after, 24 hours

and 2 weeks after)

Chi LM et al.

(2016)

(29)

1- Pain intensity

2- Tissue temperature

3- Systemic arterial pressure

1-VAS* (0-10)

2- Infrared Camera

3- Mercury sphygmomanometer

02 for pain intensity (Baseline and after

intervention) / 04 for tissue temperature

(5-minute interval between each

measurement)

AlBedah A et al.

(2015)

(36)

Pain intensity

Physical disability

1-Numeric scale (0-100)

1-PPI

2-ODQ

03 (Baseline, after, follow-up of 2 weeks)

Emerich M et al.

(2014)

(9)

1- Pain intensity

2-Physical disability

3- Nociceptive threshold

4- Pyruvate, Lactate, Glucose, Glycerin

and Adenosine

1/2-Neck Pain and Disability Scale

3-Algometer 4- Microlament with

semipermeable membrane (microdialysis)

04 for algometer (baseline, immediately

after and 140 and 280 minutes after) / 02

for Neck pain and disability scale (Baseline

and one week after / each 20 minutes

for microdialysis

Akbarzadeh M et

al. (2014)

(32)

1- Pain intensity

2-Quality of pain

1- VAS* (0-10)

2-Short-form McGill Pain Questionnaire

04 (Baseline, immediately after, 24 hours

and 2 weeks after)

Lauche R et al.

(2013)

(24)

1- Pain intensity

2- Perceived pain to the movement

3-Quality of pain

4-Physical disability

5- Psychological distress

6-Well-being

7-Quality of life

8- Nociceptive threshold

1- VAS* (0-100)

2- Flexing, extending, exing sideways and

rotating the neck laterally to the left and right

(VAS*)

3-Pain Description List

4-NDI

‡

5-Hospital Anxiety and Depression Scale

6-Questionnaire on the Assessment of

Physical Well-being

7-SF-36

†

8-Algometer

02 (Baseline, week 12)

Kim TH et al.

(2012)

(34)

1- Pain intensity

2-Physical disability

3- Physiological and psychological

symptoms

4- Range of motion

1- Numeric scale (0-100)

2-NDI

‡

3-Measure yourself medical outcome prole

2 score

4-Cervical range of motion instrument

03 (Baseline, 3 weeks, 7 weeks)

Lauche R et al.

(2012)

(25)

1- Pain intensity

2- Physical disability

3-Quality of life

4- Nociceptive threshold

1-VAS* (0-100) 2-NDI

‡

3-SF-36

†

4-Algometer 02 (Baseline and 3 days after)

Lin ML et al.

(2012)

(30)

1- Pain intensity

2- Electrical current of the meridians

1- VAS* (0-10) 2-Ryodoraku

05 (Assessments for 5 consecutive days -

2 before and 2 after)

Cramer H et al.

(2011)

(26)

1- Pain intensity

2- Pain to the movement

3-Physical disability

4-Quality of life

5- Nociceptive threshold

6- Mechanical detection threshold

7- Vibration detection threshold

1-Numeric scale (0-10)

2- VAS* (0-10)

3-NDI

‡

4-SF-36

†

5-Algometer

6- Von Frey laments

7-Diapason

02 (Baseline and 2.5 weeks after baseline

assessment)

Kim JI et al.

(2011)

(35)

1- Pain intensity

2-Physical disability

1- Numeric scale (0-100)

1-PPI

2-ODQ

03 (Baseline, after, follow-up of 2 weeks)

Lauche R et al.

(2011)

(27)

1- Pain intensity

2- Pain at rest and pain to the movement

3-Physical disability

4-Quality of life

5- Nociceptive threshold

6- Vibration detection threshold

7- Mechanical detection threshold

1-Numeric scale (0-10)

2- VAS* (0-100)

3-NDI

‡

4-SF-36

†

5-Algometer

6-Diapason

7- Von Frey laments

02 (Baseline and 18 days after

rst assessment)

Farhadi K et al.

(2009)

(33)

1- Pain intensity

2-Physical disability

3- Medication use

1-PPI

2-ODQ

3-Medication Quantication Scale

02 (Baseline and after three months of

follow-up)

*VAS – Visual Analogue Scale; †SF-36 - Short Form 36 Health Survey Questionnaire; ‡NDI - Neck Disability Index; §PPI- McGill Present Pain Intensity

questionnaire; ||ODQ - Oswestry Disability Questionnaire

Figure 3 - Evaluated outcomes, measurement tools, number of evaluations and interval between them. Belo Horizonte,

MG, Brazil, 2018. (n=16)

www.eerp.usp.br/rlae

Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM.

Study

identication

Type of

technique

Number

sessions

Duration

treatment

Application device

Time of stay of

the device

Suction method/suction

strength

Peculiarities of the

intervention

Application points

Teut M et al.

(2018)

(22)

Pulsatile dry

cupping

8 4 weeks Silicone cup 8 minutes

Automatic (Negative pressure

between 150 - 350 mbar and

aspiration intervals of 2 seconds/

weaker negative pressure around

70 milibar and aspiration intervals

of 2 seconds)

// Point in the lumbar region

Saha FJ et al.

(2017)

(23)

Cupping

massage

5 3 weeks

3.5 to 5-cm* diameter

glass cup, Karl Hecht

GmbH, Sondheim /

Rhön, Germany)

10 minutes Manual (rubber ball on top of cup)

Arsenic massage oil (Weleda AG,

Schwäbisch-Gmünd, Germany)

From the occipital bone to the middle thoracic

spine and in the upper trapezius muscle

Lin ML et al.

(2017)

(28)

Dry cupping 5 1 week

Laser / 6- cm*

diameter cups

(DongBang

Acupuncture,

Kyunggido, Korea)

5 minutes

The suction of each cup was

applied until the skin rose to 1 cm*.

The physician administered the

treatment to all patients between

3 and 6 hours (time of exuberant

ow of the bladder meridian)

Muscles of the lower back at the level of the

spinal discs 2-5

Yazdanpanahi

Z et al. (2017)

(31)

Dry cupping 4 4 days // 15 to 20 minutes // // B

†

Chi LM et al.

(2016)

(29)

Dry cupping 1 20 minutes

Glass cups with

medium size of

4 cm* diameter and

and 260 ml

‡

volume

(Cosmos International

Supplies Co., Ltd.,

Taiwan)

10 minutes Fire //

15 (jianshongshu)

21 (jianjing)

15 (jianju)

AlBedah A et al.

(2015)

(36)

Wet cupping 6 2 weeks

Disposable 40 cc

cups (Seongho trade

& company, Korea)

5 minutes Manual (suction pump)

The skin was perforated at 6

points along the site marked with

2 mm

††

deep, with disposable

lancets

2 acupoints between B

†

23, 24 and 25 (the

most painful when manually pressed or when

there were no pain points, we chose bilateral

†

25)

Emerich M et

al. (2014)

(9)

Dry cupping 1 15 minutes

168 ml

‡

glass cup /

opening area of 15.7

square cm*

15 minutes

Fire (negative pressure was

obtained by holding the ame of

a swab soaked in alcohol for 2

seconds in the opening of the cup

and then immediately pressing the

cup into the skin. The glass cup had

a faucet that could be connected to

a pressure gauge to measure the

pressure in the cup).

Above the trapezius muscle, cupping therapy

was performed above one of the sides

randomly selected in healthy volunteers or

in patients with neck pain, above the side

with predominant pain / Cupping therapy was

performed on the contralateral side of the lower

back for investigation of pain thresholds

Akbarzadeh M

et al. (2014)

(32)

Dry cupping 4 4 days

Glass cups of size 75

and 100 cm*

15 to 20 minutes

Fire (the air inside the cups was

rareed by alcohol and small cotton

balls)

// B

†

23 (Shenshu)

Lauche R et al.

(2013)

(24)

Cupping

massage

24 12 weeks

3.5-cm* diameter

glass cups (Karl

Hecht, Germany)

10 to 15 minutes //

200 ml

‡

arnica massage oil

(Weleda AG, Germany)

(the Figure 4 continue in the next page...)

www.eerp.usp.br/rlae

Rev. Latino-Am. Enfermagem 2018;26:e3094.

Study

identication

Type of

technique

Number

sessions

Duration

treatment

Application device

Time of stay of

the device

Suction method/suction

strength

Peculiarities of the

intervention

Application points

Kim TH et al.

(2012)

(34)

Dry cupping /

Wet cupping

6 2 weeks

Disposable and

sterile cups of various

sizes - 1.5 cm* to

5 cm* in diameter

(Seongho Trade &

Company, Korea)

5 to 10 minutes

Manual (suction pump - 3 to 5

pumping cycles)

The skin was punctured 6 times to

a depth of 2 mm

††

with disposable

26 gauge lancets. 3 to 5 cc** of

blood was drained

From 6 to 10 sensitive points of the posterior

neck, upper trapezius and perispinal area of

the neck and thoracic spine GV

‡‡

14,16,15,12,

20, 21, SB

17,11,12,13,14,15,15 B

†

10,11,

12,13,14,15,16,17,41,42,43,44 and Extra Head

/ neck 15

Lauche R et al.

(2012)

(25)

Wet cupping 1

10 to 15

minutos

Double wall glass

cups with 25 to

50 mm

††

diameter

10 to 15 minutes

Fire (the cups were kept inverted

over an open ame to warm the air

in. The air inside the cup cooled

and created vacuum that sucked

blood through the incisions).

The supercial incisions were

made with a disposable micro-

lancet in the areas of pain and

bulky geloses

Areas of pain

Lin ML et al.

(2012)

(30)

Dry cupping

(soft

cupping)

1 10 minutes

Laser LA400 (United

Integrated Services

Co., Ltd., Taiwan) /

It does not describe

the suction cup

material

10 minutes // // B

†

40 (Weizhong) Ashi Points

Cramer H et al.

(2011)

(26)

Cupping

massage +

Dry cupping

- Pneumatic

Pulsation

Therapy

5 2 weeks

38 mm glass cups

(scanning) and

130-mm

††

diameter

silicone cups (xed

suction cup)

10 to 15 minutes

with scanning and 5

to 10 minutes with

the xed suction

cup

Automatic (electromechanical

suction pump - Pneumatron

200S

Pneumed GmbH, Idar-Oberstein,

Germany. The negative pressure

intensity was adjusted according to

the patient’s sensitivity to produce a

strong but comfortable sensation of

oscillation - Strength: pulsatile).

Arnica massage oil (Weleda AG,

Schwäbisch Gmünd, Germany,

ingredients: sunower oil, olive

oil, arnica montana extract, betula

alba leaf extract and natural

essential oils) was applied in the

neck and shoulders region for

slippery suction cup.

Areas where manual pressure and lifting of the

skin caused the greatest discomfort

Kim JI et al.

(2011)

(35)

Wet cupping 6 2 weeks

Disposable 40 cc

cups (Seongho trade

& company, Korea)

5 minutes Manual (suction pump)

The skin was punctured at 6

points along the marked site with

2 mm

‡

deep with disposable

lancets.

2 acupoints between B

†

23, 24 and 25 (in each

session, practitioners chose the 2 most painful

points when pressed manually. When there

were no pain points, the bilateral B25 was

chosen)

Lauche R et al.

(2011)

(27)

Dry cupping 5 2 weeks

Double wall glass

cups with 25 to

50 mm

††

diameter

10 to 20 minutes

Fire (the cups were kept inverted

by an open ame to warm the air

inside, after which each cup was

placed in an aected area).

Pain diagram and physical examination were

used to identify areas of muscular tension

and myogelosis, which usually occurred in the

descending and

Farhadi K et al.

(2009)

(33)

Dry cupping /

Wet cupping

3 1 week

Plastic cups- The cup

size used was based

on the size of the

patient’s body (75 or

120 cc

3 to 5 minutes for

the dry suction cup

and then another 3

to 5 minutes for the

wet suction cup

Automatic/manual (the cup was

placed in the selected location and

the air inside the cup was rareed

by electric suction or, rarely, due to

technical reasons, manual suction).

Surface incisions were

made on the skin using the

“multiple supercial incisions”

technique with 15-21 size sterile

surgical slides.

a) between the two scapulae, opposite to the

scapular spine, at the level of the thoracic

vertebrae 1-3, in Phase 1; b) the area of the

sacrum, between the lumbar vertebra and the

coccyx bone, in Phase 2; and c) the calf area

on the middle surface of the gastrocnemius

muscle in Phase 3

*cm – Centimeter; †B – Bladder; ‡ml – Milliliter; §SB – Small bladder; ||GB – Gallbladder; ¶LB – Large bladder; **cc – Cubic centimeter; ††mm – Millimeter; ‡‡GV - Governing Vessel

Figure 4 - Intervention protocol. Belo Horizonte, MG, Brazil, 2018 (n=16)

www.eerp.usp.br/rlae

Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM.

The intervention was predominantly applied by

physicians (31.25%; n=5)

(22,25-28,34)

; followed by nurses

(18.75%; n=3)

(22,29,32)

and pharmacists (6.25%; n=1)

(32)

. And 25% of the studies (n=4)

(9,23,35-36)

reported that

the intervention was performed by a therapist, without

specifying the training area.

Only 18,75% of the studies (n = 3) presented the

time of experience of the professional who performed the

intervention, from three

(35-36)

to four years

(34)

; 37.5% of the

studies (n=6)

(9,22-25,27)

informed only that the intervention

had been performed by experienced or trained professionals,

but did not mention the time of training.

Of the 16 articles selected for the systematic

review, 10 entered for meta-analysis that investigated

the eectiveness of cupping therapy on pain intensity.

All of them approached the outcome in two comparison

groups (experimental and control), in evaluations

performed before and immediately after the treatment.

Five studies

(9,22,29,35-36)

did not enter because they did

not have enough data for this analysis and one study

(33)

performed the evaluation only three months after the

end of treatment.

The results of the meta-analysis showed that

cupping therapy was more eective in reducing pain

compared to the control group (absolute dierence

between means: -1.59, [95% Condence Interval:

-2.07 to -1.10]; p = 0.001), with moderate to high

heterogeneity (I

= 67.7%, p = 0.001) (Figure 5).

*CI - Condence interval; †% - Percentage; ‡I

- Measurement of heterogeneity

Figure 5 - Forest plot of the pain intensity score. Belo Horizonte, MG, Brazil, 2018

Discussion

Cupping therapy has shown positive results on chronic

back pain in adults, not only in behavioral variables of

pain, but also in physiological parameters in the majority

of RCTs evaluated in this study, which contributes to the

consolidation of its use in the treatment of this clinical

condition in the study population.

Regarding methodological quality, most

studies

(23,25-27,31-36)

obtained a median score (three)

according to the Jadad scale

(19)

. This score can be justied

by the lack of masking of RCTs.

It is not feasible to conceal evaluation and intervention

methods in cupping therapy

(22)

, since the marks left by

the suction cups are often visible and may persist for

several days, making it dicult to perform a masking

process

(27)

. Only one study

(28)

achieved masking properly;

however, it was true only for volunteers who received laser

therapy, an intervention used concomitantly with cupping

therapy, where sham laser acupuncture was performed

by applying the same procedure in one of the groups, but

without energy. In a second study

(24)

, there is a description

that the masking was applied to the evaluator of the

results; however, the application of suction cups causes

marks (ecchymoses, petechiae) and one of the evaluated

outcomes was the pain threshold, using the algometer;

for this evaluation, as the area must be naked, the marks

on the skin make this kind of masking impossible. Finally,

www.eerp.usp.br/rlae

Rev. Latino-Am. Enfermagem 2018;26:e3094.

in another study

(22)

, the majority of participants in the

minimal cupping group (84%) was able to identify the

allocation after four weeks, whereas in the cupping group

55% identied the allocation.

Regarding the evaluated outcomes, pain intensity

predominated, which was measured mostly by means

of the Visual Analogue Scale (VAS)

(22-25,27-30,32)

and the

Numerical Scale

(26,34-36)

, followed by the Neck Pain

and Disability Scale

(9)

, by the short version of the

McGill Pain Questionnaire

(31)

, and by the Present Pain

Intensity Scale

(33)

Although there are variations, the VAS usually

consists of scores of 0-10 or 0-100, the extreme left

being described as no pain and the extreme right as the

worst possible pain; the numerical scale has a numerical

rating of 0-10, 0-20 or 0-100. These scales can be

classied as: painless (0), mild (1-3), moderate (4-6),

and severe (7-10), and are frequently used in patients

with chronic musculoskeletal pain

(37)

. In addition, some

researchers

(38-40)

have pointed to these two scales as the

gold standard for assessing pain intensity, these being

the instruments most used when evaluating adults, both

in clinics and research.

Physical disability was the second most approached

outcome, measured by means of the Neck Disability Index

(NDI)

(23-27,34)

, of the Oswestry Disability Questionnaire

(ODQ)

(33,35-36)

and the Neck Pain and Disability Scale

(9)

In fact, the severity and chronicity of back pain are

associated with severe functional limitations

(37)

that

imply limitations in activities of daily living

(41)

In addition, patients with chronic diseases, who

require continuous treatment over a long period,

present important changes in quality of life

(42)

, being

another important outcome to be evaluated, as occurred

in six studies, through the Short Form 36 Health Survey

Questionnaire (SF-36)

(22-27)

Finally, the physiological parameter most evaluated

in the studies was the nociceptive threshold before

the mechanical stimulus, by means of a pressure

algometer

(9,23-27)

. It is known that individuals who have

pain in the spine have higher nociceptive sensitivity

compared to healthy people

(43)

. However, this is still

considered a subjective variable, since it is the patient

who determines his/her pain threshold. In fact, when

the evaluation process is more related to the symptoms,

such as subjective phenomena, especially pain, than

to physical or laboratory results, self-assessment is

considered the most reliable indicator of the existence

of pain

(44)

. Thus, the necessary information to carry out

its evaluation has its origin in the individual’s report

(45)

who is the primary source of the assessment.

The systematized analysis of cupping therapy

application methods showed that there is no

standardization in the treatment protocol for chronic

back pain. However, recent eorts have been made to

standardize the cupping therapy procedure in general

(46)

and specically for chronic back pain, since the most

appropriate type of technique, duration of treatment,

number of sessions, devices, time of application, method

and suction strength and application points have not

been determined.

It can be observed, however, that the most

applied technique was dry cupping, specically for

the lumbar

(22,28,30-32)

and cervical regions

(9,27,29,34)

This modality allows the stimulation of the acupoints

in the same way as the acupuncture needles

(47)

Researchers

(18)

suggest that laceration of the skin

and capillaries, promoted by wet cupping, may act

as another nociceptive stimulus that activates the

descending inhibitory pathways of pain control

(18)

, thus

helping to treat chronic musculoskeletal conditions

(35)

However, risk for infection, vasovagal attacks and scars

are the disadvantages of this method

(18)

. Still, compared

to cupping massage, authors

(47)

emphasize that dry

cupping has a greater analgesic eect, since the use

of lubricants can reduce the friction between the edge

of the cup and the skin, a fact corroborated by some

authors

(24)

who used arnica oil for the realization of

cupping massage.

Despite the variability in the application of the

intervention, it was possible to identify that, on

average, the cupping therapy was applied in 5 sessions,

with permanence of the cups in the skin for around 8

minutes, and interval of three to four days between the

applications. According to some researchers

(27)

, at least

ve sessions are required for any signicant eects of

cupping treatment to appear, in addition to ensuring the

feasibility of the RCT. Moreover, authors

(47)

recommend

that the cups should be left on the skin for 5 to 10 minutes

or more, which culminates in the appearance of residual

marks after treatment as a result of the rupture of small

blood vessels that are painless and disappear between 1

and 10 days

(12)

. Therefore, an interval between sessions

is necessary in order to allow the reestablishment of the

cutaneous and subcutaneous tissues.

Regarding the application cups, the disposable ones

are preferable a high-level sterilization or disinfection

process is required prior to reuse, since the pressure

exerted may cause extravasation of blood and uids from

the skin

(46)

. Nowadays, cupping therapy has increasingly

been performed with plastic cups

(47)

. The size of the

cups varies according to the place of application, but it

is often applied in places with abundant muscles, such

as the back

(48)

Regarding the suction method to create negative

pressure, the use of re predominated

(9,25,27,29,32)

www.eerp.usp.br/rlae

Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM.

followed by manual pumping

(23,34-36)

and automatic

pumping

(22,26,33)

. Suction with re is the traditional

method used in China, however, there is a risk of

burns

(18)

. Manual vacuum is created when using a

suction pump. This method allows microcirculation to

increase more eectively if compared to re

(18)

. Finally,

automatic pumping is created using an electric suction

pump, which allows to adjust and measure the negative

pressure inside the cup, being the most suitable method

for scientic research

(18)

Only three studies

(22,26,28)

reported the suction

strength used, which should be standardized in the

application protocols. The suction can be light (100 and

300 millibar/one or two manual pumpings), medium (300

and 500 milibar/three or four manual pumpings), strong

(above 500 milibar/ve or more manual pumpings) or

pulsatile (pressure inside the cups is variable, between

100 and 200 milibar every 2 seconds)

(47,49)

. The medium

suction is often indicated for painful conditions of the

musculoskeletal system

(18)

There was also no standardization in relation to the

application points of cupping therapy. Despite this, the

application in specic acupoints in the cervical region,

mainly on the bladder, gallbladder and small intestine

meridians, prevailed

(29,34)

, and in the lumbar region on

the bladder meridian

(30-32,35-36)

, followed by sensitive

points

(9,25-27,30)

named Ashi by TCM or trigger points by

Western medicine.

Meridians are passages for the ow of “qi” (vital

energy) and “xue” (blood), the two basic body uids

of TCM, which spread throughout the body surface,

uniting the interior with the exterior of the body and

connecting the internal organs, the joints and the

extremities, transforming the whole body into a single

organ

(50)

. Part of the meridians of the bladder, small

intestine and gallbladder pass through the dorsal region.

The acupuncture points are located in the meridians;

besides local action, they also play a systemic action and

reestablish the energy balance of the body by adjusting

the function of the organs, maintaining homeostasis and

treating the disease

(51)

, so the advantage in using them.

The trigger points or Ashi are specic points of high

irritability; they are sensitive to digital pressure and can

trigger local and referred pain

(52)

. They may be deriving

from dynamic overload, such as trauma or overuse, or

static overload, such as postural overloads occurring

during daily activities and occupational activities

(53)

besides emotional tension. Addressing these points can

also be a way to relieve local pain

(54)

After the application of cupping therapy, both

the acupoints of the meridians of the aected regions

and the trigger points or Ashi may present bruising,

erythema and/or ecchymoses. According to TCM, these

signs represent stagnation of “qi” and/or “xue” and may

help the therapist in identifying body disorders.

Finally, the meta-analysis revealed a signicant

reduction of the pain intensity score in adults with

chronic back pain by using cupping therapy (p = 0.001).

Compared with a control group (usual care/other

intervention/waiting list), this modality has advantages

in relieving pain, as can be seen in Figure 5.

Only two studies

(24,30)

did not present a statistically

signicant dierence between the groups on the benet

or harm of this intervention (Figure 5). In fact, the

rst study

(24)

pointed out that cupping therapy has the

same eect as other intervention (progressive muscle

relaxation) in reducing chronic nonspecic neck pain;

despite this, cupping therapy was better than relaxation

in improving well-being and decreasing sensitivity to

pressure pain. The authors

(24)

justify this result, among

other limitations, due to the fact that cupping therapy

was performed by patients’ relatives or friends at home.

The second study

(30)

, despite having found a positive

result on the intensity of pain, did not obtain a result in

the meta-analysis. It is believed that this may have been

due to the fact that both groups received the intervention

of soft cupping and both obtained positive results.

In the other studies

(23,25-28,31-32,34)

, the intervention

reduced the probability of the outcome, being the study

with the largest sample

(31)

the one the most contributed

(15.68% weight in the meta-analysis) for this (Figure 5).

In fact, all these studies reported promising results of

intervention on pain intensity.

However, the results of the eectiveness of cupping

therapy still need to be conrmed by subgroup analyzes,

based on dierent types of application techniques and

control groups. In addition, it is important to perform

meta-regression to nd the source of heterogeneity

of RCTs.

In a general way, the results showed a substantial

variation in the application of cupping therapy, especially

in relation to the type of technique, as well as dierences

in the control group, which made subgroup or meta-

regression unfeasible, respectively, due to the small

number of studies with each of these specications.

Conclusion

Cupping therapy is a promising method for the

treatment and control of chronic back pain in adults,

since it signicantly decreases pain intensity scores

when compared to control groups. However, the high

heterogeneity and the median methodological quality of

RCTs has limited the ndings.

Despite this, a protocol can be established for this

clinical condition: application of dry cupping technique

www.eerp.usp.br/rlae

Rev. Latino-Am. Enfermagem 2018;26:e3094.

in 5 sessions, with permanence of the disposable or

plastic cups on the skin for about 8 minutes, preferably

automatic or manual pumping, with medium suction

strength, and three to seven days interval between

applications. It is better to opt for acupoints of the dorsal

region, especially those from the bladder meridian

in the lumbar region, and for the meridians of the

bladder, gallbladder and small intestine in the cervical

and thoracic regions, as well as Ashi or trigger points.

This protocol needs to be validated in future studies.

And the main outcomes evaluated for this clinical

condition were pain intensity, physical disability, quality

of life and nociceptive threshold before the mechanical

stimulus (pressure).

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Received: Jul 11

2018

Accepted: Sep 17

2018

This is an Open Access article distributed under the terms of the

Creative Commons (CC BY).

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your work, even commercially, as long as they credit you for the

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oered. Recommended for maximum dissemination and use of

licensed materials.

Corresponding author:

Caroline de Castro Moura

E-mail: [email protected]

https://orcid.org/0000-0003-1224-7177

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