J. Acupunct. Tuina. Sci.

2012, 10 (5): 281-286

DOI: 10.1007/s11726-012-0620-y

Special Topic Study

Effect of Moxibustion Therapy plus Cupping on
Exercise-induced Fatigue in Athletes
灸法结合拔罐对运动性疲劳运动员的影响
Sun De-li (孙德利)1, Zhang Yan (张琰)1, Chen Da-long (陈大隆)1, Zhang A-bao (张阿宝)2, Xu Ming (徐明)2,
Li Zhi-jun (李之俊)3, Zhu Xun-sheng (朱训生)4, Jiang He-xin (蒋和鑫)1, Song Yi (宋毅)1, Hao Wang-shen (郝旺身)4
1 Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
2 Sports Hospital Affiliated to Shanghai Institute of Physical Education, Shanghai 200237, China
3 Shanghai Research Institute of Sports Science, Shanghai 200030, China
4 School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China

【摘要】目的：观察灸法结合拔罐疗法对运动性疲劳运动员主观体力感觉及血液生化指标的影响。方
法：将 30 例体操运动员随机分为 2 组，大强度运动后，治疗组 15 例采用温和灸加拔罐治疗,对照组 15
例休息 30 min，观察一次性大强度训练和周期性大强度训练前后运动员血清肌酸激酶（Creatine Kinase,
CK）、血尿素氮(Blood Urea Nitrogen, BUN)、尿常规、主观体力感觉评分表(Rating of Perceived Exertion,
RPE)和 SCL-90 症状自评量表的变化。结果：大强度训练后，治疗组升高的 CK 水平恢复明显快于对
照组。SCL-90 症状自评量表分析结果显示治疗组运动员的人际关系优于对照组。RPE 分析表明治疗组
运动员的疲劳感觉轻于对照组。结论：灸法结合拔罐疗法是消除运动性疲劳的一种有效的、简便可行
的方法。
【关键词】灸法；拔罐；肌肉疲劳；肌酸激酶；血尿素氮
【中图分类号】R246.9 【文献标志码】A
【Abstract】Objective: To observe the effect of moxibustion therapy plus cupping on perceived exertion and
blood biochemical indicators in athletes with exercise-induced fatigue. Methods: A total of 30 gymnasts
were randomized into two groups. After intensive physical training, 15 cases in the treatment group were
treated by mild moxibustion and cupping, whereas the other 15 cases in the control group took a 30-min
break. After that, the Creatine Kinase (CK), Blood Urea Nitrogen (BUN), routine urinalysis, Rating of
Perceived Exertion (RPE) and changes in Self-report Symptom Checklist 90 (SCL-90) were observed before
and after one and periodic exercises. Results: After intensive physical training, athletes in the treatment
group obtained a faster recovery of elevated CK levels than those in the control group. Analysis on the
SCL-90 has shown that athletes in the treatment group had better interpersonal relations than those in the
control group. Additionally, RPE analysis has also indicated that athletes in the treatment group had milder
fatigue than those in the control group. Conclusion: Combined moxibustion with cupping is an effective and
easy-to-operate method for exercise-induced fatigue.
【Key Words】Moxibustion Therapy; Cupping Therapy; Muscle Fatigue; Creatine Kinase; Blood Urea
Nitrogen

Exercise-induced fatigue is the decline in ability
of the bodily physiological process to sustain
specific levels of functioning and/or to maintain the
expected exercise intensity. This mainly manifests
that athletes may experience fatigue after intensive
physical training or vigorous matches and fail to
recover fast enough. Actually it’s been a frontline
Author: Sun De-li, M.D., associate chief physician. E-mail:
zjsdl@163.com
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012︱● 281
study over the last 50 years on delaying exercise-
induced fatigue and accelerating its recovery.
Chinese medicine has distinctive role in sports
medicine in China. Over the past 20 years, myriad
studies have been developed on its "theory,
principles, formulae and medicine". These studies
mainly involve eliminating exercise-induced fatigue,
enhancing workout ability and dealing with sports
injuries and exertional diseases, coupled with
●

mechanism exploration. It is now well-recognized
that Chinese external therapies such as acupuncture,
tuina and herbal fumigation-washing are superior to
conventional conservative therapies for sports
injuries and functional recovery. Facing with the
current anti-doping situation, it’s essential to screen
stimulants-free medicinals for aforementioned
studies, which adapt to different sports types,
training cycles and bodily functions under the
framework of Chinese medical theory. We used
mild moxibustion and cupping for prevention and
treatment of exercise-induced fatigue of gymnasts.
The reports are now summarized as follows.
1 Subjects and Research Methods
1.1 Observation subjects
Thirty gymnasts including 22 males and 8
females were selected from Shanghai Gymnastics
Training Center. These gymnasts were randomized
into a treatment group and a control group, 15 (11
males and 4 female) in each group. There were no
statistical significances in age, height and weight
between the two groups (P>0.05), (table 1).
Table 1. Comparison of general materials between the two
groups ( x ±s)
Groups n Age (year) Height (cm) Weight (kg)
Treatment 15 12.17±2.14 142.4±0.82 33.47±6.23
Control 15 13.64±3.34 145.0±0.14 37.67±13.69
1.2 Treatment method and observation indexes
1.2.1 The immediate effect after intensive physical
training
The coach was responsible for decision-making
of the exhaustive exercise methods.
Treatment group: After 1 h of exhaustive exercise,
placed smokeless moxa cones into a mild
moxibustion box and then applied the box to the
gymnasts’ back and low back until a tolerable local
hot sensation occurred. This took 15 min and then
applied cupping therapy, retained the cups for
15 min.
Control group: After 1 h of exhaustive exercise,
the gymnasts took a 30-min break.
Fingertip blood and urine were collected
respectively before the exhaustive exercise (resting
state), 1 h and 16 h after the exhaustive exercise for
determination of biochemical markers including
creatine kinase (CK), blood urea nitrogen (BUN),
● 282 ●︱© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012
J. Acupunct. Tuina. Sci. 2012, 10 (5): 281-286
Urea (Ur) and routine urinalysis (10 items).
1.2.2 Observation upon periodic intensive physical
training
The coach was responsible for the decision-
making of periodic exhaustive exercise. The amount
of exercise on the first day should be consistent with
that on the fifth day.
Treatment group: After 1 h of exhaustive exercise,
applied the same 30-min mild moxibustion and
cupping. The gymnasts were treated once every
other day.
Control group: After 1 h of exhaustive exercise,
the gymnasts continued to take a 30-min break.
The fingertip blood and urine were collected
respectively at 8:30 am on the 1st, 2nd, 5th and 6th
day as well as 6:00 pm on the 1st and 5th day for
determination of biochemical markers including CK,
Ur and routine urinalysis (10 items). In addition, the
Rating of Perceived Exertion (RPE) and Self-report
Symptom Checklist 90 (SCL-90) scores were
determined at 6:00 pm of the 1st and 5th day for
difference comparison in the two groups before and
after treatments.
1.2.3 Index determination method
CK and Ur determination: Collect fingertip blood
using the German-manufactured Reflotron® CK and
Ur kit and Reflotron® sprint-(whole blood) dry type
biochemistry analyzer.
Fatigue severity and self-report symptom scores
were conducted using the RPE and SCL-90.
2 Observation Outcome and Analysis
2.1 Immediate effect on CK, Ur and routine
urinalysis during exhaustive exercise
2.1.1 Immediate effect on CK during exhaustive
exercise
The CK levels of gymnasts in the two groups
were almost same during resting states before
exercise. After 1 hour of exhaustive exercise, the
CK levels of gymnasts were significantly elevated.
However, there was no statistical difference
between the two groups. After 16 h of exercise, the
CK level in the treatment group was significantly
lower than that in the control group, indicating that
mild moxibustion and cupping help to restore the
elevated CK level induced by exhaustive exercise
(Fig.1. Note: t-test showed that compared with the
J. Acupunct. Tuina. Sci. 2012, 10 (5): 281-286
intra-group results before treatment, 1) P<0.05;
compared with the concurrent control group, 2)
P<0.05).
Fig.1. Immediate effect on CK during exhaustive exercise
2.1.2 Immediate effect on Ur during exhaustive
exercise
The Ur levels of gymnasts in two groups were
almost same during resting states before exercise.
After 1 h of exhaustive exercise, the Ur levels of
gymnasts were significantly elevated. However,
there was no statistical difference between the two
groups. After 16 h of exercise, the Ur levels were
restored normal in both groups, showing no
statistical difference. This indicated that mild
moxibustion and cupping had no distinct effect on
elevated Ur level induced by exhaustive exercise
(Fig.2. Note: compared with the intra-group results
before treatment, 1) P<0.05).
Fig.2. Immediate effect on Ur during exhaustive exercise
2.2 Effect on CK, Ur, RPF and SCL-90 during
periodic exhaustive exercise
2.2.1 Effect on CK during periodic exhaustive
exercise
The CK levels of gymnasts in two groups were
almost same on the morning of the 1st day of
periodic exhaustive exercise. After exhaustive
exercise, the CK levels of gymnasts were
significantly elevated. However, there was no
statistical difference between the two groups. In
mornings of the 2nd and 5th day of exhaustive
exercise, the CK level in the treatment group was
significantly lower than that in the control group
(P<0.01). In afternoons of the 5th and 6th day, the
CK level in the treatment group was still
significantly lower than that in the control group
(P<0.05), indicating that mild moxibustion and
cupping can help to restore the elevated CK level
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012︱● 283
induced by periodic exhaustive exercise (Fig.3.
Note: t-test showed that compared with the control
group, 1) P<0.001; 2) P<0.05).
Morning Afternoon Morning Morning Afternoon Morning
of 1st day of 1st day of 2nd day of 5thday of 5th day of 6th day
Fig.3. CK changes during periodic exhaustive exercise
2.2.2 Effect on Ur during periodic exhaustive
exercise
The Ur levels of gymnasts in the two groups were
almost same in the mornings of the 1st, 2nd, 5th and
6th of periodic exhaustive exercise. The Ur levels in
both groups were significantly elevated in the
afternoon of 1st day (P<0.05) and the Ur level in the
control group was significantly elevated in the
afternoon of the 5th day. However, there was no
statistical difference between the two groups,
indicating that mild moxibustion and cupping had
no distinct effect on elevated Ur level induced by
periodic exhaustive exercise (Fig.4. Note: t-test
showed that morning-afternoon comparison of the
1st day, 1) P<0.05; morning-afternoon comparison
of the 5th day, 2) P<0.005).
Morning Afternoon Morning Morning Afternoon Morning
of 1st day of 1st day of 2nd day of 5thday of 5th day of 6th day
Fig.4. Ur changes during periodic exhaustive exercise
2.2.3 Effect on SCL-90 and RPE in gymnasts during
periodic exhaustive exercise
The SCL-90 scores after periodic exhaustive
exercise showed a statistical difference in
interpersonal relation factors between the two
groups (P<0.05). However, there were no statistical
differences in total symptom score, factors of
somatization, obsessive-compulsive, depression,
anxiety, hostility, phobic anxiety, paranoid ideation,
psychoticism, and a category of "additional items".
This indicated that mild moxibustion and cupping
could effectively improve the interpersonal relations
of gymnasts during periodic exhaustive exercise
(Fig.5. Note: t-test showed that compared with the
control group, 1) P<0.05).
●

Total Somatization Obsessive- Interpersonal Depression
syndrome compulsive relations
Fig.5. Difference comparison of SCL-90 between two groups before and after treatments
After periodic exhaustive exercise, the fatigue in
gymnasts aggravated, showing a statistical
significance between the two groups (P<0.05). This
indicated that mild moxibustion and cupping can
help to eliminate fatigue induced by periodic
exhaustive exercise (Fig.6. Note: t-test showed that
compared with the control group, 1) P<0.05).
Fig.6. Comparison of RPE scores between the two groups
3 Discussion
3.1 CK and exercise-induced fatigue
The creatine kinase is an enzyme found mainly in
the skeletal muscle, cardiac muscle, brain and
smooth muscle, especially in skeletal muscle.
Biologically, CK catalyzes the reversible conversion
of adenosine triphosphate (ATP) and
phosphocreatine (PCr). It is also a catalyzing
enzyme to supplement energy for strenuous exercise
within a short period of time and restore ATP
reaction. As a result, it is closely associated with the
energy balance and transfer during and after
exercise. Numerous studies have shown that after
exhaustive exercise, muscle soreness is highly
correlated with serum CK levels. This makes blood
CK a key index to measure exercise-induced
● 284 ●︱© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012
J. Acupunct. Tuina. Sci. 2012, 10 (5): 281-286
Anxiety Hostility Phobic Paranoid Psychoticism Additional
anxiety items
fatigue[1-3]. According to some literature reports,
moxibustion on Zusanli (ST 36) and Shenque (CV 8)
could effectively alleviate fatigue and reduce the
CK levels after fixed quantitative exercise, whereas
the CK activity in the control group was
substantially elevated, coupled with aggravated
fatigue. This indicates that moxibustion can
effectively alleviate exercise-induced fatigue[4].
Some studies have also proven that after one
strenuous exercise, needling Neiguan (PC 6) and
Zusanli (ST 36) during recovery in the treatment
group can significantly reduce the activities of CK
and CK-Mb as well as Mb contents. For the control
group, despite a reduction was also present, there
were no statistical significances. This indicates that
acupuncture can improve the recovery of CK,
CK-Mb and Mb and thus help to alleviate exercise-
induced fatigue[5]. This study has suggested that
mild moxibustion and cupping can promote the
recovery of elevated CK level induced by one
strenuous exercise or periodic exhaustive exercise,
indicating that this method has good effect in
alleviating exercise-induced fatigue.
3.2 Blood Ur and exercise-induced fatigue[6]
Blood Ur is a decomposition product of protein
and amino acid. Under normal physiological
conditions, protein and nitrogen-containing material
in amino acid deaminize first during catabolism, and
the ammonia converses into Ur in the liver. Blood
Ur is excreted from the kidney via blood circulation.
Blood Ur reflects the metabolism of protein and
amino acid and is associated with the bodily
functions, fatigue severity and loading. It is
generally believed that after long-term strenuous
J. Acupunct. Tuina. Sci. 2012, 10 (5): 281-286
exercise or reduced protein uptake, blood Ur varies
greatly. However, its elevation is related to the
sports type and individual differences. Some
scholars believe that Ur concentration of over 50%
in the next morning after load exercise indicates
overtraining. Consequently, it is completely feasible
to employ Ur changes in the diagnosis of
exercise-induced fatigue for gymnasts. For Chinese
people, the normal blood Ur during a resting state
ranges from 3.2 mmol/L to 7.0 mmol/L. Gymnasts
during routine training can still maintain a normal
blood Ur. For gymnastic training, the following
methods are often employed to determine exercise-
induced fatigue:
3.2.1 Unchanged blood Ur contents in the next
morning indicate that the amount of exercise is too
small to adequately stimulate the body.
3.2.2 The morning blood Ur was elevated during the
initial stage of exercise but gradually restored
normal, which indicates that the amount of exercise
is big enough for the body to adapt. Consequently,
the morning blood Ur can be measured every day or
every other day to determine the bodily function.
3.2.3 An elevated morning blood Ur day by day
during exercise indicates that the amount of exercise
is too big for the body to adapt. In order to prevent
overtraining, the daily blood Ur should be lower
than 8.0 mmol/L for male athletes and lower than
7.5 mmol/L for female athletes.
The differences of individual and gender should
be noted during exercise.
This study found that the average morning Ur
levels of gymnasts in both groups were all in the
normal range. Despite a little bit elevation after a
day of exercise, the Ur levels restored normal the
next morning. There were no statistical differences
between the two groups. This indicated that blood
Ur was not a response-sensitive observation index
in monitoring and observing the prevention and
treatment of exercise-induced fatigue using mild
moxibustion and cupping.
3.3 SCL-90 rating scale and exercise-induced
physiological and psychological fatigue
The exercise-induced fatigue in gymnasts can
manifest physiologically and psychologically[6].
Exercise-induced psychological fatigue is a mental
restlessness and fatigue due to long-term boring,
repetitive, heavy stress training and competition.
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012︱● 285
During heavy stress training or competition,
gymnasts need extreme mental focus and a rapid,
accurate and coordinated conversion between
excitation and inhibition of neuromuscular system.
In the meantime, the heavy stress training and
competition also require excitability and flexibility
of the cerebral cortex, proprioception of the
autonomic nervous system and function of the
vestibular system, gymnasts are highly stressful all
the time. If not alleviated on time, this highly
stressful condition may result in psychological
fatigue, manifesting as feeling bored, restlessness,
irritability, mood swings, weak willpower and
inattention. In severe cases, gymnasts can even lose
confidence in further exercise, leading to decline in
their abilities and failure to fulfill the training
program.
The SCL-90 self-rating scale[7] was employed to
assess gymnasts’ psychological states. This scale
contains 90 items involving psychosomatic factors
such as perception, thinking, emotion,
consciousness, interpersonal relations, lifestyle and
sleep. The scale can provide an overview of an
individual gymnast’s nine psychosomatic symptoms
(somatization, obsessive-compulsive, interpersonal
sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation and psychoticism) during
the recent stress state. Each item has five levels of
absent, mild, moderate, severe and very severe.
Subjects were asked to rate from 0 to 4 according to
their perception. A higher score indicates a stronger
psychosomatic response. This scale has been
extensively used in China and obtained high validity
and reliability. This study test was conducted before
and 1 week after the periodic exhaustive exercise.
The results have shown that the gymnasts’ overall
symptoms and nine psychosomatic factors were all
within the normal range, and the interpersonal
sensitivity factors in the treatment group was
significantly higher than that in the control group.
This indicated that mild moxibustion and cupping
could improve the interpersonal relations of
gymnasts with exercise-induced fatigue and was an
effective method to eliminate exercise-induced
psychological fatigue.
3.4 RPE and exercise-induced fatigue[8-9]
Since the perceived exertion during exercise is
closely associated with many factors such as
●

workload, heart functions, oxygen consumption and
build-up of metabolites, it is an important signal in
assessing exercise-induced fatigue. RPE can be
accurately used for semi-quantitative analysis on
perceived fatigue and exertion. This scale has 7
ratings and the total score is 20. Subjects describe
their perceived exertions before and immediately
after exercise. The ratings can reflect the subjects’
exercise intensity and endurance. The study findings
have shown that after 1 week of exhaustive exercise,
gymnasts’ perceived exertions became strong;
however, the RPE in the treatment group was
remarkably lower than that in the control group,
indicating that mild moxibustion and cupping could
prevent and treat exercise-induced fatigue.
Back and low back are where the Back-Shu
points are located. Mild moxibustion and cupping in
these areas can regulate functions of the Zang-fu
organs and speed up the recovery of fatigue. What’s
more, this easy-to-operate method works fast and
does not harm the skin or affect physical
training[10-13]. It can not only alleviate exercise-
induced fatigue, but also help to treat sports injuries
and improve exercise potential. In summary, it is an
effective method for the prevention and treatment of
exercise-induced fatigue.
Conflict of Interest
The authors declare that there is no conflict of interest.
Acknowledgments
This work was supported by Shanghai Sports Bureau
(04JT014); Shanghai Leading Academic Discipline
Project (S30304).
Statement of Informed Consent
All the subjects who took part in the research knew the
fact of the clinical trail.
Welcome Contribution
Welcome Subscription
● 286 ●︱© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2012
J. Acupunct. Tuina. Sci. 2012, 10 (5): 281-286
References
[1] Pang YH, Liu H, Li YY. Role of serum creatine kinase in
sports medicine monitoring. Xiandai Zhongxiyi Jiehe Zazhi,
2004, 13(16): 2150.
[2] Gui YH, Chen WB, Cao WY. Role of serum creatine kinase
in monitoring exercise load endurance of weight-lifting
athletes. Zhongguo Yundong Yixue Zazhi, 2004, 23(2):
180-184.
[3] Ding LP, Xu L. Applied study on serum creatine kinase and
blood urea nitrogen for training and pre-competition
monitoring of martial arts athletes. Zhongguo Tiyu Keji,
2003, 39(10): 54-56.
[4] Shi SS. Effect of point moxibustion on serum CK, BLA and
sports ability during exercise. Nanjing Shida Xuebao: Ziran
Kexue Ban, 2002, 25(1): 103-107.
[5] Xiang ZY, Chen YW, Yu SB, Li HY, Zhang S, Wu XP.
Experimental observation on acupuncture for exercise-
induced fatigue. Shandong Tiyu Keji, 1998, 20 (3): 25-27.
[6] Hu XF, Yang WL. Physiological and biochemical diagnosis
of exercise-induced fatigue in gymnasts. Shaanxi Shifan
Daxue Jixu Jiaoyu Xuebao, 2006, 23(1): 125-127.
[7] Xu JM. Medical Psychology. 2nd Edition. Shanghai:
Shanghai Medical University Press, 1996: 183-191.
[8] Luo L. Relationship between rating of perceived exertion
(RPE) and incremented load running breather valve.
Sichuan Tiyu Kexue, 1988, (3): 37-41.
[9] Hongtai TT. Research advance of exercise-induced fatigue.
Fujian Tiyu Keji, 1991, (10): 13-16.
[10] Sun DL, Zhang Y, Chen DL. Research progress in sports
fatigue prevented and treated by acupuncture. J Acupunct
Tuina Sci, 2009, 7(2): 123-128.
[11] Bao CL, Yuan P, Li LQ. Clinical observations on treatment
of chronic fatigue syndrome with acupuncture based on
yin-yang and qi-blood prescription of points. Shanghai
Zhenjiu Zazhi, 2008, 27(6): 11-12.
[12] Feng Z, Pang Y, Ye FW. TCM non-medicinal therapy for
regulation and treatment of chronic fatigue syndrome. J
Acupunct Tuina Sci, 2008, 6(6): 376-380.
[13] Guo FY, Xu L. Preliminary study on treatment of chronic
fatigue syndrome by herbal cake-separated moxibustion on
Five-Zang Back-Shu Points. Shanghai Zhenjiu Zazhi, 2006,
25(10): 11-12.
Translator: Han Chou-ping (韩丑萍)
Received Date: June 8, 2012