cupping therapy (1)

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CUPPING THERAPY

HEALTH TECHNOLOGY ASSESSMENT SECTION

MEDICAL DEVELOPMENT DIVISIONMINISTRY OF HEALTH MALAYSIA

010/2012


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DISCLAIMER

Technology review is a brief report, prepared on an urgent basis, which draws onrestricted reviews from analysis of pertinent literature, on expert opinion and / orregulatory status where appropriate. It has not been subjected to an externalreview process. While effort has been made to do so, this document may notfully reflect all scientific research available. Additionally, other relevant scientificfindings may have been reported since completion of this review.

Please contact: [email protected], if you would like further information.

Health Technology Assessment Section (MaHTAS),Medical Development DivisionMinistry of Health MalaysiaLevel 4, Block E1, Precinct 1Government Office Complex62590 Putrajaya

Tel : 603 88831246

Fax : 603 8883 1230

Available at the following website: http://www.moh.gov.my


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Prepared by:

Dr. Hanin Farhana KamaruzamanAssistant DirectorHealth Technology Assessment Section (MaHTAS)Ministry of Health Malaysia

Reviewed by:Datin Dr Rugayah BakriDeputy DirectorHealth Technology Assessment Section (MaHTAS)Ministry of Health Malaysia

DISCLOSURE

The authorof this report has no competing interest in this subject and thepreparation of this report is totally funded by the Ministry of Health, Malaysia.


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EXECUTIVE SUMMARY

IntroductionCupping therapy is a physical treatment which refers to a technique that usessmall glass cups or bamboo jars as suction devices that are placed on the skin.

This method is mostly used in Asian and Middle Eastern countries. Cupping isbelieved to have potential benefit in treating myriad types of disease andconditions. The most common conditions were pain related such as chronicmuscle pain, low back pain, neuralgia pain, fibromyalgia and headache.

This technology review was requested by the Director of Traditional andComplementary Medicine (TCM), Ministry of Health Malaysia to evaluate thetherapeutic effect of cupping therapy on certain diseases or conditions.

Objective/aimTo assess the efficacy, effectiveness and safety of cupping therapy in treating

diseases or medical conditions such as herpes zoster, facial paralysis, back pain,spondylosis, cerebrovascular accident, hypertension, fibromyalgia, bronchitis,asthma and headache.

Results and conclusionsThree full text articles (one systematic review and two systematic reviews withmeta-analysis) were included in this technology review discussing the efficacyand effectiveness of cupping therapy, with or without comparative treatments. Asfor safety issues, 2 articles discussed on the adverse effects of cupping therapy.

This review showed that there is insufficient high quality evidence to support theeffectiveness of cupping therapy in treating diseases or medical conditions suchas herpes zoster, facial paralysis, back pain, spondylosis, cerebrovascularaccident, hypertension, fibromyalgia, bronchitis, asthma and headache.

Although cupping therapy is considered relatively safe and no major adverseeffects were reported directly on the therapy itself, it is very important to ensurethat the practitioners are properly trained and aware of the dangers involved inthe cupping therapy.

MethodsElectronic databases were searched through the MEDLINE(R) In-process andother Non-Indexed Citations and Ovid MEDLINE(R) 1948 to present, EBMReviews - Cochrane Central Register of Controlled Trials and EBM Reviews -Health Technology Assessment. Other database was PubMed, CochraneLibrary, Australia & New Zealand Horizon Scanning Network (ANZHSN) and USFood & Drugs Administration (US FDA).


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1. INTRODUCTION

Cupping therapy is a physical treatment which refers to a technique thatuses small glass cups or bamboo jars as suction devices that are placed onthe skin.1 It has been used for thousands of years, said to be as early as

3000 BC. However, the earliest recorded evidence of cupping is in EbersPapyrus, one of the oldest medical textbooks in the world which describedthat in 1550 BC, Egyptians used cupping as one of the treatment method. Inancient Greece, Hippocrates used cupping for internal disease andstructural problems. This method is mostly used in Asian and MiddleEastern countries and has been claimed to reduce pain and othersymptoms.2

Originally, practitioners would use hollowed-out animal horns for cups andplace them over particular points or meridians on the body, especially theback part of the torso.2 Today, most therapists use cups made of thick glass

or plastic, although bamboo, iron and pottery cups are still being used insome countries. Glass cups are the preferred method of therapy becausethey do not break as easily as pottery or deteriorate like bamboo, and theyallow the therapists to see the skin and evaluate the effects of treatment.1

In general, there are two types of cupping therapy, dry cupping and wetcupping. Dry cupping is the process using vacuum on different areas of thebody in order to accumulate blood in that area without any incisions made.Olive oil may be applied to the cupping area to allow easy movements ofthe cups and create a massaging effect. In wet cupping, small incisions orpuncture are made on the skin using small razor or needle before treatment.When the cup is applied and the skin is drawn up using vacuum, a smallamount of blood may flow from the puncture sites, which are believed tohelp removing harmful substances and toxins from the body.1

Cupping is believed to have potential benefit in treating myriad types ofdisease and conditions. The most common conditions were pain related,including chronic muscle pain, low back pain, neuralgia pain, fibromyalgia,headache and migraine.3 Other common diseases that were also treatedwith cupping therapy are cough, common cold, facial paralysis, herpeszoster, stroke rehabilitation, hypertension, sinusitis, acne and others.3 Inoriental countries such as China and Korea, cupping therapy has beenapplied as a formal modality in hospitals and act as a complementarytherapy to the current modern medicine.4

This technology review was requested by the Director of Traditional andComplementary Medicine (TCM), Ministry of Health Malaysia to evaluatethe therapeutic effect of cupping therapy on certain diseases or conditions.


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2. OBJECTIVE/AIM

To assess the efficacy, effectiveness and safety of cupping therapy intreating diseases or medical conditions such as herpes zoster, facialparalysis, back pain, spondylosis, cerebrovascular accident, hypertension,

fibromyalgia, bronchitis, asthma and headache.

3. TECHNICAL FEATURES

There are several ways used by acupuncturists or other traditionalcomplementary therapists to create the suction in the cups. Conventionally,therapists swab alcohol onto the bottom of the cup, or using a cotton ballsoaked in alcohol, then lighting it and applied the cup immediately againstthe skin.1 This method utilized the flaming heating power to achieve suctionthrough negative pressure inside the cups and apply them on the desired

part of the body. This type of vacuum method is still in use today, althoughmost current modern therapists who use vacuum technology therapeuticallyrely on machines that pull the air out of the cupped part of the patients skin.Vacuum machine can be set so that the pressure inside the chamber is at aspecific strength. Depending on the conditions being treated, the cups willbe left in place for 5 to 30 minutes. Several cups may be placed on apatients body at the same time. . Some practitioners will also apply smallamounts of medicated oils or herbal oils to the skin just before the cuppingprocedure, which allow them to move the cups.

Apart from dry cupping and wet cupping, there are some other methods ofcupping being practiced worldwide such as:

a) Moving / massage cuppingPrior to applying the cups, oil is administered to the skin to facilitatesmooth movements of the cups, giving a massage effect.

b) Needle/ acupuncture cuppingAcupuncture and cupping are done in the same place, by applyingacupuncture needle first then cupping over the needle.

c) Flash cuppingCupping are performed several times in quick succession along the areabeing treated to promote blood circulation.

d) Water cuppingThis technique involves filling a glass or bamboo cup one-third full withwarm water and pursuing the cupping process quickly without spillingthe water.


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e) Medicinal / herbal cuppingBamboo cups and herbs prescribed by traditional medicine practitionerwere immersed in water, boiled and simmered for 30 minutes beforeapplying. The steam from boiled herbs will provide vacuum as well astherapeutic effect.

3.1 Mechanisms of Action

The mechanisms of action of cupping therapy and its curative process arenot yet discovered by modern science like in the case of acupuncture. Thepostulated modes of actions include the interruption of blood circulation andcongestion as well as stopping the inflammatory extravasations from thetissues.5 Others have postulated that cupping could affect the autonomicnervous system and help to reduce pain.5 However, none of these theoriesare proven and established in scientific view.

Figure 1 : Three types of cups glass, bamboo and pottery

Figure 2 : Method in creating vacuum by flaming the alcohol-swabbed cupand apply it to the skin


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Figure 3 : Modern cupping set. Image available at :http://img06.taobaocdn.com/imgextra/i6/120484/T2t6haXjRaXXXXXXXX_!!120484.jpg

Figure 4 : Wet / Bleeding cupping. Image available at:http://www.thejakartapost.com/files/images/p19-b-1_17.jpg
http://www.thejakartapost.com/files/images/p19-b-1_17.jpghttp://www.thejakartapost.com/files/images/p19-b-1_17.jpghttp://www.thejakartapost.com/files/images/p19-b-1_17.jpg


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4. METHODS

4.1. Searching

Electronic databases were searched through the MEDLINE(R) In-process

and other Non-Indexed Citations and Ovid MEDLINE(R) 1948 to present,EBM Reviews - Cochrane Central Register of Controlled Trials and EBMReviews - Health Technology Assessment. Other database was PubMed,Cochrane Library, Australia & New Zealand Horizon Scanning Network(ANZHSN) and US Food & Drugs Administration (US FDA). The searchterms used can be referred in Appendix 1.

4.2. Selection

A reviewer screened the titles and abstracts against the inclusion andexclusion criteria and then evaluated the selected full-text articles for final

article selection. The inclusion and exclusion criteria were:

Inclusion criteria

Population Herpes zoster, facial paralysis, Bells palsy, back pain,spondylosis, stroke, cerebrovascular accident, cerebralstroke, brain vascular accident, hypertension,fibromyalgia, bronchitis, asthma, headache

Interventions Cupping therapy alone or cupping therapy combined withother therapies (other traditional complementary therapysuch as acupuncture, or conventional therapy)

Comparators Conventional therapy, medicines, placebo

Outcomes Efficacy/effectiveness and safety of cupping therapyStudy design Randomized control trials, systematic reviews, meta-analysis, case control, cohort and descriptive studies

Type ofpublication

English

Exclusion criteria

Study design Abstract, animal studyType ofpublication

Other language than English

Relevant articles were critically appraised using Critical Appraisal SkillsProgramme (CASP) and evidence graded according to the US / CanadianPreventive Services Task Force (Appendix 2).


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5. RESULTS AND DISCUSSION

Three full text articles were included in this technology review discussingthe efficacy and effectiveness of cupping therapy, with or withoutcomparative treatments. As for safety issues, 2 articles discussed on the

adverse effects of cupping therapy.

5.1 EFFICACY / EFFECTIVENESS OF CUPPING THERAPY

The three studies included in this technology review were one systematicreview and two systematic reviews with meta-analysis.

Cao et alconducted a systematic review and meta-analysis to evaluate thetherapeutic effect of cupping therapy for specific disease or conditions. Theeligible studies were randomized controlled trials (RCT) that examined theeffectiveness of cupping therapy, including one or more types of cupping

methods, compared with no treatment, placebo, or conventional medication.Cupping combined with other interventions and compared with otherinterventions alone were also included. However, studies that assessing theeffectiveness of cupping therapy combined with other traditionalcomplementary (TCM) therapies, such as acupuncture, compared with non-TCM therapies were excluded. As the result, 135 studies were included inthe review and different types of cupping methods were used in the trialsthat were selected. The six most common diseases or conditions for whichcupping was applied were herpes zoster, facial paralysis (Bells plasy), ,acne, cervical spondylosis, lumbar disc herniation and also cough anddyspnea. Meta-analyses were conducted on the first four of the above listedconditions and due to the heterogeneity of the RCTs of the remaining twodiseases- lumbar disc herniation and cough and dyspnea- meta-analysescould not be completed. 4, level I Among the limitations in this study were theinconsistency of the outcome measures that has been used by each andevery single RCTs that were included in this systematic review. Theincluded trials used composite non-standardized outcome measures, whichcategorized treatment efficacy into four grades: cure, markedly effective,effective and ineffective. This classification was not internationallyrecognized and the exact meaning is open to various interpretations.

Fifteen RCTs were included to evaluate the efficacy of wet cupping therapyin treating herpes zoster. Wet cupping therapy was found to be superior topharmaceutical medications, such as antiviral, in providing cure (RR 2.07,CI 1.77 to 2.43, p


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in effecting a cure (RR 1.93, CI 1.23 to 3.04, p= 0.005, 5 trials, randommodel), but no difference in symptom improvement was observed (RR 1.00,CI 0.97 to 1.03, p= 0.99, 4 trials, random model). Wet cupping combinedwith acupuncture was superior to acupuncture alone both in providing cure(RR 1.65, CI 1.08 to 2.53, p= 0.02, 3 trials, random model) and in improving

symptoms (RR 1.13, CI 1.02 to 1.25, p= 0.02, 3 trials, random model).

4

In the same review, the authors included 17 RCTs that assessed thetherapeutic effect of cupping therapy for facial paralysis. However, two ofthe trials were excluded from meta-analysis due to the incomparabilitybetween treatment and control groups. Meta-analysis showed that flashcupping combined with acupuncture (RR 1.51, CI 1.29 to 1.76, p< 0.00001,5 trials, fixed model) and wet cupping combined with acupuncture (RR 1.60,CI 1.33 to 1.93,p< 0.00001, 6 trials, fixed model) were markedly better thanacupuncture alone in providing cure. In addition, cupping in combinationwith medications, such as neurotrophic drugs, was superior to medications

alone in reducing average cure time (MD -6.05, CI -9.83 to -2.27, p= 0.002,2 trials, random model).4

The review also included 6 trials in evaluating the efficacy of cuppingtherapy for acne. In improving the cure rate, wet cupping therapy wassignificantly better than medications, such as tanshinone, tetracycline andketoconazole (RR 2.14, CI 1.42 to 3.22, p= 0.0003, 3 trials, fixed model).Furthermore, cupping therapy combined with other interventions wassuperior to other interventions alone (RR 1.93, CI 1.40 to 2.65,p< 0.0001, 3trials, fixed model).4

Forcervical spondylosis, 6 trials evaluated the efficacy of cupping therapyon the condition were included in the review. Cupping therapy especiallywet cupping, combined with other treatment, including acupuncture andtraction, was better than other treatments alone in effecting a cure (RR 1.52,CI 1.20 to 1.92,p= 0.0005, 5 trials, fixed model) and in relieving symptoms(RR 1.52, CI 1.20 to 1.92, p< 0.00001, 6 trials, fixed model). One trialcompared wet cupping with flunarizine for symptom improvement, andfound no difference between the two groups (RR 1.18, CI 0.60 to 2.32,

p=0.63, 1 trial).4

The authors concluded that despite the large number of studies on cuppingtherapy, there was still lack of well-designed investigations. Of the 135RCTs included in this review, 84.44% were categorized as having high riskof bias based on criteria from the Cochrane Handbook for SystematicReviews of Interventions. The meta-analysis also revealed that cuppingtherapy combined with other treatments, be it acupuncture or medications,showed significant benefit over other treatments alone in effecting a cure forherpes zoster, facial paralysis, acne and cervical spondylosis. This appearsto support the common practice in the authors country, China, of combining


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TCM therapeutic modalities, either TCM with TCM, or TCM with routinemodern medicine and practice, to enhance efficacy. However, due to thelimitations especially high risk of bias of the studies that were included inthis review, the authors suggested that it is necessary to conduct furtherRCTs that are of high quality and larger sample sizes in order to draw a

definitive conclusion.

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From another oriental country, Republic of Korea, Kim et al conducted asystematic review to summarize and evaluate the effectiveness of cuppingtherapy as a singular treatment of pain. The authors included 7 RCTs thatmet the inclusion criteria of their review. All of the included trials adopted atwo-armed parallel group design. The treated pain-related conditions werelow back pain, cancer pain, trigerminal neuralgia, brachialgia paraestheticanocturna (BPN) and herpes zoster. One RCT compared the effects of drycupping on cancer pain with conventional drug therapy and reportedfavourable effects for cupping after 3-day intervention (response rate: 67%

versus 43%, p


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Cao et alconducted a systematic review and meta-analysis to evaluate thetherapeutic effect and safety of traditional Chinese medicine, includingChinese herbal medicine for treatment of fibromyalgia which ischaracterised by chronic widespread pain multiple tender points over thebody. A total of 25 RCTs were included in this review. The effects of

traditional Chinese therapies in providing pain relief and restoringfunctionality as well as improving quality of life of the patients were studied.Three of the RCTs compared acupuncture plus cupping therapy withmedications alone. However, only 2 trials were chosen for meta-analysisbecause of low risk of bias. The analysis on the 2 RCTs showed that acombination of acupuncture and cupping therapy plus medications wassignificantly better than conventional medications alone in reducing pain(pain reduction assessed using 10mm Visual Analogue Scale, MD -1.66, CI2.14 to -1.19, p< 0.00001, I2= 0%) and reducing depression symptoms(assessment of depression symptoms using Hamilton Depression Scale(HAMD) scores, MD -4.92, CI -6.49 to -3.34, p< 0.0001, I2= 32%). The

authors concluded that patients with fibromyalgia might benefit fromtraditional Chinese therapies however, more rigorously designed trials withlarger number of patients were warranted in demonstrating theeffectiveness and long term effects of these therapies.6, level 1

5.2 SAFETY OF CUPPING THERAPY

Cupping therapy is considered relatively safe with no major side effects.However, it can cause some swelling and bruising on the skin. Thesebruises are usually painless and disappear within a few days post-treatment.1 There are several instances where cupping should not beperformed. Patients with inflamed skin and those who bleed easily are notsuitable candidates for cupping. Pregnant women or menstruating womenand patients with bone fracture or muscle spasms are also believed to becontra-indicated.2 Cupping therapy also cannot be applied to a site of DeepVein Thrombosis (DVT), where there are ulcers, arteries or places wherepulses can be felt.2

The adverse effects of cupping therapy was briefly described in asystematic review done by Cao et al as the secondary outcomes of thereview. One of the trials included in the review reported that a patient hadmild scalding on the skin after having cupping therapy. However, theauthors did not discussed in detail regarding that incident.6

A case study reported by Iblheret aldescribed a significant thermal injuryfollowing cupping therapy that warranted plastic surgery assessment andmanagement. A 59 year old Greek woman arrived at the EmergencyDepartment of Freiburg University Hospital, Germany by ambulance andwas found to have extensive truncal and upper extremity burns. The patient


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reported receiving cupping treatment from her husband due to chronic backpain. Six to eight cups were heated by a burning cloth which had beensoaked in petrol before ignition. The heated cups were then applied to theskin of her back. During the treatment, the petrol container fell, spilling thecontents over the patient and she was subsequently caught on fire. The

accident had resulted in superficial to deep partial-thickness burns to theback, abdomen, chest and right arm, involving a total body surface area of15%. There were also rounded hematomas caused by cupping therapyitself. The patient needed debridement and silicon-collagen foil burndressing, which required 10-day of hospital stay. No specific details whetherher husband is a recognized cupping therapist.7, level III Eventhough theincident was rare and more of the caution during the treatment process, it isimportant to create awareness among the public and the therapists on therisk of the injuries related to cupping therapy.

5.3 LIMITATIONS

This technology review has several limitations. The selection of studies wasdone by one reviewer. Although there was no restriction in language duringthe search but only English full text articles were included in this report. Anyabstracts without a full text articles were also excluded.

6. CONCLUSION

6.1 EFFICACY/EFFECTIVENESS

This review suggested that there is insufficient high quality evidence tosupport the use of cupping therapy in treating diseases or medicalconditions such as herpes zoster, facial paralysis, back pain, spondylosis,cerebrovascular accident, hypertension, fibromyalgia, bronchitis, asthmaand headache. There was fair level of evidence to show the effectiveness ofcupping therapy in treatment of certain disease or medical conditions,especially pain-related conditions. However, most of the trials combinedcupping therapy with other traditional complementary (TCM) treatment orwith conventional medications and standard therapeutic modalities that areavailable in the hospitals. No retrievable evidence to prove that cuppingtherapy as a single treatment is effective in treating any medical conditions.

Another drawback that has been identified is most of the articles thatreported positive effects of cupping therapy are from Chinese literature andthere are hardly any studies reported in Western literature, thus, thepossibility of publication bias is undeniable. The long term effect of cuppingtherapy is not known.


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6.2 SAFETY

Although cupping therapy is considered relatively safe and no majoradverse effects reported directly on the therapy itself, it is very important toensure that the practitioners are properly trained and aware of the dangers

involved in the cupping therapy. The burns are preventable, and thereforethe first step is to increase the awareness of the public and healthcareprofessionals on the risk of these injuries. The long term complications andadverse events related to cupping therapy is not known.

7. REFERENCES

1. The Many Benefits of Chinese Cupping. Available at :

http://www.itmonline.org/arts/cupping(retrieved on 14/5/2012)

2. Evaluation of the effects of traditional cupping on the biochemical,hematological and immunological factors of human venous blood. Availableat: cdn.intechweb.org/pdfs/26488.pdf.

3. Cao H, Han M, Li X, et al. Clinical research evidence of cupping therapy inChina: a systematic literature review. BMC Complement Altern Med. 2010Nov 16;10:70.

4. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy.PLoSOne. 2012;7(2):e31793.

5. Kim JI, Lee MS, Lee DH et al. Cupping for treating pain: a systematicreview. Evid Based Complement Alternat Med. 2011;2011:467014.

6. Cao H, Liu J, Lewith GT. Traditional Chinese Medicine for treatment offibromyalgia: a systematic review of randomized controlled trials. J AlternComplement Med. 2010 Apr;16(4):397-409.

7. Iblher N, Stark B. Cupping treatment and associated burn risk: a plasticsurgeon's perspective. J Burn Care Res. 2007 Mar-Apr;28(2):355-8.
http://www.itmonline.org/arts/cuppinghttp://www.itmonline.org/arts/cuppinghttp://www.itmonline.org/arts/cupping


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8. APPENDIX

8.1. Appendix 1: LITERATURE SEARCH STRATEGY

Ovid MEDLINE In-process & other Non-Indexed citations and OvidMEDLINE 1948 topresent

1. exp herpes zoster/2. herpes zoster.tw.3. exp facial/ adj1 paralysis/4. facial paralysis.tw.5. Bells palsy.tw.6. exp back pain/7. back pain.tw.8. exp spondylosis/

9. spondylosis.tw.10. exp stroke/11. stroke.tw.12. cerebrovascular accident$.tw.13. brain vascular accident$.tw.14. cerebral stroke.tw.15. exp hypertension/16. hypertension.tw.17. exp fibromyalgia/18. fibromyalgia.tw.19. exp bronchitis/

20. bronchitis.tw.21. exp asthma/22. asthma.tw.23. exp headache/24. headache.tw.25. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or

18 or 19 or 20 or 21 or 22 or 23 or 2426. Bloodletting/ or cupping therapy.mp.27. cupping.tw.28. cupping therap$.tw.29. (cupping adj1 therap$).tw.

30. 26 or 27 or 28 or 2931. 25 AND 30


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OTHER DATABASES

EBM Reviews - CochraneCentral Register of Controlled

Trials

Same MeSH, keywords, limits used as per MEDLINE search

EBM Reviews - Database of

Abstracts of Review of EffectsEBM Reviews - Cochrane

database of systematic reviews

EBM Reviews - Health

Technology Assessment

PubMed

NHS economic evaluationdatabase

INAHTA

FDA


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8.2. Appendix 2

HIERARCHY OF EVIDENCE FOR EFFECTIVENESS STUDIES

DESIGNATION OF LEVELS OF EVIDENCE

I Evidence obtained from at least one properly designed randomized controlledtrial.

II-I Evidence obtained from well-designed controlled trials withoutrandomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies,preferably from more than one centre or research group.

II-3 Evidence obtained from multiple time series with or without the intervention.Dramatic results in uncontrolled experiments (such as the results of theintroduction of penicillin treatment in the 1940s) could also be regarded as thistype of evidence.

III Opinions or respected authorities, based on clinical experience; descriptivestudies and case reports; or reports of expert committees.

SOURCE: US/CANADIAN PREVENTIVE SERVICES TASK FORCE (Harris 2001)

cupping therapy (1)

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