Letter

when the skin is sucked in); and an attempt to test its effectiveness

Effectiveness of cupping
therapy for low back pain:
a systematic review
Cupping therapy has been used for
thousands of years in traditional
Chinese medicine for the treatment
of several chronic conditions,
such as low back pain, chronic arth-
ralgia, radiculopathy and respiratory
disease.1 Dry and wet cupping (with
controlled bleeding) are the two
main types of cupping therapy.
Other subtypes of the treatment are
cupping with retention (keeping
cups on the skin or acupuncture
points for 10–15 min); moving-
cupping (sliding cups over the skin
or acupuncture points with lubri-
cants); shaking-cupping (moving
cups up and down repeatedly on
skin or acupuncture points); quick-
cupping (removing cups immediately
balance-cupping (composite manipu-
lation, each dose including cupping
with retention 6–8 min, moving-
cupping four times, shaking-cupping
three times and quick-cupping three
times).
Nowadays, an increasing number
of patients have shown an interest in
using cupping therapy for the treat-
ment of low back pain owing to
their belief that it is more effective
than Western therapeutics. Although
cupping therapy is considered a safe,
non-invasive procedure, the outcome
does not always fulfil the expectation
of therapists and patients. Moreover,
complications of cupping therapy,
such as anaemia and skin pigmenta-
tion, have also been reported.2
Since there is no consensus on
the role of cupping therapy in the
treatment of low back pain, we
reviewed the medical literature in
Acupunct Med: first published as 10.1136/acupmed-2013-010385 on 25 July 2013. Downloaded from http://aim.bmj.com/ on 4 September 2018 by guest. Protected by copyright.
in low back pain and to further
examine this method.
The systematic research started
with a thorough English and Chinese
language literature search of PubMed
from 1980 through 2013. The
keyword search terms in combin-
ation were ‘cupping therapy’, ‘low
back pain’, ‘lumbar sprain’, ‘lumbar
myofascitis’ and ‘lumbosacral pain’.
Articles with laboratory studies were
excluded.
Three reviewers took part in the
study. One reviewer selected the
titles and abstracts for inclusion,
one extracted data from the full-text
articles and the third reviewer con-
firmed the reference lists of poten-
tially eligible studies. Identified
studies were assigned a level of evi-
dence according to the Oxford
Centre for Evidence-Based Medicine
2011 levels of evidence.3

Table 1 The studies with levels I and II evidence

Studies (level of
evidence) Treatment (N) Dose and regimen Results (p value)
4
Kim et al Intervention group Wet cupping 1. Brochures for Bilateral BL23, BL24 and BL25, 1. NRS scores >0.05
(level I) (21) 3 times weekly for 2 weeks 2. PPI scores <0.05
exercise
Control group (11) Waiting-list 3. ODQ scores >0.05
2. General advice
3. Acetaminophen
500 mg
Liu et al5 Intervention group Cupping with retention Bilateral at BL, 15 min daily 1. VAS <0.05
(level II) (25/25) Balance-cupping* Bilateral low back area, along BL and GV, 2. ODQ scores < 0.05
every 2 days
Control group (25) Diclofenac 50 mg, daily
Xuan6 Intervention Moving-cupping Bilateral at BL, 5–10 times (about 5 min), 1. VAS <0.01
(level II) group (40) alternate days for 11 days 2. SF-36 <0.01
Control group (40) Dexibuprofen 0.15 g, T.I.D. for 12 days
Hong et al7 Intervention Moving-cupping Bilateral at BL, 5–10 times (about 5 min), 1. VAS<0.012.
(level II) group (37) alternate days for 11 days 2. SF-36 <0.01
Control group (33) Dexibuprofen 0.15 g, T.I.D. for 12 days
Lo and Ma8 Intervention Balance-cupping Bilateral low back area, along BL, GV and local tender VAS <0.05
(level II) group (33) points, every 2 days for 2 weeks
Control group (31) Western medication 1 tablet of composite chlorzoxazone (chlorzoxazone
0.25 g+ acetaminophen 0.3 g),
B.I.D. for 2 weeks
Ma and Lo9 Intervention Balance-cupping Bilateral low back area, along BL and GV, every 2 days VAS <0.05
(level II) group (33)
Control group (31) Western medication 1 tablet of composite chlorzoxazone (chlorzoxazone
0.25 g+ acetaminophen 0.3 g), B.I.D.
Chen and Pan10 Intervention Moving-cupping and cupping Bilateral at BL, Huatuoliaji points and local tender points, Recurrence rate <0.05
(level II) group (60) with retention alternate days
Control group (40) Western medication 1. 2% Local anaesthetics (novocaine or lidocaine)
4–6 mL+ vitamin B12 500 mg + dexamethasone
5–10 mg for point injection, every 2 days
2. Indometacin 25 mg for oral administration, T.I.D.
*Refer to text.
B.I.D., twice a day; NRS, numerical rating scale; ODQ, Oswestry Disability Questionnaire; PPI, McGill Pain Questionnaire for pain intensity; SF-36, 36-item
Short Form; T.I.D., three times a day; VAS, visual analogue scale.

336 Acupunct Med 2013;31:336–337. doi:10.1136/acupmed-2013-010385


Through our electronic and refer-
ence search we identified 29 cita-
tions (table 1): one randomised
controlled trial (RCT, level I evi-
dence),4 six non-RCTs (level II evi-
dence),5–10 20 case reports (level
IV evidence) and two mechanism-
based reasoning studies (level V
evidence).
In the RCT, the effective rate of
the wet-cupping group was similar to
that of the waiting-list group
(p>0.05). Interventions in both
groups decreased pain, disability and
acetaminophen dosage, but a signifi-
cant decrease in pain intensity accord-
ing to the McGill pain questionnaire
(p<0.01) and reduced consumption
of acetaminophen (p=0.09) were
seen in the wet-cupping group.4
Of the six non-RCTs, one showed
that the visual analogue scale (VAS)
score and the Oswestry disability
index in the balance-cupping group
were significantly lower than in the
group with cupping with retention
and diclofenac ( p<0.05), but there
was no difference between the
cupping with retention group and
the diclofenac-only group
( p>0.05).5 The other studies indi-
vidually showed that the effective-
ness of cupping in decreasing
VAS,6–9 reducing recurrence rate10
and improving quality of life6 7 was
better than Western medication.
Although evidence level I and II
studies on the effectiveness of
cupping treatment in low back pain
have been reported, aspects such as
manipulations, sites and dosage of
cupping and Western medication in
the comparison group are not
Acupunct Med 2013;31:336–337. doi:10.1136/acupmed-2013-010385
uniform. Although RCTs provide a
higher quality of evidence, we
included non-RCTs in this study
because the limited number of
RCTs did not provide convincing
evidence.
In this article, the research results
show that cupping therapy is promis-
ing for pain control and improve-
ment of quality of life, and minimises
the potential risks of treatment.
Therefore, further studies are needed
to determine the potential role of
cupping therapy in the treatment of
low back pain.
Chia-Yu Huang,1,2 Mun-Yau Choong,2,3
Tzong-Shiun Li2,3
1
Division of Plastic Surgery, Department of Plastic
Surgery, China Medical University Hospital,
Taichung, Taiwan, Republic of China
2 5 Liu BX, Xu M, Huang CG, et al.
School of Medicine, China Medical University,
Taichung, Taiwan, Republic of China
3
Department of Plastic Surgery, Tainan Municipal
An-Nan Hospital, Tainan, Taiwan, Republic of China
Correspondence to Dr Tzong-Shiun Li,
Department of Plastic Surgery, Tainan Municipal
An-Nan Hospital, No. 66, Sec. 2 Chang-He Rd,
An-Nan District, Tainan City 70965, Taiwan,
Republic of China; li.tsa2@msa.hinet.net
Contributors C-YH: conducted the
experiment; wrote the article. M-YC:
analysed and interpreted the data;
provided materials. T-SL: designed the
experiment; proofed and revised the
article.
Competing interests None.
Provenance and peer review Not
commissioned; internally peer reviewed.
▸ Additional material is published online
only. To view please visit the journal
online (http://dx.doi.org/10.1136/
acupmed-2013-010385).
To cite Huang C-Y, Choong M-Y, Li T-S. Acupunct
Med 2013;31:336–337.
Received 25 April 2013
Accepted 8 July 2013
Published Online First 25 July 2013
Letter
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Acupunct Med: first published as 10.1136/acupmed-2013-010385 on 25 July 2013. Downloaded from http://aim.bmj.com/ on 4 September 2018 by guest. Protected by copyright.
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