CRITICAL REVIEW EVIDENCE BASED NURSING (EBN)

THE EFFECTIVENESS OF CUPPING THERAPY ON RELIEVING

CHRONIC NECK AND SHOULDER PAIN

Disusun oleh

Nabilatuz Zulfa Salimah

NIM 162310101143

Kelas C 2016

KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS JEMBER

FAKULTAS KEPERAWATAN

Jl. Kalimantan No. 37 Kampus Tegal Boto Jember Telp./Fax (0331) 323450
 BAB 1. PENDAHULUAN

1.1 Latar Belakang

Nyeri leher dan bahu kronis atau Chronic neck and shoulder pain (NSP)
adalah jenis rasa sakit yang terjadi di bagian muskoloskeletal biasanya terjadi
di usia menengah dan orang tua. Prevalensi NSP adalah sekitar 16% hingga
78% di antara populasi umum. Dampak dari penyakit kronis ini seperti
perubahan kehidupan sosial, dampak emosional, perubahan rencana masa
depan termasuk pada keluarga dan termasuk kegiatan sosial. Terapi bekam
atau Cupping Theraphy (CT) adalah pengobatan tradisional dari Tiongkok
yangtelah dipraktekkan selama ribuan tahun. Definisi Cupping Theraphy atau
terapi bekam menurut WHO adalah model terapi yang melibatkan
aplikasihisap dengan membuat ruang hampa, terapi ini biasanya dilakukan
dengan menggunakan api dalam gelas atau toples (sejenis tempat seperti
mangkuk) yang dilakukan pada bagian tubuh yang sakit atau pada bagian
tertentu (Chi dkk., 2016)
Di Taiwan, sekitar 12% dari peserta yang dilakukan penelitian terhadap
efektivitas penggunaan terapi bekam ini melaporkan bahwa penggunaan terapi
bekam ini cukup efektif untuk digunakan ssaat nyeri. Mekanisme terapi
bekam ini menciptakan vacum pada kulit dengan tekanan negatif yang
mengakibatkan kapiler pecah, terapi ini disebut dengan bekam kering atau
bekam yang ditahan. Kulit yang terlokalisasi yang sudah dilakukan teapi
bekam ini bisa memerah dan mungkin menunjukkan petekia ekimosis
(purpura atau ekstravisasi darah di bawah kulit yang ukurannya lebih besar
dari 1 cm atau hematoma) yang sering disebut dengan memar atau bercak
biru-kehitaman yang tampak pada kulit tubuh. Terapi bekam ini telah validasi
telah mempunyai beberapa fungsi seperti, menghilangkan flu, menghilangkan
pembengkakan, mempercepat penyembuhan, menyesuaikan suhu tubuh,
fibromyalgia (orang yang menderita fibromyalgia sering kali mengalami
kelelahan, gangguan tidur, gangguan ingatan dan mood), rehabilitasi untuk
pasien stroke, mengurangi rasa sakit termasuk low back pain dan penyakit
kronis lainnya (Chi dkk., 2016)
1.2 Tujuan

1.2.1 Tujuan Umum

Mengetahui efektifitas terapi bekam pada pasien dengan nyeri kronis pada
pada ekstrimitas atas

1.2.2 Tujuan Khusus

1. Mendapatkan gambaran kualitas hidup pada pasien yang

mengalami nyeri kronis pada ekstrimitas atas.

2. Mendapatkan gambaran tingkat nyeri yang dialami oleh pasien.

3. Mendapatkan gambaran keefektifan terapi bekam pada pasien

dengan nyeri kronis pada ekstrimitas atas

1.3 Manfaat Penerapan EBN

1.3.1 Bagi Pasien

Memberikan pilihan terapi dalam mengatasi nyeri yang terjadi pada

pasien dengaan nyeri ekstrimitas atas, sehingga nyeri yang dialami
oleh pasien bisa diminimalisir atau malah berkurang.

1.3.2 Bagi Pelayanan Keperawatan

Hasil penerapan EBN ini dapat menjadi terapi tambahan atau bahkan
menjadi terapi utama disamping terapi medis yang bisa diterapkan
dalam pelayanan keperawatan sehingga untuk mengatasi nyeri yang
dialami oleh kebanyakan pasien.

1.3.3 Bagi Perkembangan Ilmu Keperawatan

Hasil penerapan EBN ini diharapkan dapat memperkaya khazanah

keilmuan keperawatan dan menjadi salah satu acuan dalam
perawatan klien dengan nyeri kronis.
 BAB 2. METODOLOGI PENCARIAN

2. 1 PICO (Problem, Intervention, Comparative, Outcome)

2.1.1 Problem
Hasil pengamatan penulis dalam jurnal : kebanyakan orang
menderita rasa sakit yang serius atau berlanjut pada tahap kehidupan
mereka. Hampir 80% dari kunjungan ke fasilitas layanan kesehatan
setidaknya mereka mengeluhkan 1-2 kali gejala dari rasa sakit yang terjadi
di dalam tubuh mereka. Hampir 75% orang di Amerika telaah mengalami
nyeri kronis atau berulang, oleh karena itu manajemen nyeri yang tepat
juga berguna dalam penanganan dan perawatan untuk pasien (Cao dkk.,
2014)
2.1.2 Intervention
Kelompok terapi bekam menerima cupping therapy api pada 3 titik
akupuntur dimana di dalam jurnal ini peneliti menyebutnya dengan SI15,
6B21 dan LI15. Gelas ukuran medium dengan diameter 4cm dan volume
gelas sebesar 260ml digunakan. Peserta diminta duduk dengan nyaman di
kursi yang telah disediakan dengan kedua kaki rata di lantai dan
memperlihatkan daerah leher dan bahu mereka. Prosedur bekam adalah
sebagai berikut : alkohol swab yang telah dibuka kemudian dinyalakan,
setelah swab terbakar dengan cepat ditempatkan di dalam cangkir yang
sudah disediakan, kemudian cangkir di tempatkan pada tiga titik
akupuntur, cangkir di diamkan dan dilepas selama 10 menit dan proses
yang sama diulang dalam jumlah waktu yang sama. Seluruh perawatan
berjumlah 20 menit untuk mengobatai kedua sisi tubuh (Chi dkk., 2016)
2.1.3 Comparasion Intervention
Terapi bekam ini efektif dalam mengurangi dan mengatasi nyeri
kronis yang dialami oleh pasien dengan ganggun ekstrimitas atas. Dari
ketiga penelitian tersebut didapatkan penurunan yang signifikan terhadap
kejadian nyeri kronis yang terjadi pada pasien.
Yang membedakan dari ketiga penelitian tersebut diantaraya yaitu :
1. Pada jurnal pertama yang berjudul “ The effectiveness of cupping
therapy on relieving chronic and shoulder pain: A randomized
 controlled trial “ intervensi terapi bekam yang diberikan yaitu pada
bagian ekstrimitas atas yaitu bahu, kemudian terapi pembekaman ini
dilakukan selama 20 menit setiap 7-8 hari sekali (Chi dkk., 2016)
2. Pada jurnal kedua yang berjudul “ Cupping therapy for acute and
chronic pain management: a systematic review of randomized clinical
trials“ intervensi terapi bekam yang dilakukan ini adalah menyeluruh
pada bagian yang terdapat nyeri akut dan nyeri kronis, tidak berbatas
pada bagian tertentu saja (Cao dkk., 2014)
3. Pada jurnal ketiga yang berjudul “ Cupping therapy: an overview from
a modern medicine perspective“ adalah jurnal yang mereview tentang
publikasi penelitian ilmiah yang di dalamnya juga melakukan
intervensi terapi bekam pada pasien dengan nyeri akut maupun kronis
(Aboushanab dan AlSanad, 2018)

2.1.4 Outcome

Dengan penerapan terapi bekam atau Cupping therapy yang

dilakukan pada pasien dengan gangguan ekstrimitas atas atau pada bagian
yang terasa nyeri terbukti efektif, sangat berpengaruh dan bisa
meminimalisir atau mengatasi nyeri kronis yag dialami oleh pasien.

2.2 Pertanyaan Klinis

Apakah terapi bekam atau Cupping Therapy efektif dalam mengurangi dan
mengatasi nyeri akut maupun kronis?

2.3 Metode penelusuran journal

Unsur PICO Analisisa Kata Kunci

P Chronic or Acute Pain Chronic pain/acute pain

manegement/therapy for
acute pain management

I Cupping Therapy as pain Cupping therapy/

management for acute or complementary therapy/
chronic management cupping therapy for
 chronic and acute pain

C Penerapan terapi bekam

dalam menurunkan
intensitas nyeri pada
pasien dengan gangguan
ekstrimitas atas.

O Terdapat penurunan yang

signifikan pada kejadian
penurunan nyeri yang
terjadi pada pasien antara
sebelum dan sesudah
dilakukan intervensi

2.4 Jurnal Database yang digunakan

Menggunakan kata kunci dan beberapa sinonimnya dari analisa PICO,

peneliti memasukkannya ke dalam search engine jurnal sebagai berikut :

a. https://www.sciencedirect.com

b. https://www.hindawipublishing.com
c. https://www.Jams.com
Didapatkan 100 lebih judul artikel yang hampir sama, kemudian dipilih
sebanyak 3 journal yang sama dan relevan. Keseuaian dengan keadaan
yang sebenarnya dan perannya dalam keperawatan komplementer.
Penyusun memilih 1 jurnal pilihan untuk dijadikan sebagai jurnal utama
dan kemudia meilih 2 jurnal lainnya dijadikan sebagai jurnal pendukung
dan jurnal pembanding.

2.5 Temuan artikel pilihan dari kata kunci PICO yang digunakan sebagai
rujukan

2.5.1. The effectiveness of cupping therapy on relieving chronic neck

and shoulder pain : a randomized controlled trial

 Penjelasan jurnal utama pelaksanaan EBN

 Efektivitas terapi bekam dalam menghilangkan nyeri kronis pada
leher dan bahu : uji coba terkontrol secara acak
Latar belakang : nyeri leher dan bahu kronis atau NSP (neck shoulder
pain) adalah jenis rasa sakit di bagian muskuloskeletal yang biasanya
terjadi pada usia menengah dan orang tua. Prevalensi NSP adalah sekitar
16%-78% di antara populasi umum, NSP ini bisa berdampak pada
hubungan sosial, hubungan natar keluarga, emosional dan perubahan
rencana masa depan. Terpai bekam ini adalah pengobatan tradisional
tiongkok yang sudah dipakai dan di praktekkan selama ribuan tahun.
WHO mendefinisikan terapi bekam adalah metode terapeutik yang
melibatkan aplikasi hisap dengan membuat ruang hampa. Terapi ini
biasanya dilakukan dengan menggunakan api dalam gelas atau toples dan
di tempelkan pada dermis atau pada bagian tubuh yang sakit.
Metode : subjek penelitian ini adalah eksperimen single-blind desain.
Penelitian ini dilakukan di labolatorium penelitian keperawatan di TzuChi
di suatu universitas. Suhu ruangan di kontrol pada 20 sampai 24 derajat
dan tingkat kelembapannya di pertahankan pada 600 derajat hingga 70
derajat. Praktisi medis tiongkok juga diminta untuk memverifikasi pilihan
dan lokasi yang dipilih tiitik akupuntur dan pengobatan bekam. Ukuran
sample yang digunaka dalam studi percobaan yang dipakai untuk NSP
hasil yang signifikan secara statistik antara perbedaan kelompk 1,18.
Moetode pada penelitian kali ini menggunakan tes wilcoxon mann
whitney untuk mencapai hasil dan menggunakan nilai cronbach.
Hasil : rata-rata suhu pada titik akupuntur menunjukkan tidak banyak
perbedaan pada kelompok sebelum melakukan terapi bekam. Di titik
tertentu setelah melakukan bekam terdapat kenaikan suhu yang
menandakan bahwa terdapat perubahan yang terjadi pada bagian yan
diterapi
Kesimpulan : NSP Kronis adalah masalah umum pada orang dewasa. CT
atau terapi bekam adalah salah satu perawatan komplementar yang efektif
 dalam pengobatan tradisional di tiongkok, CT juga digunakan di seluruh
dunia, karena mudah di pelajari dan memiliki sedikit efek atau dampak.
Dalam penelitian ini satu pengobatan CT terbukti (Chi dkk., 2016)

2.5.2 Cupping therapy for acute and chronic pain management

 Penjelasan jurnal pendukung pelaksanaan EBN

Cupping therapy for acute and chronic pain management
Latar Belakang : kebanyakan orang menderita rasa sakit yang serius pada
tahap kehidupan mereka. Hampir 80% dari semua kunjungan ke pelayanan
kesehatan setidaknya ada satu keluhan terkait langsung dengan rasa sakit
dan 75% orang Amerika telah mengalami nyeri kronis atau berulang,
biaya $ 200 miliar per tahun. Sementara rasa sakit sering bersifat
profilaksis cedera lebih lanjut, manajemen nyeri yang tepat juga diakui
sebagai hak asasi manusia yang mendasar dan integral perawatan pasien
yang baik. Nyeri dapat diklasifikasikan secara fisiologis sebagai kerangka,
neuropatik, atau inflamasi; atau diklasifikasikan berdasarkan jenis jaringan
yang terlibat, seperti kulit, otot, organ, sendi dan tulang; atau terkait
dengan penyakit / kondisi, seperti kanker, fibromyalgia; atau dapat
mencerminkan keadaan psikologis, usia, jenis kelamin, dan budaya.
Namun, sebagian besar pedoman dan organisasi, termasuk Klasifikasi
Penyakit Internasional terbaru, 4 pada dasarnya mengklasifikasikan nyeri
sebagai akut atau kronis tahap awal kategorisasi.
Pengoleksian Data : Dua penulis (XY dan XL) mengevaluasi judul dan
abstrak secara mandiri. Makalah lengkap diambil untuk semua berpotensi
studi yang relevan. Ketidaksepakatan diselesaikan oleh diskusi dan jika
perlu, diadili oleh penulis ketiga
(HJC). Dua penulis (HJC dan XL) mengekstraksi data dari termasuk studi
secara mandiri. Ketidaksepakatan terjadi diselesaikan dengan diskusi
dengan penulis ketiga (JPL). Diekstraksi informasi termasuk metode studi
(desain, pengacakan metode, metode membutakan), karakteristik peserta
(Kriteria inklusi / eksklusi, ukuran sampel, jenis kelamin, usia, jenis
 penyakit / kondisi, lama sakit, sebelumnya perawatan), rincian intervensi
dan kontrol (jenis cupping, pemilihan acupoint, frekuensi dan durasi
pengobatan, jenis kontrol, rincian intervensi bersama), data tindak lanjut
(durasi tindak lanjut, tingkat penarikan dan alasan), data hasil, dan analisis
data (metode analisis, komparabilitas kelompok pada awal, statistik
teknik).
Hasil : Dari 16 percobaan termasuk, peristiwa buruk disebutkan dalam 10
uji coba. Empat uji coba melaporkan bahwa ada tidak ada kejadian buruk
di antara kelompok bekam. hingga efek samping sedang dilaporkan dalam
sisanya 6 percobaan, dengan 10,3% peserta melaporkan hematoma di situs
yang dirawat, 10,3% peserta melaporkan peningkatan rasa sakit di lokasi
asli setelah bekam atau rasa sakit di daerah yang dirawat, dan 7,5% peserta
melaporkan otot rasa sakit atau kesemutan di situs asli rasa sakit setelah
perawatan. Tidak ada efek samping yang parah terkait dengan terapi
bekam dilaporkan dalam salah satu dari 10 percobaan yang dimasukkan
(Cao dkk., 2014)

2.5.3 Cupping therapy : an overview from a modern medicine perspective

 Penjelasan jurnal pembanding pelaksanaan EBN

Cupping therapy: an overview from a modern medicine perspective
Abstrak : Terapi bekam adalah praktik pengobatan tradisional dan
komplementer kuno. Baru-baru ini, ada bukti yang berkembang manfaat
potensial dalam pengobatan nyeri terkait penyakit. Artikel ini memberikan
ikhtisar praktik terapi bekam. Selanjutnya, artikel ini menyarankan
klasifikasi baru set terapi bekam, klasifikasi baru efek samping terapi
bekam, dan klasifikasi terbaru dari terapi bekam jenis (Aboushanab dan
AlSanad, 2018)
 BAB 3. PROSEDUR APLIKASI EVIDENCE BASED NURSING

Pelaksanaan EBN ini mengacu pada penelitian :

1. Aboushanab, T. S. dan S. AlSanad. 2018

2. Lee Mei Chi., dkk 2016

3. Huijuan Cao., dkk 2014

3.1 Subyek

Subyek dalam penerapan EBN ini adalah para pasien atau klien dengan
rentang umur 20-60 tahunan atau sudah lanjut usia dengan pengalaman nyeri
yang di derita sudah berbulan-bulan bahkan sampai menahun, baik itu wanita
maupun pria. Juga memenuhi beberapa kriteria inklusi sebagai berikut (Chi
dkk., 2016):

1. Bekerja setidaknya 40 jam seminggu

2. Menderita NSP kemudian bekerja secara terus-menerus dengan intensitas

nyeri minimal 3 poin pada skala analog visual

Dan juga, peserta akan di keluarkan atau di drop out dari penelitian apabila ;

1. Infeksi, cedera atau terjadi pendarahan pada kulit di sekitar area untuk
terapi bekam
2. Terdapat neuropati di sumsum tulang belakang dan leher rahim
3. Mengkonsumsi analgesik dalam wktu 4 jam sebelum percobaan
4. Mengkonsumsi teh, kopi, minuman beralkohol atau minuman berkafein
lainnya dalam kurun waktu 4 jam sebelum pengukuran awal (Chi dkk.,
2016)

3.2 Intervensi

Kelompok terapi bekam menerima cupping therapy api pada 3 titik

akupuntur dimana di dalam jurnal ini peneliti menyebutnya dengan SI15, 6B21
dan LI15. Gelas ukuran medium dengan diameter 4cm dan volume gelas
 sebesar 260ml digunakan. Peserta diminta duduk dengan nyaman di kursi yang
telah disediakan dengan kedua kaki rata di lantai dan memperlihatkan daerah
leher dan bahu mereka. Prosedur bekam adalah sebagai berikut : alkohol swab
yang telah dibuka kemudian dinyalakan, setelah swab terbakar dengan cepat
ditempatkan di dalam cangkir yang sudah disediakan, kemudian cangkir di
tempatkan pada tiga titik akupuntur, cangkir di diamkan dan dilepas selama 10
menit dan proses yang sama diulang dalam jumlah waktu yang sama. Seluruh
perawatan berjumlah 20 menit untuk mengobatai kedua sisi tubuh (Chi dkk.,
2016)
3.3 Proses Penilaian
Intensitas Nyeri Leher dan Bahu. Nyeri dinilai menggunakan VAS; skala
likert digunakan untuk mengevaluasi subyektif pengalaman intensitas nyeri.
Intensitas nyeri leher. Tes melibatkan (1) condong ke depan dan ke belakang,
(2) berputar ke kiri dan kanan, dan (3) condong ke kiri dan kanan.Penilaian
intensitas nyeri bahu terlibat (1) mengangkat kedua lengan, meregangkan dada,
dan memperpanjang lengan mundur untuk menyentuh bagian belakang leher
dan (2) mengangkat kedua lengan ke atas, menempatkannya di telinga, dan
menempatkan telapak tangan bersama. Subjek diminta untuk memilih titik
pada skala yang paling akurat mencerminkan level mereka rasa sakit sebelum
dan kemudian setelah rasa sakit mendorong gerakan. Sedangkan terapi bekam
ini, dilakukan selama beberapa minggu dan juga diukur setelah dan sebelum
masa intervensi (Chi dkk., 2016)
 BAB 4. PEMBAHASAN

Dalam penelitian disebutkan bahwa terjadi penurunan gejala dari masing-

masing kelompok. Kelompok intervensi terapi bekam maupun control. Namun
tingkat penurunan intensitas nyeri terdapat perbedaan yang signifikan antara
sebelum melakukan terapi dan sesudah melakukan terapi. Terjadi perbedan
tekanan darah antara sesudah dilakukan terapi bekam dengan sebelum, sesudah
dilakukan terapi bekam Tekanan darah sistemik (SBP) menurun dari 117,7 ±
2,9mmHg ke 111,8 ± 2,3mmHg, dalam bekam grup (𝑃 = 0,003). Kelompok
kontrol juga menunjukkan sedikit reduksi dari 113.8 ± 3.0mmHg menjadi 109.7 ±
3.1mmHg (𝑃 = 0,117). Tidak ada perbedaan yang signifikan antara keduanya
kelompok; namun bekam tampaknya memiliki pengaruh dalam penurunan
tekanan darah sistemik (Chi dkk., 2016)
Kemudian dalam penanganan nyeri terbukti intensitas berubah. Pada
awalnya, VAS nyeri leher Intensitas (NPI) adalah 9,7 ± 1,6 pada kelompok bekam
dan 9,7 ± 1,6 pada kelompok kontrol. NPI pasca perawatan menurun 6,1 pada
kelompok bekam dan menurun 0,2 pada kelompok kelompok kontrol
TheANCOVAtest memperlihatkan perbedaan signifikan antara kelompok (𝑃
<0,001). VAS intensitas nyeri bahu (SPI) adalah 8,5 ± 0,9 untuk kelompok bekam
pada awal dan 8,5 ± 0,9 pada kontrol posttreatment bekam menurun hingga 5,9
padakelompok dan menurun oleh 0,6 di dalam kelompok kontrol. Perbedaan
antara kelompok secara statistik signifikan (𝑃 <0,001) (Chi dkk., 2016)
 BAB 5. PENUTUPAN

5.1 Kesimpulan

Nyeri pada leher dan bahu adalah sejenis rasa sakit yang biasanay terjadi
di usia menengah dan orang tua. Dampak yang terjadi apabila terjadi nyeri
adalah perubahan pada hubungan sosial bahkan keluarga, dampak emosiaonal
dan perubahan rencana masa depan juga bisa saja terganggu. Nyeri pada leher
dan bahu kronis adalah masalah umum pada orang dewasa, Cupping Therapy
atau terapi bekam ini adalah salah satu perawatan yang efektif dan pengobatan
tradisional Tiongkok yang paling banyak diminati karena mudah dipelajari dan
memiliki sedikit efek. Dalam penelitian ini, pengobatan secara komplementer
dengan menggunakan terapi bekam ini terbukti menurunkan tekanan darah
sistemik dan juga meningkatkan kekebalan tubuh dengan pembuangan darah
yang kurang bagus dan tubuh akan memproses dan memproduksi darah kembali.
Terapi bekam ini meniru sifat analgesik yang tidak memiliki sisi negatif dan
dapat dianggap aman untuk digunakan dalam pengobatan dan perawatan untuk
penyakit yang dapat menyebabkan nyeri.

5.2 Saran

5.2.1 Bagi Profesi Keperawatan

Penerapan terapi komplementer bekam dapat digunakan

dan diterapkan untuk mendukung pemulihan, kesehatan dan
peningkatan kualitas hidup pasien khususnya pasien yang
menderita penyakit kemudian menyebabkan nyeri kronis. Baik
dalam mengurangi atau meminimalisir intensitas nyeri dan
meningkatkan kualitas hidup pasien. Oleh karena itu perawat perlu
banyak belajar terkait tata cara pelaksanaan terapi bekam dengan
benar dan tata cara pelaksanaannya pada pasien.

5.2.2 Bagi Mahasiswa Keperawatan

Perlunya untuk memperkaya wawasan terkait intervensi-

intervensi keperawatan terbaru guna meningkatkan keterampilan
dan menambah wawasan terakit dengan intervensi-intervensi
dalam melakukan asuhan keperawatan, dan juga untuk menerapkan
hasil-hasil penelitian yang sudah diteliti dan sudah diuji klinis
sebagai intervensi yang baru dan layak digunakan di lapangan serta
efektif untuk membantu klien dalam mengatasi masalah kesehatan
yang mereka alami.
 DAFTAR PUSTAKA

Aboushanab, T. S. dan S. AlSanad. 2018. Cupping therapy: an overview from a

modern medicine perspective. JAMS Journal of Acupuncture and Meridian
Studies. 11(3):83–87.
Cao, H., X. Li, X. Yan, N. S. Wang, A. Bensoussan, dan J. Liu. 2014. Cupping
therapy for acute and chronic pain management: a systematic review of
randomized clinical trials. Journal of Traditional Chinese Medical Sciences.
1(1):49–61.
Chi, L.-M., L.-M. Lin, C.-L. Chen, S.-F. Wang, H.-L. Lai, dan T.-C. Peng. 2016.
The effectiveness of cupping therapy on relieving chronic neck and shoulder
pain: a randomized controlled trial. Evidence-Based Complementary and
Alternative Medicine. 2016(1):1–7.
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2016, Article ID 7358918, 7 pages
http://dx.doi.org/10.1155/2016/7358918

Research Article
The Effectiveness of Cupping Therapy on Relieving Chronic
Neck and Shoulder Pain: A Randomized Controlled Trial

Lee-Mei Chi,1,2 Li-Mei Lin,3 Chien-Lin Chen,4,5 Shu-Fang Wang,6

Hui-Ling Lai,7 and Tai-Chu Peng1,7
1
Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
2
Department of Nursing, Tzu Chi University of Science and Technology, Hualien 970, Taiwan
3
Department of Nursing, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan
4
Department of Chinese Medicine, Taipei Tzu Chi Hospital, New Taipei City 23142, Taiwan
5
School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 970, Taiwan
6
Chinese Lactation Consultant Association, Hualien 970, Taiwan
7
Department of Nursing, Tzu Chi University, Hualien 970, Taiwan

Correspondence should be addressed to Tai-Chu Peng; ptc2008@mail.tcu.edu.tw

Received 15 October 2015; Accepted 4 January 2016

Academic Editor: Haroon Khan

Copyright © 2016 Lee-Mei Chi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The research aimed to investigate the effectiveness of cupping therapy (CT) in changes on skin surface temperature (SST) for
relieving chronic neck and shoulder pain (NSP) among community residents. A single-blind experimental design constituted of
sixty subjects with self-perceived NSP. The subjects were randomly allocated to two groups. The cupping group received CT at SI 15,
GB 21, and LI 15 acupuncture points, and the control group received no intervention. Pain was assessed using the SST, visual analog
scale (VAS), and blood pressure (BP). The main results were SST of GB 21 acupuncture point raised from 30.6∘ C to 32.7∘ C and from
30.7∘ C to 30.6∘ C in the control group. Neck pain intensity (NPI) severity scores were reduced from 9.7 to 3.6 in the cupping group
and from 9.7 to 9.5 in the control group. The SST and NPI differences between the groups were statistically significant (𝑃 < 0.001).
One treatment of CT is shown to increase SST. In conjunction with the physiological effect the subjective experience of NSP is
reduced in intensity. Further studies are required to improve the understanding and potential long-term effects of CT.

1. Introduction In Taiwan, approximately 12.8% of the participants

Chronic neck and shoulder pain (NSP) is a type of mus-
culoskeletal pain typically occurring in middle- and older-
aged people [1–3]. The prevalence of NSP is approximately
16% to 78% among the general population [2–4]. The impact
of chronic pain on the family includes social activities, life
changes, emotional impact, and alteration of future plans [5].
Cupping therapy (CT) is a traditional Chinese medical
(TCM) treatment which has been practiced for thousands of
years. The World Health Organization’s (WHO) definition of
cupping is a therapeutic method (Code 5.3.2) involving the
application of suction by creating a vacuum. This is typically
done using fire in a cup or jar (Code 5.3.7) on the dermis of
the affected part of the body [6].
reported the use of cupping therapies in the past year [7].
The cupping mechanism constitutes creating a vacuum on the
skin, with the ensuing negative pressure resulting in capillary
rupture. This method is known as retained or dry cupping
[8]. The skin of the localized area becomes flushed and may
show petechiae and ecchymosis [9] or bruising, in which
the duration is therapeutically beneficial [10]. Cupping has
multiple therapeutic functions which include (1) warming
the channels to remove cold, (2) promoting qi and blood
circulation, (3) relieving swelling, (4) accelerating healing,
(5) adjusting body temperature, (6) fibromyalgia [11], (7)
stroke rehabilitation, hypertension, musculoskeletal pain,
herpes zoster [8, 12], (8) facial paralysis, acne, and cervical
spondylosis [13], and (9) alleviating pain [14], including
2 Evidence-Based Complementary and Alternative Medicine
chronic neck [15–17], shoulder pain [2], and low back pain
[17, 18].
Traditional acupuncture points, jianshongshu (SI 15),
jianjing (GB 21), and jianju (LI 15), have been suggested for
improving NSP. The SI 15 point is positioned on the back,
approximately 3 to 4 cm lateral to the lower border of the
spinous process of the seventh cervical vertebra (dazhui). This
point is associated with shoulder and back pain and coughing.
The GB 21 is situated at the midpoint that connects the dazhui
point (DU 14) and the acromion (the shoulder peak). It is
primarily used to treat headaches, neck pain, stroke-induced
speech impairment, and shoulder, back, and arm pain. The
LI 15 point is located on the lateral side of the arm and on
the deltoid muscle. It is the depressed area distal and anterior
to the acromion when the arms are stretched outward or
forward. This point is used to treat shoulder joint pain and
hemiplegia [19].
The current literature remains sparse for studies on skin
temperature differences at acupuncture points in relation to
thermal effect of cupping therapy. Liu et al. showed that
localized skin temperature increased [20, 21], while blood
pressure decreased [22], after CT. It is suggested that these
physiological responses to CT may be related to the positive
therapeutic effect. Currently, due to the paucity of available
research focusing on skin temperature changes due to CT,
the potential effect and its relationship remains unclear.
This study investigated the effectiveness of CT for relieving
chronic NSP among community residents and the changes in
skin surface temperature (SST).
2. Methods
2.1. Subjects. This study was a single-blind experimental
design. Subjects with diagnosed and self-perceived chronic
NSP were recruited in Hualien City, Taiwan, via advertising
and e-mail from October 2012 to February 2013. This research
was conducted in a nursing research laboratory at the Tzu Chi
University of Science and Technology. The room temperature
was controlled at 20 to 24∘ C and the humidity level was
maintained at 60 to 70%. A Chinese traditional medicine
nurse and traditional Chinese medical practitioner were
also asked to verify the choice and location of the selected
acupuncture points and the cupping treatment.
The inclusion criterion is as follows: (1) working at least
40 hours a week and (2) suffering work-related NSP contin-
uously for at least 3 consecutive months with an intensity
of at least 3 points on the visual analog scale (VAS, 0–10).
Participants were excluded if the following exist: (1) infection,
injury, or bleeding of the skin surrounding the area for cup-
ping therapy, (2) neuropathy in the cervical spinal cord, (3)
analgesic ingestion within 4 hrs preceding experiment, and
(4) consumed coffee, tea, or any other caffeinated beverage
within 4 hrs prior to the baseline measurement. Also, no
tobacco products had been smoked for a minimum of 30 min
before the baseline data were recorded.
2.2. Sample Size. In the pilot study (𝑛 = 6) for NSP a
statistically significant result between group difference of 1.18
(effect size = 0.81) using the VAS was found. Employing
Recruitment advertising (N = 62)
Exclusion (n = 2)
analgesic medication
Allocation
Randomization (N = 60)
Cupping group (n = 30) Control group (n = 30)
Received cupping therapy (n = 30) Received resting (n = 30)
Data analysis
Skin surface temperature Pain intensity
Figure 1: Flowchart of this study.
the Wilcoxon Mann-Whitney test (G power v 3.1.3) [23] to
achieve a power of 0.8, with Cronbach’s 𝛼 value = 0.05 and
an effect size of 0.80, the required size for each group is
minimum of 27 subjects.
2.3. Randomization. Subjects were assigned “cupping group”
or “control group” based on random selection from sealed
envelopes which had been sequence coded prior to study
commencement. Neither the researcher nor the participants
were aware of which group the participants would be assigned
to. Figure 1 displays the flowchart of the study.
This study was reviewed and approved by the Research
Ethics Committee of the Buddhist Tzu Chi General Hospital
(Registration number 101-60). Written consent was obtained
from the participants prior to the start of the study. The
objectives of the research were explained and the option to
withdraw from the study at any time was made known.
2.4. Intervention. The cupping group received fire CT at three
acupuncture points, SI 15, GB 21, and LI 15. The medium
size glass cup with diameter of 4 cm and volume of 260 mL
(Cosmos International Supplies Co., Ltd., Taiwan) was used.
Participants were asked to sit comfortably in a chair with
both feet flat on the floor and expose their neck and shoulder
regions. The cupping procedure is as follows: (1) an alcohol
swab is ignited, (2) the burning swab is quickly placed inside
the cup and withdrawn, (3) the cups are placed over the three
acupuncture points, (4) the cups were then removed after
10 min [24], and (5) the same process was repeated for the
same amount of time on the subject’s left side (Figure 2(a)).
The entire treatment totaled 20 minutes to treat both sides of
the body.
Evidence-Based Complementary and Alternative Medicine 3

35.0 35.0

30.0 30.0

(∘ C)

(∘ C)
1 33.28
25.0 2 33.32 25.0
3 32.21

(a) (b)

Figure 2: The skin surface temperature (∘ C) at SI 15, GB 21, and LI 15 acupuncture points displayed by infrared camera by cupping (a) and
after cupping therapy (b).

Participants in the control group received resting for Table 1: Group demographic characteristics. Categorical variables:
20 min. Chi-square test. Continuous variables: Mann-Whitney 𝑈 test.

Variables Cupping Resting 𝑃

2.5. Outcomes. Participant characteristics included demo-
graphic data such as age, sex, and a brief medical history
including past experience of cupping.
2.5.1. Skin Surface Temperature (SST) and Blood Pressure (BP).
An infrared camera (FLIR ThermaCAM P25 HS system)
was used to measure SST of the right SI 15, GB 21, and
LI 15 acupuncture points (Figure 2(b)). Measurements were
recorded for SST at 4 time points with a 5-minute interval
between each measurement. The FLIR infrared camera is an
infrared thermal detector, with 320 × 240 pixel geometric
resolution of 76.800 pixels per picture. Measurements can
be performed which range from 0 to 250∘ C ± 0.001∘ C.
The data was transferred to a notebook computer using the
ThermaCAM Researcher V.2.8 software (FLIR Systems Inc.,
Portland, Oregon, USA).
BP was measured using a mercury sphygmomanometer
(Model S-300, standard sphygmomanometer, Taiwan) using
the participants’ right arm. BP was recorded both before and
after intervention.
2.5.2. Neck and Shoulder Pain Intensity. Pain was scored using
VAS; a Likert scale was used for evaluating the subjective
experience of pain intensity [25, 26]. The neck pain intensity
test involved (1) leaning forward and backward, (2) rotating
to the left and right, and (3) inclining to the left and right
[27]. The shoulder pain intensity assessment involved (1)
raising both arms, stretching the chest, and extending the
arms backward to touch the back of the neck and (2) raising
both arms upward, placing them against the ears, and placing
the palms together [28]. The subjects were asked to select a
point on the scale that most accurately reflected their level of
pain before and then after the pain inducing movement [29].
2.6. Statistical Analysis. Data were analyzed using SPSS
V.18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The
univariate analysis of covariance (ANCOVA) was used to
assess the level of NSP intensity. ANCOVA was used to assess
𝑛 = 30 𝑛 = 30
Gender (%) 0.640
Male 3 (10.0) 2 (6.7)
Female 27 (90.0) 28 (93.3)
Age (mean ± SD) 43.6 ± 8.0 42.5 ± 7.4 0.486
the changes in the SST and BP, while adjusting the baseline for
both groups. The Friedman test was conducted to evaluate the
overall changes within each group. Wilcoxon test was used to
compare the difference within groups. A 𝑃 value of <0.05 was
considered statistically significant.
3. Results
The study recruited a total of sixty-two participants and
excluded two cases due to analgesic ingestion prior to the
experiment. The participant gender representation within the
study was female (91.7%; 𝑛 = 55) and 8.3% male (𝑛 = 5).
The subjects aged from 24 to 61 years with a median age of
43.6 ± 8 years. There were no significant differences between
the cupping and control groups for subjects’ gender and age
at baseline (Table 1).
3.1. Skin Surface Temperature (SST) Changes. The average
temperatures at the SI 15 acupuncture point showed no
significant differences between groups before CT. The SST at
the SI 15 point increased to a peak of 32.8 ± 0.5∘ C at 5 minutes
after CT. This temperature is significantly higher than the
baseline (30.7 ± 0.5∘ C) (𝑃 < 0.01) (Table 2). The Friedman
tests revealed that, from baseline to 5 minutes after cessation
of treatment, CT acts to increase the SST of SI 15 (𝑃 < 0.01).
During the resting period for the control group, the SI 15
temperature showed no significant difference from baseline
(𝑃 > 0.05) (Figure 3(a)).
The average temperatures at the GB 21 acupuncture point
showed no significant differences between groups before
4 Evidence-Based Complementary and Alternative Medicine

Table 2: Changes in SST at three acupuncture points between groups at 5-minute intervals. p 5th min: the 5th min of rest after cupping therapy.
Note: + ANCOVA was used to compare groups’ difference after adjustment of baseline differences. ++ Friedman test was used to compare the
difference within group. ∗ 𝑃 < 0.05.

Mean (SEM) Friedman test

Measurement indices
Baseline 5 min 10 min p 5th min 𝜒2 𝑃++
SI 15
Cupping 30.68 (0.51) 31.33 (0.45) 32.18 (0.46) 32.82 (0.53) 14.040 0.003∗
Resting 30.99 (0.57) 30.72 (0.58) 30.78 (0.57) 30.89 (0.59) 3.367 0.338
𝐹 — 11.915 32.684 48.949
𝑃+ — 0.011∗ 0.001∗ 0.001∗
GB 21
Cupping 30.62 (0.50) 31.09 (0.61) 32.08 (0.71) 32.72 (0.62) 14.040 0.003∗
Resting 30.71 (0.42) 30.57 (0.50) 30.61 (0.47) 30.60 (0.45) 1.653 0.647
𝐹 — 16.930 8.548 22.729
𝑃+ — 0.004∗ 0.022∗ 0.002∗
LI 15
Cupping 29.39 (0.39) 29.78 (0.42) 30.70 (0.47) 31.12 (0.78) 11.880 0.008∗
Resting 29.65 (0.37) 29.56 (0.40) 29.65 (0.43) 29.64 (0.46) 0.120 0.989
𝐹 — 9.007 28.726 24.828
𝑃+ — 0.020∗ 0.001∗ 0.002∗

CT. The SST of the GB 21 point gradually increased to
a peak of 32.7 ± 0.6∘ C after 5-minute CT. This value is
significantly higher than the baseline of 30.6 ± 0.5∘ C (𝑃 <
0.01). The Friedman tests revealed that, from baseline to
5 minutes after CT, the SST of GB 21 remained elevated
(𝑃 < 0.01). The control group, during the resting period,
showed a gradual decrease in temperature to 30.6 ± 0.5∘ C at
15 minutes at the GB 21 acupuncture point. There were no
significant differences from baseline (30.7 ± 0.4∘ C) (𝑃 > 0.05)
(Figure 3(b)) for GB 21 within the control group.
The SST of the LI 15 was 29.4 ± 0.4∘ C at baseline within the
cupping group and 29.7±0.4∘ C within the control group (𝑃 >
0.05). The SST of the LI 15 point increased to 31.1 ± 0.8∘ C at 5
minutes after CT, which is significantly higher than baseline
(𝑃 < 0.01). The Friedman test supports the within group
results, which show that, from baseline to 5 minutes after
cessation of treatment, SST remains elevated at LI 15 (𝑃 <
0.01). The ANCOVA test indicates significant differences
between the groups at each time point for GB 21, SI 15, and LI
15 acupuncture points (𝑃 < 0.05) (Figure 3(c)). It is important
to note that the results for LI 15 show lower temperatures. This
is due to the distance from the acupuncture point to the lens
of the infrared camera.
3.2. BP Changes. The systemic blood pressure (SBP) decreased
from 117.7 ± 2.9 mmHg to 111.8 ± 2.3 mmHg, in the cupping
group (𝑃 = 0.003). The control group also showed slight
reduction from 113.8 ± 3.0 mmHg to 109.7 ± 3.1 mmHg (𝑃 =
0.117). There was no significant difference between the two
groups; however cupping appears to have some influence on
the SBP.
3.3. Pain Intensity Changes. At baseline, the VAS of neck pain
intensity (NPI) was 9.7 ± 1.6 in the cupping group and 9.7 ±
1.6 in the control group. The posttreatment NPI decreased
by 6.1 in the cupping group and decreased by 0.2 in the
control group (Figure 4(a)). The ANCOVA test demonstrated
significant differences between the groups (𝑃 < 0.001).
The VAS of shoulder pain intensity (SPI) was 8.5 ± 0.9 for
the cupping group at the baseline and 8.5 ± 0.9 in the control
group. The posttreatment SPI decreased by 5.9 in the cupping
group and decreased by 0.6 in the control group (Figure 4(b)).
The difference between the groups was statistically significant
(𝑃 < 0.001).
4. Discussion
The CT therapeutic method can cause vasodilatation and
stimulate blood circulation to increase metabolism and
accelerate the elimination of waste and toxins from the
body. This effect acts to improve physical function [30]
and affect BP [22]. Xu et al. demonstrated changes in skin
temperature in the cupping area before and after cupping.
When the cup was removed, 10 minutes after cupping, the
skin temperature in the cupping area was elevated compared
to the control area and showed significant difference [21].
Al-Rubaye also showed immediate clinical changes after
cupping which included the sensation of increased warmth
on the skin surface [22]. Similarly, Liu et al. showed that
blood flow to the skin of the back in healthy humans on
acupuncture points increased immediately following removal
of the cup [20]. After CT, several other immediate signs of
the therapeutic method may be observed and are dependent
on the modality in use. Cupping increases blood flow to the
cupped region (hyperemia); the subject experiences warmth
as a result of vasodilatation. Due to vasodilatation and edema,
histological changes are readily observable at the skin surface.
After cupping effects often include erythema, edema, and
ecchymosis in a variety of circular arrangements [31].
Evidence-Based Complementary and Alternative Medicine 5

34 34
∗ ∗

Temperature at GB 21
33 ∗ 33
Temperature at SI 15

∗
32 ∗ 32 ∗
31 31
30 30
29 29
28 28
Baseline 5 10 Post 5 Baseline 5 10 Post 5
Time (min) Time (min)
Cupping Cupping
Resting Resting
(a) (b)
34
33
Temperature at LI 15

32 ∗
∗
31
∗
30
29
28
Baseline 5 10 Post 5
Time (min)
Cupping
Resting
(c)

Figure 3: Change in SST (∘ C) at three acupuncture points during cupping therapy at 5-minute intervals. ∗: difference between groups at SI
15 (a), GB 21 (b), and LI 15 (c) acupuncture points (𝑃 < 0.05).

12 12
11 ∗ 11
10 10
9 9 ∗
Shoulder pain intensity
Neck pain intensity

8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0 0
Baseline After cupping Baseline After cupping
Time (min) Time (min)
Cupping Cupping
Resting Resting
(a) (b)

Figure 4: Visual analog scale (mean ± SEM) of subjects with chronic neck pain (a) and chronic shoulder pain (b). ∗: univariate analysis of
covariance (ANCOVA) was used to compare groups’ difference after adjustment of baseline differences (𝑃 < 0.05).
6 Evidence-Based Complementary and Alternative Medicine
Cupping increased SST in this study. The results showed
that SST at GB 21 was elevated from 30.6 to 32.1∘ C during
the cupping period and increased after removal of the cup.
Similarly, both SI 15 and GB 21 acupuncture points showed
increased SST (2.1∘ C) after cup removal at the 5 min interval.
At the LI 15 acupuncture point SST was elevated by 1.7∘ C.
The study outcome supports the efficacy of CT as a
complementary therapy for treating NSP. The results indicate
that CT provides significant and effective relief of NSP
compared to the control.
Yuan et al. conducted a systematic review and meta-
analysis of traditional Chinese medicine for neck pain and
low back pain. It was suggested that cupping may be more
effective than medications for treatment of chronic neck or
lower back pain [17]. Lauche et al. targeted 50 participants
with nonspecific neck pain and implemented 10 to 15 min of
cupping therapy on the lower trapezius muscle. Their results
showed that, at rest and during movement, the pain level
on the VAS (0–10) decreased by 1.79 and 1.97, after cupping,
respectively [16]. Kim et al. found that 6 sessions of cupping
therapy (wet and dry) on neck pain acupuncture points in 40
patients were more effective than the use of a heating pad [15].
The German study of Lauche et al. found that home-based
CT was more effective than progressive muscle relaxation in
patients with chronic neck pain. The pain reduction effect
remained evident at the one week after intervention interval
[32].
Huang et al. employed cupping therapy around the
neck and shoulder regions, combined with acupuncture and
massage. This treatment was implemented once a day to
comprise one session. A full course of treatment entails five
sessions and a total of four courses were conducted for the
experiment. Their results illustrated that this regimen could
significantly reduce shoulder pain [33]. The current study
used ANCOVA to assess the level of NPI and SPI. The baseline
was adjusted in both groups to control for the potential bias
when using VAS. This allows for a more reliable assessment
of the CT effect.
In the current study, no participants experienced local-
ized skin burns or adverse reactions in the treatment regions.
Two participants in the cupping group reported mild low
back pain related to the seated position. In the systematic
review by Yuan et al. no serious or life-threatening side effects
were noted [17]. The majority of adverse effects are related
to wet cupping therapy, which results in (1) skin laceration,
(2) whole body itching, (3) pain at the cupping sites, (4)
generalized body ache [15], (5) factitious panniculitis, and (6)
iron deficiency anemia [9]. Dry cupping, by comparison, is a
safe and effective treatment modality for NPI and SPI.
CT is often used to treat pain, such as low back pain,
fibromyalgia, shoulder pain, chronic nonspecific neck pain,
cardiovascular diseases, angina, arthritis, and high blood
pressure. The clinical evidence of CT is minimal [34]. Find-
ings from this study strongly suggest that CT is effective for
relieving pain, with no adverse effects. CT has the potential to
eliminate reliance on analgesics and reduce health care costs.
Limitations of the study were primarily based on the
limited availability of the participants. As participants were
available for only one session, follow-up or multiple sessions
were not possible. Improving the validity and reliability of
this research requires (1) increasing the number of therapy
sessions, (2) enlarging the sample size, (3) achieving equal
representation of both sexes, and (4) age distribution.
5. Conclusion
Chronic NSP is a common problem in adults. CT is one of
many effective treatments in traditional Chinese medicine.
CT is used worldwide, as it is easy to learn and has few side
effects. In this study, one treatment of CT is shown to increase
SST and reduce SBP. In conjunction with the physiological
effects, the subjective experience of NSP is reduced. CT
mimics an analgesic effect which has no known negative side
effects and may be considered safe. However, further studies
are required to improve the understanding and potential
long-term effects of CT.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Acknowledgments
The authors thank the Office of Research and Development
of Tzu Chi University of Science and Technology for funding
this project (Grant no. TCCT-992A14). The support and
cooperation of all the participants are appreciated.
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traditional cupping on pain and mechanical thresholds in 1–9, 2013.
patients with chronic nonspecific neck pain: a randomised [33] J. J. Huang, S. Y. Su, L. M. Lei et al., “Treatment of shoulder
controlled pilot study,” Evidence-Based Complementary and pain after apoplectic hemiplegia by acupuncture, massage and
Alternative Medicine, vol. 2012, Article ID 429718, 10 pages, 2012. cupping,” Shaanxi Journal of Traditional Chinese Medicine, vol.
[17] Q. L. Yuan, T. M. Guo, L. Liu et al., “Traditional Chinese 30, no. 5, pp. 591–593, 2009.
medicine for neck pain and low back pain: a systematic review [34] B. Chen, M.-Y. Li, P.-D. Liu, Y. Guo, and Z.-L. Chen, “Alternative
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[18] C.-Y. Huang, M.-Y. Choong, and T.-S. Li, “Effectiveness of
cupping therapy for low back pain: a systematic review,”
Acupuncture in Medicine, vol. 31, no. 3, pp. 336–337, 2013.
[19] D. H. Chen, Ed., Clinical Graphic Acupuncture Points, Wen-
guang, Taipei, Taiwan, 1993.
[20] W. Liu, S. A. Piao, X. W. Meng, and L. Wei, “Effects of cupping on
blood flow under skin of back in healthy human,” World Journal
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[21] P. C. Xu, S. L. Cui, A. C. W. Derrik et al., “Preliminary obser-
vation on effect of cupping on the skin surface temperature
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Moxibustion, vol. 24, no. 4, pp. 59–61, 2014.
[22] K. Q. A. Al-Rubaye, “The clinical and histological skin changes
after the cupping therapy (Al-Hijamah),” Journal of the Turkish
Academy of Dermatology, vol. 6, no. 1, pp. 1–7, 2012.
[23] F. Faul, E. Erdfelder, A. Buchner, and A.-G. Lang, “Statistical
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pp. 1149–1160, 2009.
[24] D. Y. Lai and M. L. Chang, “The nursing of traditional Chinese
medicine: theory and practice,” in Nursing of Cupping, H. C.
Chiang, Ed., pp. 69–81, Wagner, Taichung, Taiwan, 2005.
[25] N. Sahin, E. Ozcan, K. Sezen, O. Karatas, and H. Issever,
“Efficacy of acupunture in patients with chronic neck pain—
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Journal of Traditional Chinese Medical Sciences (2014) 1, 49e61

H O S T E D BY Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.elsevier.com/locate/jtcms

Cupping therapy for acute and chronic

pain management: a systematic review
of randomized clinical trials
Huijuan Cao a, Xun Li a, Xue Yan b, Nissi S. Wang c,
Alan Bensoussan d, Jianping Liu a,*

a
Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine,
Beijing, China
b
Jilin Hospital of Traditional Chinese Medicine, the Affiliated Hospital to Changchun
University of Chinese Medicine, Changchun, China
c
Pamir Communications, Daly City, USA
d
Centre for Complementary Medicine Research, University of Western Sydney, Sydney,
Australia

Received 3 April 2014; accepted 15 June 2014

Available online 9 December 2014

KEYWORDS Abstract Objective: Cupping as a traditional therapy is used to treat a myriad of health con-
Cupping therapy; ditions, including pain. This systematic review assessed the effectiveness and safety of cupping
Pain; for different types of pain.
Systematic review Methods: Thirteen databases and four trial registries were searched for randomized clinical
trials. Meta-analysis of data was conducted if there was non-significant clinical and statistical
heterogeneity (measured by I2 test) among trials.
Results: Sixteen trials with 921 participants were eligible and included. Six trials were assessed
as low risk of bias, another six trials were of unclear risk of bias, and the remaining four trials
were of high risk of bias. Pain was related to three acute and seven chronic diseases. Meta-
analysis showed a beneficial effect of cupping compared to wait-list control (visual analogue
scale (VAS), MD
1.85 cm, 95%CI
2.66 to
1.04) and heat therapy (numerical rating scale,
MD
2.05 cm, 95%CI
2.93 to
1.17). Cupping combined with acupuncture was superior to
acupuncture alone on post-treatment pain intensity (VAS, MD
1.18 cm, 95%CI
1.68 to

0.68), however, no difference was found between this comparison based on changes in pain
intensity (difference of VAS, MD 0.16 cm, 95%CI
0.54 to 0.87). Results from other single
studies showed significant benefit of cupping compared with conventional drugs or usual care.

* Corresponding author. Beijing University of Chinese Medicine, Bei San Huan Dong Lu 11, Chaoyang District, Beijing 100029, China. Tel.:
þ86 10 64286760.
E-mail addresses: Liujp@bucm.edu.cn, jianping_l@hotmail.com (J. Liu).
Peer review under responsibility of Beijing University of Chinese Medicine.

http://dx.doi.org/10.1016/j.jtcms.2014.11.003
2095-7548/ª 2014 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
50
Hematoma and pain at the treated site, increasing local pain or tingling were reported as mild
adverse effects of cupping.
Conclusion: This review suggests a potential positive short-term effect of cupping therapy on
reducing pain intensity compared with no treatment, heat therapy, usual care, or conventional
drugs.
ª 2014 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/3.0/).
Introduction
Most people suffer serious pain at some stage of their lives.
Nearly 80% of all visits to general practice involve at least
one complaint directly related to pain, and 75% of Ameri-
cans have experienced chronic or recurrent pain, costing
$200 billion annually.1 While pain is often prophylactic to
further injury, appropriate pain management is also
recognized as a fundamental human right and integral to
good patient care.2
Pain can be classified physiologically as skeletal,
neuropathic, or inflammatory3; or be classified by type of
tissue involved, such as skin, muscle, viscera, joint and
bone; or related to disease/condition, such as cancer, fi-
bromyalgia; or may reflect psychologic states, age, gender,
and culture. However, most guidelines and organizations,
including the latest International Classification of Disease,4
fundamentally classify pain as either acute or chronic as
the initial stage of categorization.
Traditional Chinese medicine (TCM) has been used to
treat pain for more than 2000 years, which holds that pain
is mainly caused by disorder (insufficiency or disturbance)
of qi (energy) and blood circulation, causing blood stasis or
qi blockage in the organs, energy channels, and other parts
of the body.5
Cupping therapy is a TCM healing modality that has been
applied in Asia, particularly in China, as well as northern
Europe (Scandinavia).6 Cups can be made of different ma-
terials such as bamboo, glass, or earthenware. During
treatment the air inside the cups is first rarefied to create a
partial vacuum, which can be accomplished by various
means such as heat or vacuum apparatus. The cups are then
applied on the skin over prescribed acupuncture points.
The resulting effect is local hyperemia or homeostasis as
treatment for a specific disease.7
There are seven major types of cupping techniques in
China.8 Dry cupping is the most commonly used type, which
uses the flaming heating power to achieve suction, then
wet cupping (use blood-letting on the tender point before
suction), moving cupping (move the cup towards one di-
rection), flash cupping (remove the cups after suction
without delay), et al. Different techniques are applied for
different purposes of treatment. The principle of cupping
treatment is to regulate and promote movement of qi and
blood.9 By doing so, cupping is able to alleviate pain,
caused by blood stasis and qi blockage. Cupping may also
accelerate microcirculation and relieve muscular spasm.10
A previous review of the efficacy of cupping therapy was
conducted in 2010,8 among the top 20 diseases/conditions
in that review, 12 ailments involving 342 studies were
H. Cao et al.
related to pain. In the update review which published in
2012,11 nearly all 135 included trials were reported as high
risk of bias for their methodological quality. In addition,
only one systematic review of seven studies assessed the
effect of cupping for pain conditions, including cancer pain,
low back pain, trigeminal neuralgia, et al.12 Though evi-
dence from these studies was positive, the number of
studies and total sample size were too small for the authors
to draw a firm conclusion. Thus, considering the large
number of cupping trials and the uncertainty of its thera-
peutic effect, this review re-evaluates cupping therapy for
pain management to reflect current research evidence.
Methods
The protocol of this review was registered and published at
PROSPERO (CRD42013006756), accessible at: http://www.
crd.york.ac.uk/PROSPERO/display_record.asp?
IDZCRD42013006756.
Criteria for considering studies for this review
Studies considered for inclusion were parallel-group ran-
domized controlled trials (RCTs) that used any form of
cupping (dry cupping, wet cupping, flash cupping, moving
cupping, medicinal cupping, needling cupping, or water
cupping) compared with no treatment or other active
therapies. Participants had to be 18 years or older and
could be of any gender. Pain conditions, known or idio-
pathic, including musculoskeletal pain, neurologic pain, or
pain caused by infection or other disease with at least
moderate pain (e.g. baseline visual analog scale, or VAS,
pain intensity score in excess of 3 cm) were included.
Comparisons also included a combination of cupping ther-
apy plus other therapies versus other therapies alone. Trials
used combined therapy employing cupping therapy with
other TCM therapy (such as acupuncture or herbal medi-
cine) compared with other interventions were excluded.
We contacted authors to confirm their randomization
methods. Trials that used inappropriate or spurious
randomization or trials that authors were unable to provide
information on randomization methodology were excluded.
Primary outcomes included: patient-reported pain in-
tensity, which was assessed qualitatively or quantitatively
through any type of pain severity score (e.g. VAS) and
tender point counts for certain diseases, such as fibromy-
algia; patient-reported pain episodes; numbers of patients
who had at least 50% of maximum possible pain relief over
baseline; and number of patients who had at least 30% of
Cupping therapy for acute and chronic pain management
maximum possible pain relief over baseline. Secondary
outcomes included: patient or provider global evaluation;
psychosocial function outcomes, such as the Hamilton
Depression Scale; quality of life (QoL), such as SF-36; and
adverse effects, which was assessed by reporting early
study discontinuations, worsening of pain, and other
adverse events during the treatment and follow-up periods.
Literature search
We identified all relevant RCTs regardless of language or
publication status (published, unpublished, in-press, or in-
progress). Nine English databases and four Chinese data-
bases were searched from inception to December 2013,
including the Cochrane Central Register of Controlled Trials
(CENTRAL), PubMed, EMBASE, Cumulative Index of Nursing
and Allied Health Literature (CINAHL), Scopus, Science Di-
rection, Biomed Central, Current Content, Health and
Medical Complete, China Network Knowledge Infrastruc-
ture (CNKI), Chinese Scientific Journals Database (VIP), Wan
Fang Database (for unpublished graduate theses in China),
and Chinese Biomedicine (CBM).
We also searched ongoing trials from the metaRegister of
Controlled Trials, the U.S. National Institutes of Health
Ongoing Trials Register, the Australian New Zealand Clinical
Trials Registry, and the World Health Organization Inter-
national Clinical Trials Registry Platform. Reference lists of
all relevant papers found electronically were also searched.
Search terms included “pain” or “analgesic*”, which was
combined with “cup*”, “cupping”, or “suction”.
Data collection and extraction
Two authors (XY and XL) evaluated the titles and abstracts
independently. Full papers were retrieved for all poten-
tially relevant studies. Disagreements were resolved by
discussion and if needed, arbitrated by a third author
(HJC).
Two authors (HJC and XL) extracted the data from the
included studies independently. Disagreements were
settled by discussion with a third author (JPL). Extracted
information included study methods (design, randomization
method, blinding method), characteristics of participants
(inclusion/exclusion criteria, sample size, gender, age,
type of disease/condition, duration of pain, previous
treatments), details of intervention and control (type of
cupping, selection of acupoints, frequency and duration of
treatment, type of control, details of co-interventions),
follow-up data (duration of follow-up, withdrawal rates and
reasons), outcomes data, and data analysis (methods of
analysis, comparability of groups at baseline, statistical
techniques).
Assessment of risk of bias in included studies
We applied the assessment of risk of bias provided by the
Cochrane Handbook for Systematic Reviews of In-
terventions13 to generate a risk of bias assessment table for
each study. Categories of selection bias, performance bias,
detection bias, attrition bias, reporting bias, and other
biases were assessed. There were three potential bias
51
judgments: “low risk”, “high risk”, or “unclear risk”. If a
study had insufficient methodological details, judgment of
the study was deemed “unclear”. An “unclear” judgment
was also made when what occurred in the study was known
but the risk of bias was unknown or when an item was not
relevant to the study at hand, particularly for assessing
blinding and incomplete outcome data, or when the
outcome was assessed by the item which had not been
measured in the study.
Data analysis
Statistical analyses were accomplished with Review Man-
ager 5.2, the Cochrane statistical package (available from
ims.cochrane.org/revman/download). One author (XL) was
responsible for entering data into the software. Data entry
was checked by a second author (HJC). Data were summa-
rized using risk ratios (RR) with 95% confidence intervals (CI)
for binary outcomes or mean difference (MD) with 95% CI for
continuous outcomes. When needed, authors of included
trials were contacted to obtain missing information.
Meta-analysis was used for studies when the I2 statistic
was less than 75%. A random-effects model was used unless
the degree of heterogeneity was readily explainable or
when the measure of heterogeneity I2 statistic was less
than 25%, in which case, the fixed-effect model was used.13
If data permitted, we planned to conduct subgroup an-
alyses with a minimum of two trials for different groups
split by age, gender, disease, or pain severity. If available,
we would perform sensitive analysis regarding “study size,”
when only studies with at least two groups and 100 par-
ticipants per group were included.
Summary of finding (SOF) tables were generated using
GRADE Pro software (version 3.2 for Windows). The SOF
table evaluated the overall quality of the body of evidence
for pain relief using GRADE Working Group criteria (study
limitations, consistency of effect, imprecision, indirect-
ness, and publication bias).
Results
Search results
Our search strategy (Fig. 1) identified a total of 55 out of
2298 citations from 13 databases and 4 trial registrations
assessing the effects of cupping on pain outcomes. After
full text reading, only 16 studies met our inclusion criteria.
Two trial abstracts14,15 were counted as studies awaiting
classification, as these authors did not respond to requests
for additional information, thus data from these two
completed but unpublished clinical trials could not be
included in this review.
Characteristics of included trials
Sixteen trials with a total of 921 participants (average 28 per
group) were included (Table 1). Males accounted for 41.26%
of the participants. Eight trials were conducted in China and
published in Chinese,16,19,25,26,28e31 the remaining 8 trials
were published in English,17,18,20e24,27 among which 5 studies
52
Figure 1
were conducted in Germany,17,22e24,27 2 in Korea,20,21 and
1 in Iran.18 Targeted diseases included chronic neck pain
(4 trials),17,21e23 non-specific low back pain (2 trials),18,20
herpes zoster (2 trials),29,31 osteoarthritis (2 trials),27,28
shoulder pain (1 trial),25 postapoplectic shoulder-hand syn-
drome (1 trial),19 scapulohumeral periarthritis (1 trial),16
carpal tunnel syndrome (1 trial),24 acute ankle sprain
(1 trial),30 and headache (1 trial).26
Among the 16 trials, wet cupping was assessed in 11
trials,16,18e21,24e26,28,30,31 dry cupping in 2 trials,22,27 mov-
ing cupping,23 medicinal cupping,30 and combined dry and
moving cupping17 were assessed in 1 trial each. Compari-
sons included cupping versus wait-list control,22,24,27,30
cupping versus other treatment (usual care, heat therapy,
muscle relaxation, or exercise),17,18,21,23,29 cupping versus
medications (flunarizine 10 mg daily for headache, diclo-
fenac 100 mg daily for osteoarthritis, or mecobalamin in-
jection 0.5 mg daily for herpes zoster),26,28,29 and cupping
plus other treatments (acupuncture, exercise, or medica-
tions) versus other treatments alone.16,19,20,25,31
All trials reported one of our pre-defined primary out-
comes d pain intensity, which was measured by either VAS,
numerical rating scale (NRS), present pain intensity (PPI),
McGill Pain Questionnaire (MPQ), or short-form MPQ (SF-
H. Cao et al.
Study flow diagram.
MPQ). No trial reported tender point counts, patient-
reported episodes of pain, or numbers of patients who
had at least 30% or 50% of maximum pain relief over base-
line. QoL measured by SF-36 was reported in 5 tri-
als,17,22e24,27 and adverse events were described in 10
trials.17,20e24,26,27,29,30
Risk of bias in included studies
Risk of bias was evaluated for different categories (Fig. 2).
All 16 trials were assessed as “low risk of bias” on random
sequence generation items. Methods of random sequence
generation included central randomization (1 trial),31
random number table (9 trials),16,18,19,23e26,28,29 and com-
puter software (6 trials).17,20e22,27,30 Thirteen trials had
“low risk” of selection bias, of which 12 trials employed
sealed opaque envelopes17,18,20e25,27e30 and the remaining
trial used central randomization to perform allocation
concealment.31 No trial applied blinding of participants and
practitioners. The primary outcome of the included trials
was pain intensity assessment, a subjective measure per-
formed by participants themselves. For this reason, we
assessed all 16 trials as “high risk” of performance bias.

Table 1 Characteristics of 16 included trials.
Study ID Participants
(T: Treatment; C: Control)
Chen 20095 Condition: Scapulohumeral
periarthritis
Gender (male/female):
T 16/14; C 15/13
Age (yrs, MD  SD): T 52  1.6;
C 53  1.3
Pain intensity at baseline
(VAS, cm): T 4.63  1.42; C
4.63  1.42
Cramer 20118 Condition: Chronic neck pain
Gender (male/female): T 4/20;
C 6/18
Age (yrs, MD  SD): T
44.5  10.8; C 47.9  13.5
Pain intensity at baseline (NRS,
cm): T 4.12  1.45; C
4.20  1.57
Farhadi 20099 Condition: Non-specific low
back pain
Gender (male/female):
T 30/18; C 37/13
Age (yrs, MD  SD): T
44.9  14.8; C 41.8  13.9
Pain intensity at baseline (PPI):
T 2.7  0.8; C 2.7  0.9
Fu 200910 Condition: Post-apoplectic
shoulder-hand syndrome
Gender (male/female):
T 24/16; C 22/18
Age (yrs, MD  SD): T 63  2; C
63.9  15.2
Intervention
Wet cupping: Tapping with
plum-blossom needles on ashi
points around shoulder joint
until bleeding; cups applied
and retained on ashi points
10 min. Once every 2 days.
Electro-acupuncture: Same as
in control group.
Moving and dry cupping: Arnica
oil massaged onto neck and
shoulder; glass cup applied on
the skin and glided over the
painful region in sweeping
movements for 10e15 min,
then 4 cups applied and
retained over the trapezius
muscle for 5e10 min. Once
every 3e4 days.
Wet cupping: Sites between 2
scapulas at T1eT3 level on day
0; between lumbar vertebrae
and coccyx on day 3; over
center of gastrocnemius on day
6. At each treatment session:
Cups applied and retained 3
e5 min, then removed;
multiple superficial incisions
made with surgical blade; cup
re-applied and retained 3
e5 min until filled with blood.
Procedure done 3 times.
Acupuncture: Needles inserted
at ashi points, LI15, SJ14, LI4,
LI10, LI11, LI14 for 30 min,
once daily.
Wet cupping: Puncture ashi,
LI15, SJ14, LI11 with tri-
Cupping therapy for acute and chronic pain management
Control Treatment Outcome measurements
duration
Electro-acupuncture: Needles 60 days VAS, frequency of pain,
inserted at LI15, SJ14, SI9, voluntary movement of
GB21, Ex-UE, SI11, LI11; after shoulder joint
deqi, needles connected to
electric stimulator for 30 min.
Once daily.
Usual care: Participants 14 days AE, NDI, NRS, SF-36, VAS
continued self-directed
standard medical care
(physical therapy, exercise,
analgesics) with general
practitioner or orthopaedist.
Usual care: 1) early return to 6 days MQS III, PPI, ODI
usual activities encouraged,
excluding heavy manual labor;
2) activity change to minimize
symptoms; 3) acetaminophen
or NSAIDs; 4) short duration
muscle relaxants or opioids; 5)
bed rest, not more than 2 days;
6) spinal manipulation.
Acupuncture: Same as in 30 days VAS, frequency of pain,
treatment group. voluntary activity of shoulder
Stroke therapy: Usual care and joint, effectiveness rate
medications, herbal medicine,
acupuncture, physical
rehabilitation, and patient
(continued on next page)
53

Table 1 (continued )
Study ID Participants
(T: Treatment; C: Control)
Pain intensity at baseline
(VAS, cm): T 5.26  1.23; C
4.98  1.54
Kim 201115 Condition: Non-specific low
back pain
Gender (male/female): T 5/16;
C 3/8
Age (yrs, MD  SD): T
44.2  9.4; C 48  5.4
Pain intensity at baseline
(NRS, cm): T 5.81  1.12; C
5.27  0.80
Kim 201217 Condition: Neck pain
Gender (male/female): T 7/13;
C 11/9
Age (yrs, MD, range): T 25.5
(22.5e40.5); C 28 (25e31.5)
Pain intensity at baseline
(NRS, cm): T 5.93  1.63; C
6.49  1.49
Lauche 201118 Condition: Non-specific neck
pain
Gender (male/female): T 7/15;
C 4/20
Age (yrs, MD  SD): T
48.6  11.2; C 53.0  11.4
Pain intensity at baseline
(VAS, cm): T 4.55  2.09; C
4.23  1.80
Lauche 201319 Condition: Chronic neck pain
Gender (male/female): T 6/24;
C 10/21
Age (yrs, MD  SD): T
54.5  12.3; C 53.7  13.4
Pain intensity at baseline
(VAS, cm): T 5.58  1.97;C
5.63  1.86
54
Intervention Control Treatment Outcome measurements
duration
ensiform needle; cups applied education.
and retained until 2e5 ml blood
is let. Once daily.
Stroke unit therapy: Same as in
control group.
Wet cupping: Bilateral BL23, Wait-list 14 days AE, NRS, ODI, PPI, number of
BL24, BL25 punctured with Exercise: 8 types of stretching acetaminophen tablets used
acupuncture needle to 2 mm and strengthening exercises.
depth; cups applied and
retained for 5 min. Three times
weekly.
Exercise: Same as in control
group.
Wet cupping: 6e10 tender Heat therapy: Hot water bottle 14 days AE, cervical spine range of
points on posterior neck, upper applied to neck and upper motion, EQ-5D, MYMOP2, NDI,
trapezius, and perispinal area trapezius for 10 min, three NRS, SRI-SF, FSS
of the neck and thoracic spine times weekly.
were punctured 6 times with
acupuncture needle to 2 mm
depth until 3e5 ml of blood
were let; cups applied and
retained for 5e10 min. Three
times weekly.
Dry cupping: Cups retained on Wait-list 25 days AE, MDT, NDI, NRS, SF-36, PD,
affected areas for 10e20 min. PM, PPT, PR, VAS, VDT
Treatment every 3e4 days.
Moving cupping: cupping Progressive muscle relaxation: 84 days AE, FEW-16, GKÜ, PD, PPT,
massage with arnica massage participants asked to practice PSQ-20, VAS, pain perception
oil, 10e15 min twice weekly. relaxation for 20 min at home scale, NDI, HADS SF-36
H. Cao et al.
twice weekly.

Table 1 (continued )
Participants
Study ID (T: Treatment; C: Control)
Michalsen 200921 Condition: Carpal tunnel
syndrome
Gender (male/female): T 2/24;
C 4/22
Age (yrs, MD  SD): T
57.2  7.7; C 59.3  8.3
Pain intensity at baseline
(VAS, cm): T 6.15  2.49; C
5.86  2.51
Ouyang 200122 Condition: Shoulder pain
Gender (male/female): T 18/8;
C 22/8
Age (yrs, MD, range): T 58.2
(27e75); C 56.8 (29e71)
Pain intensity at baseline
(VAS, cm): T 6.37  3.22; C
6.25  3.01
Song 201323 Condition: Headache (blood-
stasis syndrome)
Gender (male/female):
T 16/29; C 8/27
Age (yrs, MD  SD): T
35.4  3.1; C 36.1  2.3
Pain intensity at baseline
(VAS, cm): T 6.76  1.48; C
6.44  1.78
Teut 201226 Condition: Osteoarthritis
Gender (male/female): T 5/16;
C 8/11
Age (yrs, MD  SD): T
68.1  7.2; C 69.3  6.8
Pain intensity at baseline
(VAS, cm): T 6.02  1.22; C
5.79  0.80
Cupping therapy for acute and chronic pain management
Treatment
Intervention Control duration Outcome measurements
Wet cupping: Skin over Heat therapy: Heating pad 1 session AE, VAS, DASH, Levine-CTSQ,
trapezius punctured repeatedly applied for 15 min to shoulder SF-36,
with microlancet; cups applied areas bilaterally with
and retained for 5e10 min or participant in supine position.
removed when partially filled Single treatment.
with blood. Single treatment.
Wet cupping: Ashi points Physical rehabilitation: Routine 30 days Brunnstrom Grade, frequency
around shoulder joint rehabilitation 30 min once of pain, VAS
punctured first; cups applied daily.
and retained for 10 min. Once
every 2 days.
Physical rehabilitation: Same
as in control group.
Wet cupping: Puncture ashi Drugs: Flunarizine 10 mg oral 60 days AE, effectiveness rate, onset
points, temple, G20, GV14 with once daily at bedtime. time, VAS
lotus needle; cups applied and
retained for 15 min. Twice
weekly.
Dry cupping: Pulsatile cupping Wait-list 28 days AE, SF-36, VAS, WOMAC
administered by a mechanical Paracetamol on demand with
cupping device with flexible maximum dosage of 2 g daily.
silicone cups to the knee joint
for 10 min and plastic cups
applied bilaterally to lower
back for 5 min. Twice weekly.
Paracetamol on demand with
maximum dosage of 2 g daily.
(continued on next page)
55
Table 1 (continued )

Study ID Participants
(T: Treatment; C: Control)
Wu K 201329 Condition: Osteoarthritis
Gender (male/female): T 8/22;
C 7/23
Age (yrs, MD  SD): T
56.7  6.6; C 57.4  5.8
Pain intensity at baseline
(VAS, cm): T 6.97  0.85; C
7.00  0.87
Wu X 201330 Condition: Herpes zoster
neuralgia
Gender (male/female): T 12/7;
C1 10/9; C2 10/9
Age (yrs, MD  SD): T 63  10;
C1 63  9; C2 68  7
Pain intensity at baseline
(SF-MPQ): T 23.95  3.25; C1
23.21  5.12; C2 22.68  2.91
Wu 200731 Condition: Acute ankle sprain
Gender (male/female):
T 10/21; C 11/19
Age (yrs, MD  SD): Not
reported
Pain intensity at baseline
(VAS, cm): T 8.61  1.06; C
8.74  0.92
Zhang 200932 Condition: Herpes zoster
Gender (male/female):
T 10/15; C 12/13
Age (yrs, range): T 18e66; C 19
e67
Pain intensity at baseline
(VAS, cm): Not reported
Intervention
Wet cupping: Acupuncture
needles inserted 3e4 mm at Ex-
LE4, Ex-LE5, ST34, SP10, SP9,
and ashi points; cups applied
and retained 3e4 min. Once
every 2 days.
Medicinal cupping: Bamboo
cups boiled in herbal decoction
for 2 min; herbs comprised of
Suberect Spatholobus Stem
30 g, Fructus Liquidambaris
30 g, Rhizoma Gastrodiae 15 g,
Rhizoma Chuanxiong 20 g,
Herba Asaricum Radice 15 g,
Areca Peel 30 g, Morus Alba
Corticis 30 g, Frankincense 20 g,
Myrrh 20 g; cups applied on ashi
points for 5 min. Once daily.
Drugs: Ibuprofen 0.3 g twice
daily.
Wet cupping: Affected area
punctured with bloodletting
needle; cups applied and
retained for 10 min. Once daily.
Wet cupping: Tapping with
plum-blossom needles on ashi
points; cups applied and
retained on ashi points for 5
e10 min. Once daily.
Electro-acupuncture: Same as
in control group.
56
Control Treatment Outcome measurements
duration
Drugs: Diclofenac 50 mg twice 14 days Effectiveness rate, VAS,
daily. WOMAC
C1-Heat therapy: 14 days AE, effectiveness rate, SF-MPQ
40 cm  40 cm towel dipped in (VAS, PPI, PRI)
boiling herbal decoction (same
prescription as treatment
group) and applied on ashi
points for 5 min. Once daily.
Ibuprofen 0.3 g twice daily.
C2-Drugs: Mecobalamine
injection 0.5 mg injection once
daily plus ibuprofen 0.3 g twice
daily
Wait-list 5 days AE, degree of swelling,
effectiveness rate, function
activity, VAS
Electro-acupuncture: Needles 10 days Effectiveness rate, VAS
inserted at ashi points, Jiaji
points, TE6, SI3; needles at TE6
and SI3 attached to electric
stimulator for 30 min. Once
daily.

H. Cao et al.
Abbreviations: AE Z adverse events; DASH Z Disabilities of the Arm, Shoulder and Hand; EQ-5D Z EuroQol Health Index; FEW-16 Z Questionnaire on the Assessment of Physical
Wellbeing; FSS Z Fatigue Severity Scale; GKÜ Z Health Related Control Beliefs; HADS Z Hospital Anxiety and Depression Scale; Levine-CTSQ Z Levine carpal tunnel syndrome ques-
tionnaire; MDT Z mechanical-detection thresholds; MQS III Z Medication Quantification Scale version III; MYMOP2 Z Measure Yourself Medical Outcome Profile; NDI Z Neck Disability
Index; NRS Z numeric rating scale; ODI Z Oswetry Disability Index; PD Z pain diary; PM Z maximal pain related to movement; PPI Z present pain intensity scale; PPT Z pressure pain
thresholds; PR Z pain at rest; PSQ-20 Z Perceived Stress Questionnaire; SF-MPQ Z Short-Form McGill Pain Questionnaire; SRI-SF Z short form stress response inventory; VAS Z visual
analog scale; VDT Z vibration detection thresholds; WOMAC Z Western Ontario and McMasters Universities Osteoarthritis Index.
Cupping therapy for acute and chronic pain management
Figure 2 Risk of bias summary review authors’ judgments about each risk of bias item for each included study.
Blinding of outcome assessors or statisticians was carried
out in 6 trials with “low risk of bias” for this item.17,21e24,31
Four trials reported as “open label study” in their protocol
did not use blinding methods at all and were assessed as
“high risk” of detection bias.19,20,25,27 One trial that did not
apply an appropriate statistical method in addressing
missing data was evaluated as “high risk” of attrition bias.25
Considering the difficulty of blinding of participants and
practitioners in cupping studies, the overall quality of 5
included trials17,21e24 were defined as “low risk of bias”, in
which only performance bias was unavoidable. Four trials,
which had more than one item with high risk of bias, were
evaluated as overall “high risk of bias”.19,20,25,27 The
remaining 7 trials were evaluated as “unclear risk of bias”
for overall methodological quality.16,18,26,28e31
Effects of interventions
Estimate effect of cupping therapy for pain management
from 16 included trials was evaluated (Table 2). Despite
variation in diseases/conditions among the included trials,
the principal aim of all 16 trials was to relieve pain.
Therefore, change in pain intensity post-treatment was the
primary outcome in all trials. Based on this, we decided to
perform data pooling on the primary outcomes although
there was variation in disease/conditions.
For primary outcomes, pain intensity was measured by
VAS, NRS, PPI, or SF-MPQ in the trials. Due to similarity of
the VAS and NRS scales (pain intensity weighted from 0 to
10 cm/100 mm), trials that used these two measurement
scales were considered similar for the purposes of outcome
assessment. However, to render the two scales compara-
ble, data (both MD and SD) of different trials were con-
verted from a scale of 0e100 mm into 0e10 cm, dividing by
10. For secondary outcomes, QoL was measured by SF-36 in
5 trials. Total scores for mental domain and physical
domain were analyzed separately for those trials.
Cupping therapy versus wait-list control
Three trials compared cupping therapy to wait-list control
group22,27,30 (Table 2). Meta-analysis of 2 trials22,27 showed 4
weeks’ dry cupping therapy produced better effect on
57
reducing pain (VAS, MD
1.85 cm, 95%CI
2.66 to
1.04,
P < 0.00001, I2 Z 0%, P value for heterogeneity Z 0.60, fixed
model, 2 trials, 86 participants), and on improving QoL (SF-
36 mental scores, MD 5.90, 95%CI 0.16 to 11.64, P Z 0.04,
I2 Z 50%, P value for heterogeneity Z 0.16, random model;
SF-36 physical scores, MD 3.77, 95%CI 1.27 to 6.26,
P Z 0.003, I2 Z 0%, P value for heterogeneity Z 0.78, fixed
model, 2 trials, 86 participants). The remaining trial30 also
showed significant effect of wet cupping therapy for pain
reduction (VAS, MD
7.07 cm, 95%CI
7.45 to
6.69,
P < 0.00001, 61 participants).
Cupping therapy versus conventional medications
Three trials compared wet cupping therapy to western
drugs26,28,29 (Table 2). Due to the different types of medi-
cations used in the control groups among these 3 trials,
meta-analysis was not conducted. However, each of these
trials found wet cupping was superior to conventional drugs
(mecobalamin injection, diclofenac after 2 weeks’ treat-
ment, or flunarizine after 2 months’ treatment) for pain
reduction.
Cupping therapy versus other comprehensive
treatment
Six trials used comparisons between cupping therapy and
other comprehensive treatment, including usual care (ex-
ercise, bed rest, or analgesics), heat therapy, and progres-
sive muscle relaxation17,18,21,23,24,29 (Table 2). Meta-analysis
of 2 trials showed significant difference between wet
cupping therapy and heat therapy on reducing pain (NRS, MD

2.05 cm, 95%CI
2.93 to
1.17, P < 0.00001, I2 Z 0%, P
value for heterogeneity Z 0.82, fixed model, 2 trials, 92
participants) after 1e2 weeks’ treatment.21,24 Another 2
trials also found that after 2 weeks’ treatment wet cupping
(PPI, MD
2.10, 95%CI
2.54 to
1.66, P < 0.00001, 98
participants)18 and moving and dry cupping therapy (NRS,
MD
1.72 cm, 95%CI
2.74 to
0.70, P Z 0.0009, 48 par-
ticipants)17 was superior to usual care (including exercise,
analgesics). However, the remaining 2 trials reported no
difference between moving cupping and progressive muscle
relaxation (VAS, MD
0.54 cm, 95%CI
1.90 to 0.82,
 58
Table 2 Estimate effect of cupping for pain management (regardless of type of diseases) from 16 included trials.
Outcome or subgroup Studies Participants Statistical method Effect estimate P value
Cupping therapy versus waiting list/no treatment
Pain intensity measured by VAS 3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Dry cupping versus wait-list 2 86 Mean Difference (IV, Fixed, 95% CI)
1.85 [
2.66,
1.04] <0.00001
Wet cupping versus wait-list 1 61 Mean Difference (IV, Fixed, 95% CI)
7.07 [
7.45,
6.69] <0.00001
Quality of life measured by SF36-physical score 2 86 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Dry cupping versus waiting list 2 86 Mean Difference (IV, Fixed, 95% CI) 3.77 [1.27, 6.26] 0.003
Quality of life measured by SF36-mental score 2 86 Mean Difference (IV, Random, 95% CI) Subtotals only
Dry cupping versus waiting list 2 86 Mean Difference (IV, Random, 95% CI) 5.90 [0.16, 11.64] 0.04
Cupping therapy versus conventional drugs
Pain intensity measured by VAS 3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Wet cupping versus flunarizine 1 90 Mean Difference (IV, Fixed, 95% CI)
1.40 [
2.08,
0.72] <0.0001
Wet cupping versus diclofenac 1 60 Mean Difference (IV, Fixed, 95% CI)
0.50 [
0.80,
0.20] 0.0009
Pain intensity measured by SF-MPQ 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Medicinal cupping plus ibuprofen versus mecobalamin injection 1 38 Mean Difference (IV, Fixed, 95% CI)
5.47 [
8.41,
2.53] 0.0003
plus ibuprofen
Cupping therapy versus other treatment
Pain intensity measured by VAS/NRS/PPI 5 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Wet cupping versus usual care 1 98 Mean Difference (IV, Fixed, 95% CI)
2.10 [
2.54,
1.66] <0.00001
Wet cupping versus heat therapy 2 92 Mean Difference (IV, Fixed, 95% CI)
2.05 [
2.93,
1.17] <0.00001
Moving and dry cupping versus usual care 1 48 Mean Difference (IV, Fixed, 95% CI)
1.72 [
2.74,
0.70] 0.0009
Moving cupping versus progressive muscle relaxation 1 61 Mean Difference (IV, Fixed, 95% CI)
0.54 [
1.90, 0.82] 0.43
Pain intensity measured by SF-MPQ 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Medicinal cupping plus ibuprofen versus medicinal heat therapy 1 38 Mean Difference (IV, Fixed, 95% CI)
3.10 [
6.83, 0.63] 0.10
plus ibuprofen
Quality of life measured by SF36-mental scores 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Moving and dry cupping versus usual care 1 48 Mean Difference (IV, Fixed, 95% CI) 1.76 [
4.83, 8.35] 0.60
Moving cupping versus progressive muscle relaxation 1 61 Mean Difference (IV, Fixed, 95% CI)
0.70 [
6.84, 5.44] 0.82
Quality of life measured by SF36-physical scores 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Moving and dry cupping versus usual care 1 48 Mean Difference (IV, Fixed, 95% CI) 7.11 [2.59, 11.63] 0.002
Moving cupping versus progressive muscle relaxation 1 61 Mean Difference (IV, Fixed, 95% CI) 3.70 [
0.90, 8.30] 0.12
Cupping therapy plus other treatments versus other treatments alone
Pain intensity measured by VAS/NRS 4 Mean Difference (IV, Fixed, 95% CI) Subtotals only
Wet cupping plus acupuncture versus acupuncture 2 138 Mean Difference (IV, Fixed, 95% CI)
1.18 [
1.68,
0.68] <0.00001
Wet cupping plus exercise versus exercise alone 1 56 Mean Difference (IV, Fixed, 95% CI)
0.53 [
1.18, 0.12] 0.11
Wet cupping plus exercise/acetaminophen versus 1 32 Mean Difference (IV, Fixed, 95% CI)
0.16 [
1.32, 1.00] 0.79
exercise/acetaminophen alone
Difference in pain intensity measured by VAS 3 Mean Difference (IV, Random, 95% CI) Subtotals only
Wet cupping plus acupuncture versus acupuncture alone 2 82 Mean Difference (IV, Random, 95% CI) 0.16 [
0.54, 0.87] 0.65

H. Cao et al.
Wet cupping plus exercise versus exercise alone 1 56 Mean Difference (IV, Random, 95% CI) 0.64 [0.07, 1.21] 0.03
Abbreviations: NRS Z numeric rating scale; PPI Z present pain intensity scale; SF-MPQ Z Short-Form McGill Pain Questionnaire; VAS Z visual analog scale.
Cupping therapy for acute and chronic pain management
P Z 0.43, 61 participants)23 after 12 weeks’ treatment or
between medicinal cupping and heat therapy (SF-MPQ, MD

3.10, 95%CI
6.83 to 0.63, P Z 0.10, 38 participants)29
after 2 weeks’ treatment.
Two17,23 of the 6 trials assessed QoL by SF-36. A signifi-
cant difference was found in 1 trial17 only between moving
cupping therapy and usual care on improving QoL physical
scores (MD 7.11, 95%CI 2.59 to 11.63, P Z 0.002, 48 par-
ticipants) after 2 weeks’ treatment.
Cupping therapy plus other treatments versus
other treatments alone
Comparisons between cupping therapy combined with other
treatments and other treatments alone were assessed in five
trials.16,19,20,25,31 These treatments included acupuncture,
exercise, and combination of exercise and acetaminophen.
Meta-analysis of 2 trials found a significant difference be-
tween combinations of wet cupping plus acupuncture and
acupuncture alone in relieving pain (VAS, MD
1.18 cm, 95%
CI
1.68 to
0.68, P < 0.00001, I2 Z 0%, P value for
heterogeneity Z 0.97, fixed model, 2 trials, 138 partici-
pants) after 1e2 months’ treatment.16,19 One trial found the
combination of wet cupping and exercise was superior to
exercise alone25 on pain reduction as revealed by the dif-
ference in VAS from baseline to post-treatment (MD 0.64 cm,
95%CI 0.07 to 1.21, P Z 0.03, 56 participants). However, no
difference was found in the other 3 trials between cupping
therapy combined with exercise and exercise alone on pain
reduction in either the meta-analysis (difference of VAS, MD
0.16 cm, 95%CI
0.54 to 0.87, P Z 0.65, I2 Z 28%, random
effect model, 2 trials, 82 participants)20,31 or in the other
two single trials (VAS, MD
0.53 cm, 95%CI
1.18 to 0.12,
P Z 0.11, 56 participants; NRS, MD
0.16 cm, 95%CI
1.32 to
1.00, P Z 0.79, 32 participants).20,25
Safety assessment of cupping therapy
Of the 16 included trials, adverse events were mentioned in
10 trials.17,20e24,26,27,29,30 Four trials reported that there
was no adverse event among cupping groups.20,26,29,30 Mild
to moderate adverse events were reported in the remaining
6 trials,17,21e24,27 with 10.3% of participants reporting he-
matoma at the treated site, 10.3% participants reporting
increased pain in the original location after cupping or pain
at the treated area, and 7.5% participants reporting muscle
soreness or tingling in the original site of pain after treat-
ment. No severe adverse event related to cupping therapy
was reported in any of the 10 included trials.
Discussion
Summary of main results
From our review of 16 trials involving 921 participants we
observed that cupping therapy reduces pain intensity in
chronic or acute pain. Due to potential clinical and/or
statistical heterogeneity, only 4 meta-analyses (with two
trials in each) could be conducted. Compared to wait-list
group or heat therapy, cupping therapy showed better
59
effectiveness for pain reduction based on pain intensity
measurements after treatment. Wet cupping combined
with acupuncture also showed better effect on post-
treatment pain intensity than acupuncture alone. No
changes in pain intensity were evident when cupping
combined with exercise was compared with exercise alone.
Results from other single studies showed a potential benefit
of cupping therapy compared with conventional medica-
tions and usual care.
Ten trials reported outcomes on safety issues. Hema-
toma and pain at the treated site or increased pain or
tingling was mentioned as mild adverse events of cupping
therapy among about 10% patients.
Quality of evidence
None of the 16 included trials blinded participants or
practitioners, most likely resulting in performance bias.
Valid placebo controls are difficult to apply for manual in-
terventions, such as acupuncture and cupping, due to the
unique technique applied by the practitioner and sensa-
tions experienced by subjects during treatment. Consid-
ering the difficulty of blinding practitioners and
participants in cupping studies, the overall quality of 6
included trials were defined as “low risk of bias,” in which
only performance bias was unavoidable.
Findings of this review suggest that cupping therapy
reduces pain intensity based on participant self-reporting.
VAS scores were reduced an average 2 cm compared with
control. Quality of evidence for pain relief varied from
“moderate” to “high” among comparisons between cupping
and wait-list control, conventional drugs, or other treat-
ments (Summary of Findings tables in Supplemental
Information). However, due to the fact that only trials
with small sample sizes were available and that there were
potential risks of bias (based on methodological quality
assessment) within the included studies, combination of
cupping therapy and other treatments compared with other
treatments alone showed “low” evidence of benefit.
Potential bias/limitations of the review
As predefined, we only searched Chinese and English data-
bases. However, cupping therapy is also commonly used in
other Asian countries, such as Japan and Korea. In this review,
one half of the included trials were retrieved from the Chinese
literature, which may have introduced potential selection
bias, thus limiting external generalization of the evidence.
Second, though statistical heterogeneity among trials
within meta-analysis was not significant, characteristics of
included participants were different in types of original
diseases/conditions and even in details of interventions
(point selection, treatment frequency, and treatment
duration). Due to the limited number of included trials,
subgroup analysis could not be conducted for further
assessment.
Comparison with previous reviews
Kim’s review published in 2011,12 found 6 of 7 trials showed
cupping had a positive effect for low back pain, cancer
60
pain, trigeminal neuralgia, and brachialgia paraesthetica
nocturna compared with usual care, anticancer drugs, an-
algesics, or heat therapy. Only one trial failed to find su-
perior effects of cupping on herpes zoster pain compared
with medication. However, due to the poor quality of most
of the trials, valid conclusions could not be drawn.
Our review was restricted to trials that clearly described
randomization methods and included participants with
moderate intensity pain at baseline. Five of the 7 trials in
Kim’s review did not meet these criteria, and therefore
they were not included in our review. Kim’s review included
published studies through January 2009. In comparison, our
review completed at the end of 2013 provides the latest
evidence with 14 additional trials. We found that in the
majority of trials, cupping therapy appeared to have a
positive effect on pain, especially when compared with
wait-list controls, usual care, conventional medications, or
heat therapy. Thus, level of evidence was “moderate” to
“high” for these comparisons.
Implications for practice
Our review found at least moderate evidence that cupping
is more efficacious than no treatment or other treatments
(such as heat therapy, usual care, and conventional medi-
cations) in reducing pain over the short-term (within 4
weeks). However, the limited number of trials deterred us
from conducting subgroup analyses to validate specific ef-
fects of cupping in terms of category of pain (chronic or
acute). Interestingly, our review did find that wet cupping,
mainly on ashi points, was the most commonly used method
(68.75% trials) for treating pain, presumably because there
is empirical evidence of its effectiveness.
Adverse effects resulting from cupping are related to
ecchymoses (which typically resolve within several days),
swelling, and/or burns in some cases.6 In our review, 10.34%
of the included trials reported ecchymoses at sites of
treatment as a mild adverse event with lesions fading within
2e5 days after treatment. Ecchymoses is regarded as normal
reaction after cupping which will automatically disappear in
a few days, and there is no need for any treatment.32 Ac-
cording to TCM, ecchymoses presents better qi and blood
circulation, and some studies report better effectiveness of
cupping when ecchymoses happens.33e35 Other mild adverse
events reported were increased pain or tingling. As there is
no systematic evidence available on the safety of cupping
therapy as a guide, practitioners should remain vigilant of
the time cups are retained on the skin and the strength of
the suction to avoid these adverse events.
Implications for research
Seven of the 16 included trials provided access information
to their registered protocols, allowing us to retrieve addi-
tional information. Authors are encouraged to register their
study protocols before trial implementation to ensure a
high standard of research is maintained so that valid con-
clusions can be reached.
Lack of blinding remains a major pitfall of conducting
trials on traditional manual therapies, such as acupuncture
and cupping. Attempts have been made to design sham
H. Cao et al.
placebo controls for cupping therapy,36 though robust
testing remains to be done. Researchers should therefore
be aware of the potential high risk of performance bias due
to the lack of appropriate blinding methods. Though
blinding of participants and practitioners is difficult for
studies on cupping therapy, blinding of outcome assessors
and statisticians can still be undertaken.
Author contributions
Huijuan Cao participated in conception and design of the
study, coordinated contributions from the co-authors,
analysis and interpretation of data, draft and final
approval of the manuscript. Jian-Ping Liu participated in
the design of the study, critical revision and final approval
of the manuscript. Xun Li acquired, analysis and interpre-
tation of data, manuscript writing, and final approval of the
manuscript. Xue Yan: acquired of data, critical revision and
final approval the manuscript. Nissi S. Wang participated in
conception and design of the study, critical revision and
final approval the manuscript. Alan Bensoussan partici-
pated in conception and design of the study, critical revi-
sion and final approval the manuscript.
Competing interests
The authors declare that they have no competing interests.
Acknowledgement
Hui-Juan Cao, Xun Li and Jian-Ping Liu are supported by the
Research Capacity Establishment Grant (No. 201207007)
from the State Administration of Traditional Chinese Med-
icine, and by the Innovative Research Team (No. 2011-
CXTD-09) from Beijing University of Chinese Medicine.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.jtcms.2014.11.003.
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 J Acupunct Meridian Stud 2018;11(3):83e87

Available online at www.sciencedirect.com

Journal of Acupuncture and Meridian Studies

journal homepage: www.jams-kpi.com

Review Article

Cupping Therapy: An Overview from a

Modern Medicine Perspective
Tamer S. Aboushanab 1,*, Saud AlSanad 1,2

1
National Center for Complementary and Alternative Medicine, Ministry of Health, Riyadh,
Saudi Arabia
2
College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi
Arabia
Available online 7 February 2018

Received: Nov 9, 2017 Abstract

Revised: Nov 25, 2017 Cupping therapy is an ancient traditional and complementary medicine practice.
Accepted: Feb 1, 2018 Recently, there is growing evidence of its potential benefits in the treatment of pain-
related diseases. This article gives an overview of cupping therapy practice. Further-
KEYWORDS more, this article suggests a new classification of cupping therapy sets, a new classifica-
Cupping therapy; tion of cupping therapy adverse events, and an updated classification of cupping therapy
Hijama; types.
Types;
Classification;
Adverse events;
Indications

1. Introduction and brief history
Cupping therapy is an ancient technique of healing [1].
Cupping is performed by applying cups to selected skin
points and creating a subatmospheric pressure, either by
heat or by suction [2].
Eber’s papyrus (1550 BC) from Ancient Egypt is one of the
oldest medical texts to mention cupping therapy. Cupping
therapy is part of numerous ancient healing systems, such as
Chinese, Unani, traditional Korean, Tibetan, and Oriental
medicine [3]. The ancient Greek physician Hippocrates
compiled extensive descriptions of the cupping application.

* Corresponding author. National Center for Complementary and Alternative Medicine, Ministry of Health, 11662, P.O 88300, Riyadh, Saudi
Arabia.
E-mail: tamer.shaban@gmail.com (T.S. Aboushanab), s.alsanad@nccam.gov.sa (S. AlSanad).
pISSN 2005-2901 eISSN 2093-8152
https://doi.org/10.1016/j.jams.2018.02.001
ª 2018 Medical Association of Pharmacopuncture Institute, Publishing services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
84
He described two different types of cups: one with a narrow
opening and a long handle and the other with a wider
opening. The first type was used to treat deep accumulation
of fluids, while the second type was used to treat the spread
of pain [4]. Cupping therapy was a popular historical treat-
ment in Arabic and Islamic countries. It was recommended by
Arabic and Islamic physicians such as Ibn Sina (AD 980e1037),
Al-Zahrawi (AD 936e1036), and Abu Bakr Al-Razi (AD
854e925). Al-Zahrawi described cupping sites and illustrated
cupping tools with diagrams [5]. Cupping therapy practice
spread to Italy and, subsequently, the rest of Europe be-
tween the 14th and 17th centuries, during the Renaissance.
Cupping was a very popular treatment of gout and arthritis in
Italy during this period [6].
2. Mechanisms of action and reported effects
of cupping therapy
The mechanism of action of cupping therapy was not
clear until now [7]. The main proposed mechanisms of ac-
tion were effects of subatmospheric pressure suction,
promoting peripheral blood circulation, and improving im-
munity. [8].
Reported effects of cupping therapy include promotion
of the skin’s blood flow [9], changing of the skin’s biome-
chanical properties [10], increasing pain thresholds,
improving local anaerobic metabolism [11], reducing
inflammation [12], and modulation of the cellular immune
system. [13].
Many theories explain the mechanism of action of
cupping. Guo et al. suggested the immunemodulation the-
ory, suggesting that cupping and acupuncture had the same
mechanisms of action. Immunemodulation theory suggests
that changing the microenvironment by skin stimulation
could transform into biological signals and activate the
neuroendocrine immune system [14]. Shaban and Rarvalia
proposed the genetic theory, which suggested that skin’s
mechanical stress (due to subatmospheric pressure) and
local anaerobic metabolism (partial deprivation of O2),
during cupping suction could produce physiological and
mechanical signals which could activate or inhibit gene
expression. In wet cupping therapy, superficial scarifications
could activate the wound-healing mechanism and gene-
expression program [15]. Modulation of genetic expression
was reported in various acupuncture studies [16,17].
In summary, there is no clear identified mechanism of
action of cupping therapy. Clinical studies in the field of
cupping therapy mechanisms of action are highly
recommended.
3. Classification of cupping therapy types
Early classification of cupping therapy categorized it
broadly into dry and wet cupping [18]. Another classification
of cupping therapy was developed in 2013, categorizing
cupping into five categories. The classification was updated
in 2016 [19]. The updated classification categorized cupping
therapy into six categories. The first category is “technical
types”, which includes dry, wet, massage, and flash cupping.
The second category is “power of suction”, which
T.S. Aboushanab, S. AlSanad
includes light, medium, and strong cupping. The third cate-
gory is “method of suction”, which includes fire, manual
vacuum, and electrical vacuum cupping. The fourth category
is the “materials inside cups”, which includes herbal, water,
ozone, moxa, needle, and magnetic cupping. The fifth
category is “area treated”, which includes facial, abdom-
inal, female, male, and orthopedic cupping. The sixth cate-
gory is “other cupping types”, which includes sports,
cosmetic, and aquatic cupping [19].
This article suggested a new update of cupping therapy
classification by merging category five and six into one main
category: “condition and area treated”. The name of the
fourth category was changed from “materials inside cups”
to “added therapy types”, and aquatic cupping was added
to this category. The aim of this update is to give a precise
classification of cupping therapy types [Fig. 1].
4. Classification of cupping therapy sets
A typical cupping therapy set should contain six or more
different-sized cups and a method of suction. Cupping
therapy sets can be classified into three main categories:
the first category is “cupping sets related to the types of
cups”, which includes plastic, glass, rubber, bamboo,
ceramic, metal, and silicone cupping sets. The second
category is “cupping sets related to the methods of
suction”, which includes manual, automatic, and self-
suction cupping sets. The third category is “cupping sets
related to uses”, which includes facial, female, male, and
massage cupping sets [Fig. 2] [20].
5. Indications
Cupping therapy has been used for health promotion,
preventive, and therapeutic purposes. Cupping therapy has
reported benefits in the treatment of lower back pain
[21,22,23], neck and shoulder pain [24,25,26,27], headache
and migraine [28,29], knee pain [30], facial paralysis
[31,32], brachialgia [33], carpal tunnel syndrome [34], hy-
pertension [35,36], diabetes mellitus [37], rheumatoid
arthritis [38], and asthma [39,40]. These diseases can be
categorized into localized diseases (neck pain, lower back
pain, and knee pain) and systematic diseases (diabetes
mellitus, hypertension, and rheumatoid arthritis).
Cupping therapy sites are selected according to the
treated ailment. The back is the most common site of
application, followed by the chest, abdomen, buttocks, and
legs. Other areas, such as the face, may also be treated by
cupping [41].
6. Contraindications
In general, cupping is contraindicated directly on veins,
arteries, nerves, skin inflammation, any skin lesion, body
orifices, eyes, lymph nodes, or varicose veins. Cupping is
also contraindicated on open wounds, bone fractures, and
sites of deep vein thrombosis.
Cupping therapy contraindications can be classified into
absolute and relative contraindications. Until we have suf-
ficient information regarding the safety of cupping therapy,
it is absolutely contraindicated in cancer patients and those
Cupping Therapy Overview 85

Figure 1 Classification of cupping therapy types.

Figure 2 Classification of cupping sets.

86
Table 1 Classification of cupping therapy adverse events.
Preventable Nonpreventable cupping
cupping adverse event adverse event
Scar formation Koebner phenomenon
Burn Headaches
Bullae formation Dizziness
Abscess and skin Tiredness
infection
Pruritus Vasovagal attack
Anemia Nausea
Panniculitis Insomnia
with any organ failure (renal failure, hepatic failure, and
heart failure). It is also absolutely contraindicated in pa-
tients using a pacemaker and those suffering from hemo-
philia or similar conditions. Relative cupping therapy
contraindications include acute infection, using anticoagu-
lants, severe chronic disease (such as heart diseases),
pregnancy, puerperium, menstruation, anemia, recent wet
cupping session, recent blood donation, medical emergen-
cies, and patient’s refusal of the procedure [42,43,44].
7. Adverse events
Cupping therapy is relatively safe. Cupping therapy
adverse events (AEs) are infrequently reported but are not
rare. Most AEs are mild to moderate in severity [45].
Most AEs related to cupping therapy are scar formations,
followed by burns. Other observed AEs are headache, pru-
ritus, dizziness, tiredness, muscle tension, anemia, nausea,
bullae formation, small hematoma or pain at cupping site,
abscess formation, skin infection, insomnia, hyperpigmen-
tation, and vasovagal attack [46]. This article suggested a
new classification of cupping therapy AEs into those that
are preventable and nonpreventable [Table 1].
8. Infection control measures
Following infection control measures is an essential part
of the clinical practice for preventing cupping therapy-
related infection. Hand washing is a critical component of
any infection control program. Wearing personal protective
equipment such as gloves, masks, protective eyewear, and
gowns is important. Disinfection of the skin before cupping
by US Food and Drug Administration (FDA)-approved or
hospital-grade solutions is very important. Disinfection of
patients’ beds or using disposable plastic bed covers is very
important after treating each patient. Following medical
waste segregation and disposal guidelines is essential. Using
disposable cups, vacuum pumps, and surgical blades is rec-
ommended. Try to use a secondary disposable container for
lubricants/skin disinfectants used on a single patient before
disposal. Use on another patient is prohibited [47,48,49].
9. Summary
In summary, cupping therapy is an ancient traditional
and complementary medicine practice. There is growing
T.S. Aboushanab, S. AlSanad
evidence of its potential benefits in the treatment of some
diseases, especially pain-related conditions. Following
infection control measures is a very important component
of the cupping therapy practice. This article suggested a
new classification of cupping therapy sets, a new classifi-
cation of cupping therapy AEs, and an updated classifica-
tion of cupping therapy types.
Disclosure statement
None declared.
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