BMJ Open 2018;8:e021070.
Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysisSeoyoun Kim 1,2, Sook-Hyun Lee 1, Me-Riong Kim3 , Eun-Jung Kim 4, Deok-Sang Hwang 5, Jinho Lee 6, Joon-Shik Shin 6, In-Hyuk Ha 3, Yoon Jae Lee 1
1 Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
2 Graduate School of Public Health, Korea University, Seoul, Republic of Korea
3 Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
4 Department of Acupuncture and Moxibustion, College of Korean Medicine, Dongguk University, Gyeongju, Republic of Korea
5 Department of Obstetrics & Gynecology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
6 Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
Abstract
Objectives: Neck pain is a significant condition that is second only to depression as a cause of years lived with disability worldwide. Thus, identifying and understanding effective treatment modalities for neck pain is of heightened importance. This systematic review aimed to investigate the effects of cupping on neck pain from the current literature.
Design: Systematic review and meta-analysis of randomised controlled trials (RCTs).
Setting: Nine databases, including Chinese, Korean and Japanese databases, were searched for data up to January 2018 with no restrictions on publication language.
Participants: Patients with neck pain.
Interventions: Cupping therapy as the sole or add-on intervention compared with no treatment or active controls.
Primary and secondary outcome measures: Pain severity, functional disability and quality of life.
Results: Eighteen RCTs were selected. Compared with the no intervention group, the cupping group exhibited significant reduction in pain (mean difference (MD) -2.42(95% CI -3.98 to -0.86)) and improvement in function (MD -4.34(95% CI -6.77 to -1.19)). Compared with the active control, the cupping group reported significant reduction in pain (p=0.0009) and significantly improved quality of life (p=0.001). The group that received control treatment with cupping therapy (add-on group) displayed significant pain reduction compared with the active control group (p=0.001). Of the 18 studies, only 8 reported occurrence of adverse events, which were mostly mild and temporary.
Conclusions: Cupping was found to reduce neck pain in patients compared with no intervention or active control groups, or as an add-on treatment. Depending on the type of control group, cupping was also associated with significant improvement in terms of function and quality of life; however, due to the low quality of evidence of the included studies, definitive conclusions could not be drawn from this review. Future well-designed studies are needed to substantiate the effectiveness of cupping on neck pain.
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https://bmjopen.bmj.com/content/8/11/e021070Excerpts:
"One type of complementary therapy that can be used for neck pain is cupping. Cupping is a physical treatment, typically used by acupuncturists and other complementary medicine therapists, that uses glass or plastic cups placed on the skin over a painful area or acupuncture point to create negative pressure through suction. The rationale for use of cupping is not yet fully understood; it is described as a detoxification process by which waste matter and toxins are removed, and as a harmonisation process for the imbalance of Qi, a traditional Chinese medicine term for ‘vital energy’.8 Cupping has been used globally for several thousand years, particularly in countries such as Egypt and China.8 Today, cupping is widely used as a holistic treatment in Europe for inpatient care and the prevention and treatment of various disorders, as well as for promotion of general health.9 In South Korea, cupping is a popular treatment, and is covered by national health insurance; in 2013 alone, insurance claims for cupping reached a total 215?billion Korean won.10
"There are two types of cupping: dry and wet. Dry cupping is a technique in which cups are applied to the skin to create a vacuum for suction without drawing blood, whereas in wet cupping, blood is drawn with scarification before applying the cups for blood-letting. Cupping therapy is used for poststroke rehabilitation and hypertension, and has been reported to be effective for treating pain and musculoskeletal disorders.11 12 A systematic literature review published by Yuan et al in 2015 reviewed the effects of cupping on neck pain, reporting that cupping is effective for reducing pain and improving function.13 However, only articles published up to 2013 were included in that review, and as new clinical trials investigating cupping for neck pain have since been published, an updated systematic review on the topic is needed. Moreover, Yuan et al 13 restricted the publication language to include only English and Chinese language articles."
[Discussion]
"When compared with inactive controls, cupping significantly reduced pain, and improved function and QoL. However, the heterogeneity between studies was quite high in terms of pain reduction, and the quality of evidence was lowered as a consequence...Although in most studies the quality of evidence was found to be low to very low, the marked pain reduction and improvement in function and QoL found to be associated with cupping may be clinically relevant. When compared with active controls, the cupping group exhibited significant reduction in pain but no significant differences in functional improvement."
"When used to compliment existing treatments, cupping was found to significantly reduce pain, with an MD of -0.87 (95% CI -1.14 to -0.61). However, in addition to statistical significance, the effect size of a treatment should be assessed for clinical significance. Based on four studies of cupping, Lauche et al 38 proposed the minimal clinically important difference (MCID) of VAS to be -8 (-0.8 of a 10-point scale), the NDI to be -3 and the physical component summary of SF-36 to be +5.1. From the current meta-analysis, cupping exhibited an MD of -2.42 compared with the waiting list control, -0.89 compared with the active control and -0.87 as an add-on treatment, which all surpasses the above criteria for the MCID of VAS. With regard to NDI, cupping indicated an MD of between -4.34 and -4.36, depending on the type of control, which also meets the MCID criteria. For the physical component summary, however, cupping failed to display a treatment effect larger than MCID. In contrast, cupping showed an effect size exceeding MCID when compared with the active control, which calls for further investigation.
"Cupping has been used for several thousand years in such diverse regions as early Egypt and China.8 In traditional Chinese medicine, cupping is widely used to eliminate stagnated Qi and Blood, and facilitate circulation.39 Since ancient times, cupping has been considered to be effective in the local treatment of areas of inflammation.40 A previous review analysing the reported mechanism of cupping suggested that the positive effects of cupping are the result of a haemodynamic mechanism facilitating muscle function, as demonstrated by the reduction of deoxy-haemoglobin and elevated oxy-haemoglobin levels in muscle areas treated with cupping.41 Other studies have suggested that cupping involves a mechanism for removing oxidative stress,42 and produces therapeutic effects through diffuse noxious inhibitory control43; this would contribute to the alleviation of pain."
"However, adverse reactions to cupping may vary according to the proficiency of the practitioner, type of procedure and disinfection and sterilisation processes implemented during the treatment procedure.47...Another limitation was the low or very low quality of evidence for all outcomes; this low quality of evidence was primarily caused by risk of bias and unexplained heterogeneity between studies. Additionally, many selected studies did not maintain rigorous standards or procedures regarding allocation and blinding. Furthermore, the outcomes included for analysis in this study were all patient-reported outcomes (ie, pain, disability, QoL), and none of the included studies were designed to assess the placebo effect of cupping. It is possible that the results may have been influenced by the fact that all outcome measures were patient-reported and the lack of blinding."
"Nevertheless, cupping may be an important and cost-effective therapy for the treatment of neck pain."
"Conclusion
"The current results suggest that cupping may be effective for patients with neck pain in terms of reducing pain and improving function and QoL, when compared with no treatment or active controls. The level of evidence for the findings of the included studies, however, was found to be low or very low, thus preventing strong conclusions from being drawn for the effectiveness of this treatment. Although this study did not identify notable AEs in the articles reviewed, cupping is not without side effects, and further well-designed, large-scale studies employing standardised procedures are needed to thoroughly examine potential adverse effects. Furthermore, wet cupping requires rigorous education and training on hygiene and precautions, as it entails a blood-letting process. Although definite conclusions cannot be drawn from this study, cupping appears to be a potentially effective and safe therapy for neck pain."
"Funding This study was supported by the Traditional Korean Medicine R&D Program funded by the Ministry of Health & Welfare through the Korea Health Industry Development Institute (KHIDI) (HB16C0035)."
