Effectiveness of cupping therapy for low back pain: a systematic review.

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Letter

Effectiveness of cupping

therapy for low back pain:

a systematic review

Cupping therapy has been used for

thousands of years in traditional

Chinese medicine for the treatment

of several chronic conditions,

such as low back pain, chronic

arth-ralgia, radiculopathy and respiratory

disease.

1

Dry and wet cupping (with

controlled bleeding) are the two

main types of cupping therapy.

Other subtypes of the treatment are

cupping with retention (keeping

cups on the skin or acupuncture

points for 10–15 min);

moving-cupping (sliding cups over the skin

or acupuncture points with

lubri-cants); shaking-cupping (moving

cups up and down repeatedly on

skin or acupuncture points);

quick-cupping

(removing

cups

immediately

when the skin is sucked in); and

balance-cupping (composite

manipu-lation, each dose including cupping

with retention 6–8 min,

moving-cupping four times, shaking-moving-cupping

three times and quick-cupping

three times).

Nowadays, an increasing

number

of patients have shown an interest in

using cupping therapy for the

treat- ment of low back pain

owing to their belief that it is more

effective than Western therapeutics.

Although cupping therapy

is

considered a safe, non-invasive

procedure, the outcome does not

always fulfil the expectation of

therapists and patients. Moreover,

complications of cupping

therapy, such as anaemia and skin

pigmenta-tion,

have

also

been

reported.

2

Since there is no consensus on

the role of cupping therapy in the

treatment of low back pain, we

reviewed the medical literature in

an attempt to test its effectiveness

in low back pain and to further

examine this method.

The systematic research started

with a thorough English and Chinese

language literature search of PubMed

from 1980 through 2013. The

keyword search terms in

combin-ation were ‘cupping therapy’, ‘low

back pain’, ‘lumbar sprain’, ‘lumbar

myofascitis’

and ‘lumbosacral

pain’. Articles with

laboratory

studies were excluded.

Three reviewers took part in the

study. One reviewer selected the

titles and abstracts for inclusion,

one extracted data from the full-text

articles and the third reviewer

con-firmed the reference lists of

poten- tially eligible studies.

Identified studies were assigned a

level of evi- dence according to

the Oxford Centre for

Evidence-Based Medicine

2011 levels of evidence.

3

Table 1

The studies with levels I and II evidence

Studies (level of

evidence) Treatment (N) Dose and regimen Results ( p value) Kim et al4

(level I)

Intervention group

(21) Wet cupping 1. Brochures for_exercise Bilateral BL23, BL24 and BL25,3 times weekly for 2 weeks 1. NRS scores >0.052. PPI scores <0.05 Control group (11) Waiting-list

2. General advice 3. Acetaminophen

500 mg

3. ODQ scores >0.05

Liu et al5 Intervention group Cupping with retention Bilateral at BL, 15 min daily 1. VAS <0.05 (level II) (25/25) Balance-cupping* Bilateral low back area, along BL and GV,

every 2 days 2. ODQ scores < 0.05

Control group (25) Diclofenac 50 mg, daily Xuan6

(level II) Interventiongroup (40)

Moving-cupping Bilateral at BL, 5–10 times (about 5 min), alternate days for 11 days

1. VAS <0.01 2. SF-36 <0.01 Control group (40) Dexibuprofen 0.15 g, T.I.D. for 12 days

Hong et al7

(level II) Interventiongroup (37) Moving-cupping Bilateral at BL, 5–10 times (about 5 min),alternate days for 11 days 1. VAS<0.012.2. SF-36 <0.01 Control group (33) Dexibuprofen 0.15 g, T.I.D. for 12 days

Lo and Ma8

(level II) Interventiongroup (33) Balance-cupping Bilateral low back area, along BL, GV and local tender points, every 2 days for 2 weeks VAS <0.05 Control group (31) Western medication 1 tablet of composite chlorzoxazone (chlorzoxazone

0.25 g+ acetaminophen 0.3 g), B.I.D. for 2 weeks Ma and Lo9

(level II) Interventiongroup (33) Balance-cupping Bilateral low back area, along BL and GV, every 2 days VAS <0.05 Control group (31) Western medication 1 tablet of composite chlorzoxazone (chlorzoxazone

0.25 g+ acetaminophen 0.3 g), B.I.D. Chen and Pan10

(level II) Intervention_{group (60)} Moving-cupping and cupping_{with retention} Bilateral at BL, Huatuoliaji points and local tender points,_{alternate days} Recurrence rate <0.05

*Refer to text.

Control group (40) Western medication 1. 2% Local anaesthetics (novocaine or lidocaine) 4–6 mL+ vitamin B12 500 mg + dexamethasone 5–10 mg for point injection, every 2 days 2. Indometacin 25 mg for oral administration, T.I.D.

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B.I.D., twice a day; NRS, numerical rating scale; ODQ, Oswestry Disability Questionnaire; PPI, McGill Pain Questionnaire for pain intensity; SF-36, 36-item Short Form; T.I.D., three times a day; VAS, visual analogue scale.

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Letter

Through our electronic and

refer-ence search we identified 29

cita-tions (table 1): one randomised

controlled trial (RCT, level I

evi-dence),

4

six non-RCTs (level II

evi-dence),

5–10

20 case reports (level

IV evidence) and two

mechanism-based reasoning studies (level V

evidence).

In the RCT, the effective rate of

the wet-cupping group was similar

to that of the waiting-list

group ( p>0.05). Interventions in

both groups

decreased

pain,

disability and acetaminophen dosage,

but a signifi- cant decrease in pain

intensity accord- ing to the McGill

pain questionnaire ( p<0.01) and

reduced

consumption

of

acetaminophen ( p=0.09) were

seen in the wet-cupping group.

4

Of the six non-RCTs, one showed

that the visual analogue scale

(VAS) score and the Oswestry

disability index in the

balance-cupping group were significantly

lower than in the group with

cupping with

retention and

diclofenac ( p<0.05), but there was

no difference between the cupping

with retention group and the

diclofenac-only group (

p>0.05).

5

The other studies

indi-vidually showed that the

effective-ness of cupping in decreasing

VAS,

6–9

reducing recurrence rate

10

and improving quality of life

6 7

was

better than Western medication.

Although evidence level I and II

studies on the effectiveness of

cupping treatment in low back pain

have been reported, aspects such as

manipulations, sites and dosage of

cupping and Western medication in

the comparison group are not

uniform. Although RCTs provide a

higher quality of evidence, we

included non-RCTs in this study

because the limited number of

RCTs did not provide convincing

evidence.

In this article, the research

results show that cupping therapy is

promis- ing for pain control and

improve- ment of quality of life, and

minimises the potential risks of

treatment. Therefore, further studies

are needed to determine the potential

role of cupping therapy in the

treatment of low back pain.

Chia-Yu Huang,1,2 _{Mun-Yau Choong,}2,3 Tzong-Shiun Li2,3

1_{Division of Plastic Surgery, Department of Plastic} Surgery, China Medical University Hospital, Taichung, Taiwan, Republic of China 2_{School of Medicine, China Medical University,} Taichung, Taiwan, Republic of China

3_{Department of Plastic Surgery, Tainan Municipal} An-Nan Hospital, Tainan, Taiwan, Republic of China Correspondence to Dr Tzong-Shiun Li, Department of Plastic Surgery, Tainan Municipal An-Nan Hospital, No. 66, Sec. 2 Chang-He Rd, An-Nan District, Tainan City 70965, Taiwan, Republic of China; li.tsa2@m s a.hinet.net Contributors C-YH: conducted the experiment; wrote the article. M-YC: analysed and interpreted the data; provided materials. T-SL: designed the experiment; proofed and revised the article.

Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http: / /dx.doi.org/10.1136/ a cupmed-2013-010385).

To cite Huang C-Y, Choong M-Y, Li T-S. Acupunct Med 2013;31:336–337.

Received 25 April 2013 Accepted 8 July 2013

Published Online First 25 July 2013

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