Journal of Bodywork & Movement Therapies 24 (2020) 503e518

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Myofascial Pain and Treatment

Dry cupping for musculoskeletal pain and range of motion: A

systematic review and meta-analysis
Sarah Wood a, *, Gary Fryer b, Liana Lei Fon Tan c, Caroline Cleary d
a
The Institute for Health and Sport, Victoria University, Melbourne, Australia
b
College of Health & Biomedicine, Victoria University, Melbourne, Australia
c
Endeavour College of Natural Health, Melbourne, Australia
d
Torrens University, Melbourne, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: This review evaluated the efficacy and safety of western dry cupping methods for the
Received 28 April 2019 treatment of musculoskeletal pain and reduced range of motion.
Received in revised form Methods: A systematic literature search was performed until April 2018 for randomised controlled trials
16 March 2020
(RCTs) pertaining to musculoskeletal pain or reduced range of motion, treated with dry cupping. Out-
Accepted 7 June 2020
comes were pain, functional status, range of motion and adverse events. Risk of bias and quality of
evidence was assessed using the modified Downs & Black (D&B) checklist and GRADE.
Results: A total of 21 RCTs with 1049 participants were included. Overall, the quality of evidence was fair,
with a mean D&B score of 18/28. Low-quality evidence revealed dry cupping had a significant effect on
pain reduction for chronic neck pain (MD,
21.67; 95% CI,
36.55, to
6.80) and low back pain
(MD,
19.38; 95%CI,
28.09, to
10.66). Moderate-quality evidence suggested that dry cupping
improved functional status for chronic neck pain (MD,
4.65; 95%CI,
6.44, to
2.85). For range of
motion, low quality evidence revealed a significant difference when compared to no treatment
(SMD,
0.75; 95%CI,
0.75, to
0.32).
Conclusion: Dry cupping was found to be effective for reducing pain in patients with chronic neck pain
and non-specific low back pain. However, definitive conclusions regarding the effectiveness and safety of
dry cupping for musculoskeletal pain and range of motion were unable to be made due to the low-
moderate quality of evidence. Further high-quality trials with larger sample sizes, long-term follow
up, and reporting of adverse events are warranted.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction
Musculoskeletal pain is highly prevalent and a significant
contributor to global disability and disease, with most countries
reporting neck and low back pain as a leading cause of disability
(Vos et al., 2017). Improving function and controlling pain are key
aims for the treatment of musculoskeletal pain, which typically
consists of a combination of physical therapy, self-management and
short-term analgesic medication (Babatunde et al., 2017). The
application of dry cupping therapy for reducing musculoskeletal
pain and improving mobility has become an increasingly frequent
practice among manual and physical therapists in western clinical
* Corresponding author.
E-mail address: sarah.wood@live.vu.edu.au (S. Wood).
practice (Rozenfeld and Kalichman, 2016). Dry cupping involves the
use of glass, plastic or bamboo cups that are placed over localised
areas of skin. A vacuum suction is achieved with heat from a flame,
a manual handheld pump or electrical pumping devices to create a
negative pressure, drawing localised skin and soft tissue structures
into the cup (Rozenfeld and Kalichman, 2016; Tham et al., 2006).
Depending on geographical region and culture, there are variations
in nomenclature to describe the numerous cupping approaches (Al
Bedah et al., 2016). Wet cupping is the most commonly docu-
mented application of cupping described in traditional medical
literature; whereby superficial skin incisions are made using a
surgical instrument to promote blood-letting (Al Bedah et al., 2016;
Farhadi et al., 2009). In contrast, dry cupping does not involve in-
cisions or penetrate the skin barrier.
Recent systematic reviews have investigated the use of cupping
in musculoskeletal pain conditions (Azizhani et al., 2018 Kim et al.,

https://doi.org/10.1016/j.jbmt.2020.06.024
1360-8592/© 2020 Elsevier Ltd. All rights reserved.
504 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518
2018). However, there remains an absence of reviews specifically
examining the use of dry cupping for the treatment of musculo-
skeletal pain and range of motion. Therefore, this study aims to
critically evaluate the evidence from randomised controlled trials
(RCTs) to determine the efficacy and safety of western dry cupping
methods for the treatment of musculoskeletal pain and range of
motion.
2. Methods
The protocol for this systematic review was registered on
PROSPERO (Registration Number: CRD42018088855). The protocol
for this review followed the Preferred Reporting Items for Sys-
tematic Reviews and Meta-analyses (PRISMA).
2.1. Criteria for considering trials for the current review
2.1.1. Types of trials
Randomised controlled trial (RCTs) pertaining to the effects of
dry cupping therapy for musculoskeletal pain and range of motion
were included.
2.1.2. Types of participants
Participants were limited to adults (18 years and older) that
received dry cupping treatment for musculoskeletal pain or re-
striction in range of motion. There were no restrictions to duration
of pain period.
2.1.3. Types of intervention
Treatment was limited to dry cupping therapy for a musculo-
skeletal condition as the sole intervention or combined with
another modality. Any other form of cupping (e.g., wet cupping)
was excluded.
2.1.4. Types of comparison
Western medicine, sham cupping treatment or cross over
intervention used as a control were included. Trials were excluded
if the comparison was not relevant to Western Medicine.
2.2. Included outcome measures
2.2.1. Primary outcomes
The primary outcomes were pain and functional status. Pain was
measured by visual analogue scale (VAS), numerical rating scale
(NRS), Short Form McGill Pain Questionnaire (SMPQ) and pain
pressure thresholds (PPT). Functional status was measured by
validated self-reported functional ability questionnaires, SF-36,
neck disability index, Roland-Morris Disability Questionnaire,
Oswestry Disability Index and WOMAC.
2.2.2. Secondary outcomes
Secondary outcomes were range of motion and adverse events.
Range of motion was measured by goniometer, inclinometer or
digital software. Any adverse events reported for each trial were
recorded.
2.3. Literature searches
The following databases were searched from their inception
until April 2018: Cochrane Central Register of Controlled Trials,
EBSCO Host, PEDro, ProQuest, PubMed, Science Direct and Scopus.
In addition, a manual search for citation references in relevant
literature was applied. Search strategies are outlined in Appendix A.
2.4. Trial selection
Only RCTs relating to the effects of dry cupping therapy and
published in the English language were included in the systematic
review. Trials published in the form of dissertations or grey litera-
ture were included. A flowchart depicting the trial selection process
using the preferred reporting items for systematic review and
meta-analysis (PRISMA) is shown in Fig. 1.
2.5. Data extraction
Author SW independently extracted data from the included
trials using a Cochrane Collaboration standardised data extraction
form LT verified the extracted data.
2.6. Assessment of heterogeneity
Assessment of heterogeneity was based on the calculation of I2.
The Cochrane Collaboration provides the following interpretation
of I2: 0%e30%, might not be important; 30%e60%, may represent
moderate heterogeneity; 50%e75%, may represent substantial
heterogeneity; and 75%e100%, considerable heterogeneity
(Higgins and Green, 2011).
2.7. Assessment of risk of bias and methodological quality
The Downs & Black (D&B) quality assessment scale was applied
to evaluate the methodological quality of the included trials
(Downs and Black, 1998). SW and CC completed an independent
evaluation of the included trials; disagreement and discrepancies
between author evaluations were resolved through discussion or
by consulting a third review author, GF. The D&B assessment scale
is a validated risk of bias tool and has been found to have good
inter-rater reliability (Downs and Black, 1998). The modified D&B
assessment scale provides individual scores for each section and an
overall numeric rating, out of a possible 28-points. The following
score ranges were given to corresponding quality levels: excellent
(26e28), good (20e25), fair (15e19), and poor (14).
2.8. Data analysis
A quantitative meta-analysis of the included trials was conducted
using RevMan 5.3 software (RevMan, Version 5.3., Cochrane Centre).
For binary outcomes, data were summarised using risk ratios (RR)
with 95% CI, and for continuous outcomes, data were summarised
using mean difference (MD) or standard mean difference (SMD) with
95% CI. When heterogeneity I2 statistic was less than 25% a fixed-effect
model was applied, greater than 25%, a random-effects model was
applied (Higgins and Green, 2011). Scores for outcome measures, such
as visual analogue scale were converted to a 100-point scale.
2.9. Assessment of clinical relevance
Assessment of clinical relevance was made using the recom-
mendations of the Cochrane Back Review Group, defined as follow:
small effect as MD less than 10% of the scale (e.g., 10 mm on a
100 mm VAS) and SMD or 'd' scores less than 0.5. Medium effect as
MD 10%e20% of the scale and SMD or 'd' scores from 0.5 to 0.8.
Large effect as MD greater than 20% of the scale and SMD or 'd'
scores greater than 0.8 (Furlan et al., 2009).
2.10. Quality of evidence
The overall quality of evidence for each outcome was assessed
using the Grading of Recommendations, Assessment, Development
 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518 505

Fig. 1. Flowchart of study selection depicted by preferred reporting items for systematic review and meta-analysis (PRISMA). Abbreviations: RCT, randomised controlled trial; MSK,
musculoskeletal; TCM, Traditional Chinese Medicine.

and Evaluation (GRADE) approach. Quality of evidence is specified
as high, moderate, low and very low. Key factors are (1) limitations
in study design, (2) inconsistency of results, (3) indirectness or
generalisation of findings, (4) imprecision, and (5) other (such as
publication bias). Depending on the quality of evidence evaluated,
levels of evidence can be downgraded to moderate, low, or even
very low (Ryan and Hill, 2016).
3. Results
3.1. Included trials
The literature search identified 262 trials (Fig. 1). Duplicates
were removed, and 232 trials remained for title and abstract
screening. A total of 21 RCTs including 1049 participants met the
inclusion criteria. Significant characteristics of the included trials
are summarised in Table 1. Sample sizes varied from 14 to 141, with
a median of 40 participants. Of the 21 included trials, 7 trials
originated from Germany, 6 from the United States, 2 from both
India and Korea, and 1 each from Turkey, Taiwan, Iran and Egypt.
The treated musculoskeletal conditions were neck pain (Arslan
et al., 2015; Chi et al., 2016; Cramer et al., 2011; Lauche et al 2011,
2013; Saha et al., 2017; Yim et al., 2017); low back pain (Akbarzadeh
et al., 2014; El Rahim et al., 2017; Singh et al., 2016); knee osteo-
arthritis (Khan et al., 2013; Teut et al., 2012); plantar fasciitis (Ge
et al., 2017); and fibromyalgia (Lauche et al., 2016). Numerous tri-
als investigated the use of dry cupping for increasing range of
motion for the hamstring muscle (Barger, 2016; Kim et al., 2017;
LaCross, 2014), iliotibial band (Biehl, 2017; Doozan, 2015) and
shoulder (Smith, 2015). The number of treatment sessions ranged
Table 1

506
Overview of included clinical trials.

Study ID, year Aim Sample Participants a. Intervention b. Control Treatment Total Follow Outcome Measurement Authors conclusions D&B
and country size/ (a. duration No. of up measures times score
drop Intervention; sessions
outs b. Control

Akbarzadeh To investigate the effect of dry 100/0 Condition: Dry cupping (fire Routine care 4 days 4 2 VAS (cm), Baseline: “The study results showed Good
et al. (2014) cupping therapy at BL23 point on low back pain cupping): and referral to weeks SMPQ before cupping therapy to be effective quality
Iran the intensity of low back pain in post labour Performed on the lumbar specialist in intervention in sedation of pain. Thus, it can 21/28
primiparous women Gender erector spinae muscle case of severe Post: after be used as an effective
(female): (BL23) for 15e20 min pain intervention, treatment for reducing the low
a: 50; b: 50 every day at 2-week back pain”
Mean age follow up
(SD):
a: 25.0 (4.2)
b: 27.0 (3.8)
“Cupping therapy is a non-

S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

Arslan et al. To investigate the effectiveness of 40/0 Condition: Dry moving cupping Unclear 5 weeks 10 Nil VAS Baseline: Poor
(2015) active dry cupping of the upper upper (vacuum cupping): before invasive and harmless quality
Turkey shoulder and neck to alleviate shoulder and Performed twice weekly intervention therapeutic application, and it 11/28
pain neck pain 30 min cupping session to Post: after can be confidently used to
Gender upper shoulders and neck intervention reduce upper shoulder and
(female) neck pain …”
a: 20; b: 20
Mean age
(SD):
Not reported
Barger (2016) To examine the effects of 20/0 Condition: Dry cupping (vacuum Graston Single 1 Nil ROM, Baseline: “The results of this study Poor
United States compressive or decompressive hamstring cupping): Technique for Session Muscle before suggest that both GT and MFD quality
(thesis soft tissue techniques on flexibility 6 stationary cups over the 4 min Strength, intervention are effective therapies for 14/28
publication) hamstring flexibility, strength, Gender hamstrings for 3 min, PFAQ, GROC Post: after improving hamstring flexibility
and perceived function (male): 1 min of moving cupping intervention and strength and decreasing
a: 10; b: 10 pain immediately following the
Mean age therapy”
(SD)
21.35 (1.76)
Biehl (2017) To determine if dry cupping is an 40/0 Condition: Dry cupping (vacuum Sham cupping Single 1 24 h AROM, Baseline: “… This study supports the Fair
United States effective treatment intervention ITB flexibility cupping): session PROM before assumption that dry cupping quality
(thesis in releasing ITB tightness and Gender 4 stationary cups placed intervention may be a safe and effective 15/28
publication) increasing hip and knee range of (male/ along the ITB for 7 min Post: after treatment option to combat ITB
motion in a physically active female): 17/ intervention, tightness seen by clinicians.”
population. 23 at 24 h follow
Mean age up
(SD):
21 (1.8)
Chi et al. To investigate the effectiveness of 60/0 Condition: Dry cupping (fire Rest for 20 min Single 1 Nil VAS, SST, BP Baseline: “One treatment of cupping Good
(2016) cupping therapy in changes of chronic neck cupping): session before therapy is shown to increase quality
Taiwan skin surface temperature for and shoulder Cups placed on 3 intervention SST and reduce systemic blood 23/28
relieving chronic neck and pain acupoints for 10 min Post: after pressure. Cupping therapy
shoulder pain Gender before repeating on intervention mimics an analgesic effect
(male/ opposite side which has no known negative
female) side effects and may be
a: 3/27; b: 2/ considered safe”
28
Mean age
(SD):
a: 43.6 (8.0)
b: 42.5 (7.4)
To investigate the effect of 50/2 Condition: Dry cupping (pneumatic Usual care 14 days 5 18 days Baseline: “Pneumatic pulsation therapy
pneumatic pulsation therapy on chronic neck pulsatile cupping): before appears to be a safe and
Cramer et al. chronic neck pain compared to pain Glass cupping massage VAS, NDI, intervention effective method to relieve pain Good
(2011) standard medical care Gender over neck and shoulders PPT, MDT, Post: after and to improve function and quality
Germany (male/ for 10e15min with a VDT, SF-36 intervention quality of life in patients with 24/28
female) mechanical device, chronic neck pain”
a: 4/20; b: 6/ followed with 4 stationary
18 cups applied to the
Mean age trapezius muscle for 5
(SD): e10min
a: 44.46
(10.79)
b: 47.88
(13.50)
Doozan (2015) To evaluate the effectiveness of 32/3 Condition: Dry cupping (vacuum Non-treatment 6 weeks 6 2 ROM Baseline: “The study results showed Poor
United States Chinese cupping in increasing ITB flexibility cupping): leg used as weeks before Chinese cupping is beneficial as quality
(thesis iliotibial band range of motion Gender a1: 8 cups over ITB left for control intervention a short term and a possible 11/28
publication) (male) 5e10min þ stationary During: 2 long-term therapeutic
a1: 10; a2: 9; bike for 10 min. weeks, 4 technique that can be used to

S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

a3: 10 a2: Cupping for weeks increase ROM in athletes”
Mean age 10 min þ stretch protocol. Post: after
(SD): a3: 10 min stationary intervention,
a1: 20.6 (1.3) bike þ stretch protocol at 2 weeks
a2: 19.9 (1.2) follow up
a3: 20.3 (1.2)
El Rahim et al. To investigate the effect of 60/0 Condition: Dry cupping (fire 30 min of 4 weeks 12 Nil ROM, SMPQ, Baseline: “Cupping therapy and Good
(2017) cupping therapy with inferential mechanical cupping): traditional RMDQ before interferential therapy in quality
Egypt therapy on mechanical low back LBP a1: Cupping physical intervention addition to traditional physical 20/28
pain Gender therapy þ physical therapy Post: after therapy can be used as an
(male/ therapy intervention effective treatment in patients
female) a2: Cupping with mechanical low back
a1: 10/10 therapy þ interferential pain”
a2: 10/10 therapy for
b: 10/10 30min þ physical therapy
Mean age
(SD):
a1: 27.35
(4.23)
a2: 28.8
(4.57)
b: 27.3 (4.32)
Ge et al. (2017) To determine the effects of dry 29/0 Condition: Dry cupping (vacuum 10 min of 4 weeks 8 Nil VAS, FAAM, Baseline: “The results support that both Fair
United States cupping on pain and function plantar cupping): interferential LEFS, PPT before dry cupping therapy and quality
with plantar fasciitis fasciitis Cupping applied to the therapy intervention electrical stimulation therapy 16/28
Gender most painful site for During: at could reduce pain and increase
(male/ 10 min each session function in the population
female) Post: after tested”
a: 4/10; b: 10/ intervention
5
Mean age
(SD):
a: 40.1 (14.6)
b: 39.3 (13.5)
Khan et al. To evaluate the effect of cupping 62/22 Condition: Dry cupping (fire Medication 15 days 11 Nil Grading Baseline: “The study proved cupping to Fair
(2013) therapy in a clinical setting for knee OA cupping): Acetaminophen scales (pain, before be a good analgesic and anti- quality
India knee osteoarthritis Gender Stationary cups applied stiffness, intervention inflammatory with efficacy 17/28
(male/ around the knee for crepitus, Post: after better than acetaminophen.
female) 15 min oedema, intervention Thus, cupping can be
a: 6/14; b: 8/ movement, recommended for other painful
12 tenderness) conditions besides being a line
Mean age of treatment for osteoarthritis”

507
(continued on next page)
Table 1 (continued )

508
Study ID, year Aim Sample Participants a. Intervention b. Control Treatment Total Follow Outcome Measurement Authors conclusions D&B
and country size/ (a. duration No. of up measures times score
drop Intervention; sessions
outs b. Control

(SD)
Unable to
determine
Kim et al. To measure the effects of cupping 30/0 Condition: Dry cupping (fire Passive stretch Single 1 Nil ROM, PPT, Baseline: “It was evident from findings of Fair
(2017) on flexibility, muscle activity, and hamstring cupping): to the session EMG before this study that cupping therapy quality
Korea pain threshold of the hamstring flexibility Cups applied to the hamstring intervention has as much positive effect on 19/28
muscle compared to passive Gender hamstring muscle for muscle and Post: after flexibility, pain threshold, and
stretching in healthy subjects (male/ 5 min held for 10 s x 9 intervention muscle contraction as passive
female) reps stretching”
a:12/3
Mean age

S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

(SD)
30.10 (5.52)
LaCross (2014) To examine the effectiveness of 17/0 Condition: Dry cupping (vacuum Heat pack for Single 1 Nil ROM, PFAQ, Baseline: “Results of this study suggest Fair
United States MFD and moist heat pack with hamstring cupping): 10min þ foam session GROC before that either treatment may be quality
(thesis foam roller on hamstring pathology Cups applied to roll intervention beneficial for ROM increases in 17/28
publication) pathology Gender hamstrings þ active Post: after patients with hamstring
(male/ movement protocol with intervention injuries”
female) cups in place
a: 8/1; b:5/3
Mean age
(SD)
Unable to
determine
Lauche et al. To determine whether a series of 50/4 Condition: Dry cupping (fire Wait list 2 weeks 5 18 days VAS, NDI, Baseline: “A series of five dry cupping Good
(2011) cupping treatments effectively non-specific cupping): PD, SF-36, before treatments appeared to be quality
Germany relieves chronic non-specific neck neck pain Cups retained on affected PPT, MDT, intervention effective in relieving chronic 24/28
pain Gender areas for 10e20 min every VDT During: at non-specific neck pain. Not
(male/ 3e4 days each session only subjective measures
female) Post: after improved, but also mechanical
a: 7/15; b: 4/ intervention pain sensitivity differed
20 significantly between the two
Mean age groups, suggesting that
(SD) cupping has an influence on
a: 48.6 (1.2) functional pain processing”
b: 53.0 (11.4)
Lauche et al. This study aimed to test the 61/7 Condition: Dry cupping: Progressive 12 weeks 24 Nil VAS, NDI, Baseline: “… cupping massage is no more Good
(2013) efficacy of 12 weeks of a partner- non-specific Cupping massage twice muscle PD, SF-36, before effective than progressive quality
Germany delivered home-based cupping neck pain weekly for 10e15 min relaxation PPT, HADS, intervention muscle [relaxation] in reducing 23/28
massage, compared to the same Gender FEW-16, Post: after chronic non-specific neck pain.
period of progressive muscle (male/ PSQ-20, intervention Both therapies can be easily
relaxation in patients with female) patient used at home and can reduce
chronic non-specific neck pain. a: 16/45; b: 6/ expectations pain to a minimal clinically
24 relevant extent.”
Mean age
(SD)
a: 54.16
(12.7)
b: 54.5 (12.3)
Lauche et al. This study aimed to investigate 141/48 Condition: Dry cupping (pneumatic b1: Sham 18 days 5 6 VAS, FIQ, SF- Baseline: “Five cupping treatments were Excellent
(2016) the efficacy of cupping therapy fibromyalgia pulsatile cupping): cupping months 36, PPT, before more effective than usual care quality
Germany compared to usual care and a Gender 4-8 cups retained on b2: usual care MFI-20, intervention to improve pain intensity and 26/28
sham procedure to improve (male/ trapezius, levator scapula, PSQI, PPT, Post: after quality of life in patients
symptoms and quality of life in female) latissimus dorsi, or Blinding intervention, diagnosed with the
 patients diagnosed with a: 1/46 gluteus maximus for success, at 6-month fibromyalgia syndrome. Given
fibromyalgia syndrome. b: 1/47 30 min, twice weekly satisfaction, follow up that effects were small, and
b2: 0/46 safety cupping was not superior to
Mean age sham cupping treatments
(SD) currently no recommendation
a:54.35 (10.6) for cupping in the treatment of
b1: 56.3 (8.7) fibromyalgia can be made.”
b2: 56.8 (7.7)
Saha et al. To test the efficacy of cupping 50/5 Condition: Dry cupping (vacuum Usual care 2 weeks 5 3 VAS, NDI, Baseline: “Cupping massage appears to Good
(2017) massage in patients with chronic chronic neck cupping): weeks SF-36, PPT, before be effective in reducing pain quality
Germany non-specific neck pain pain Cupping massage twice MVD, VDT intervention and increasing function and 25/28
Gender weekly for 10 min Post: at 3- quality of life in patients with
(male/ week follow chronic non-specific neck pain”
female) up
a: 4/21; b 0/
25
Mean age

S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

(SD)
a: 54.3 (8.6)
b: 53.3 (11.1)
Singh et al. Clinical evaluation of Hijamat Bila 40/12 Condition: Dry cupping (vacuum Diclofenac 15 days 6 Nil VAS Baseline: “The result was clinically Poor
(2016) Shurt (Dry cupping) in the low back pain cupping): sodium 50 mg before significant in both therapies, quality
India management of Waja ul zahar Gender Cupping over lumbosacral orally twice a intervention but hijamat bila shurt was more 8/28
(Low Back Pain) (male/ region for 20min day During: at effective in comparison to
female) each session diclofenac sodium.”
4:1 ratio Post: after
Mean age intervention
(SD)
20 (60)
Smith (2015) To assess the effectiveness of MFD 30/0 Condition: Dry cupping (vacuum Rest for 7 min Single 1 Nil ROM, Baseline: “Due to lack of statistical Poor
United States on shoulder ROM and strength in shoulder cupping): session strength before significance in all variables quality
(thesis healthy overhead athletes ROM IASTM þ cupping to intervention except [external rotation] ROM, 13/28
publication) Gender rotator cuff þ active Post: after this study demonstrates little
(male/ movement protocol with intervention to no clinical relevance to the
female) cups in place for a total of use of MFD for the purpose of
15/15 10e15 min increase immediate shoulder
Mean age ROM and strength”
(SD)
22.5 (2.21)
Teut et al. To investigate the effectiveness of 40/0 Condition: Dry cupping (pneumatic No intervention 4 weeks 8 12 WOMAC, Baseline: “Dry cupping with a pulsatile Good
(2012) cupping in relieving the knee OA pulsatile cupping): weeks VAS, SF-36 before cupping device relieved quality
Germany symptoms of knee osteoarthritis Gender Silicone dry cupping via intervention symptoms of knee OA 24/28
(male/ mechanical cupping Post: after compared to no intervention”
female) device over low back and intervention,
a: 5/16; b 8/ knee joint for 10 min at 12-week
11 follow up
Mean age
(SD)
a: 68.1 (7.2)
b: 69.3 (6.8)
Teut et al. “The aim of our study was to 110/0 Condition: Dry cupping (pneumatic Medication 4 weeks 8 12 VAS, SF-36 Baseline: “Both forms of cupping were Excellent
(2018) investigate the effectiveness of chronic LBP pulsatile cupping): paracetamol weeks before effective in cLBP without quality
Germany dry pulsatile cupping in reducing Gender Silicone dry cupping via 4  500mg/day intervention showing significant differences 26/28
pain and improving back function (male/ mechanical cupping Post: after in direct comparison after four
and quality of life in patients with female) device over low back for intervention, weeks, only pulsatile cupping
nonspecific cLBP” a1: 43.2/16 8 min, twice weekly at 12-week showed effects compared to
a2: 36.1/13 a: 150e350 mbar follow up control after 12 weeks.”
b: 32.4/12 a2: 70 mbar (minimal
Mean age cupping)

509
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 510 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

from 1 to 24, with a duration of 4e30 min per session. There was

detection threshold; MFD Myofascial Decompression; MFI-20 The Multidimensional Fatigue Inventory; NDI Neck Disability Index; OA Osteoarthritis; PFAQ Perceived functional ability scale; PSQ-20 Perceived Stress Ques-
rating of change scale; GT Graston Technique; HADS Hospital Anxiety and Depression Scale, IASTM Instrument-assisted soft tissue mobilisation; LBP Low back pain; LEFS Lower Extremity Functional Scale; MDT Mechanical
Abbreviations: AKE Active Knee Extension Test; cLBP Chronic Low Back Pain; FAAM Foot and Ankle Ability Measure; FEW-16 (German) Assessment of Physical Wellbeing; FIQ Fibromyalgia Impact Questionnaire; GROC Global

tionnaire; Pain pressure threshold; PSQI Pittsburgh Sleep Quality Inventory; RMDQ Rowland Morris Disability Questionnaire; ROM Range of motion; SD Standard Deviation; SF-36 36-Item Short Form Survey; SST Skin surface
variation in dry cupping methods implemented, including vacuum

effective in improving the ROM quality

of the cervical spine and pain 14/28
cupping, fire cupping, stationary or static cupping, moving cupping,
score

“… Cupping treatment is more Poor

D&B

and myofascial decompression with active movements.

McKenzie stretching method

thresholds compared to the
3.2. Excluded trials
Measurement Authors conclusions

A total of 232 titles and abstracts were screened for eligibility.

Seventy-eight trials did not include RCT methodology; 21 used wet
cupping application; 30 were not related to a musculoskeletal
condition; 24 trials were not relevant; 33 trials pertained to
Traditional Chinese Medicine (TCM) theory; 19 were not published
…”

in the English language, and 1 trial was unable to be accessed.

Twenty-six articles were accessed in full, with a further 5 trials
intervention

intervention

excluded; 3 did not include RCT methodology, 1 was unable to be

Post: after
Baseline:

accessed in full, and 1 used wet cupping application.

before
times

3.3. Risk of bias and methodological quality

ROM, PPT
measures
Follow Outcome

Methodological quality of the trials ranged from excellent to fair.

Overall, the quality of evidence was found to be fair, with a mean
D&B score of 18/28. Two trials from Germany were rated excellent
quality with a D&B score of 26/28 and were found to have low
temperature; VAS Visual analogue scale; VDT Vibration detection threshold; WOMAC Western Ontario McMasters University Osteoarthritis Index.
Nil
up

internal bias (Lauche et al., 2016; Teut et al., 2018). Seven trials were
sessions

rated as being good, with scores ranging from 20 to 25 (Akbarzadeh

No. of
Treatment Total

et al., 2014; Chi et al., 2016; Cramer et al., 2011; Lauche et al 2011,
1

2013; Saha et al., 2017; Teut et al., 2012). Six trials were rated fair,
with a score ranging from 15 to 19 (Biehl, 2017; El Rahim et al.,
duration

stretch protocol session

2017; Ge et al., 2017; Khan et al., 2013; Kim et al., 2017; LaCross,
Single

2014). Six trials were rated poor quality, with high internal bias
and scores ranging from 8 to 14 (Arslan et al., 2015; Barger, 2016;
Doozan, 2015; Singh et al., 2016; Smith, 2015; Yim et al., 2017).
McKenzie's
b. Control

Cupping applied to upper for 8 min

Blinding of both the participant and outcome assessors was only

carried out by 2 trials (Biehl, 2017; Lauche et al., 2016); 2 trials
attempted to blind the participants only (Teut et al., 2018; Yim et al.,
2017) and 2 trials attempted to blind the outcome assessors (Kim
scapulae muscle to 8 min

et al., 2017; Lauche et al., 2013). All 21 trials were RCTs; however,
Dry cupping (vacuum

trapezius & levator

only 11 of the trials described adequate randomisation techniques

and only 8 of the 21 trials sufficiently concealed randomised
Participants a. Intervention

intervention assignment. Inadequate reporting of the random

cupping):

variability in the data were observed in 10 of the trials, with failure

to report confidence intervals for normally distributed data or
interquartile ranges for non-normally distributed data.
b: 50.7 (10.7)
a1: 49.0 (3.7)
Intervention;

Meta-analysis results are depicted in the forest plots (Figs. 2e10)

22.66 (2.98)
Neck ROM
Condition:
b. Control

Mean age

and GRADE summaries are presented in Tables 2e7. All results are
a2: 47.5

female)
Gender
(male/

based on the short-term effects of dry cupping (<3 months).

(13.8)

12/6
(SD)

(SD)
(a.

3.4. Dry cupping therapy for chronic non-specific neck pain

Sample

drop
size/

“… to investigate the differences 18/0

outs

3.4.1. Effects of dry cupping vs. no treatment on pain for non-

the cervical vertebrae by applying
in the angle of the cervical spine

specific neck pain

and the pain thresholds around

the McKenzie exercise and the

Five trials including 239 participants were analysed for the ef-
fect of dry cupping for pain relief in chronic non-specific neck pain
(Arslan et al., 2015; Chi et al., 2016; Cramer et al., 2011; Lauche et al.,
2011; Saha et al., 2017). The 5 trials compared cupping therapy to
cupping therapy.”

no intervention (Arslan et al., 2015; Chi et al., 2016), standard

medical care (Cramer et al., 2011), wait-list (Lauche et al., 2013), and
usual care (Saha et al., 2017). All 5 trials reported a statistically
significant effect on reducing pain, in favour of dry cupping. Meta-
Aim
Table 1 (continued )

analysis of the 5 trials (Fig. 2) revealed a statistically significant

effect on pain relief in favour of dry cupping, with a MD of
21.67
Study ID, year
and country

(95% CI,
36.55,
6.80; I2 ¼ 94%) and a large effect was observed
Yim et al.
(2017)

with a SMD of
1.04 (95% CI,
1.79,
0.28). Heterogeneity was

Korea

considerable between the 5 trials; omission of the outlying trial by

Chi et al. (2016) reduced heterogeneity and resulted in a MD
 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518
of
12.40 (95% CI,
15.99,
8.81; I2 ¼ 0%). For chronic neck pain,
there was low-quality evidence (downgraded due to inconsistency
and imprecision) that dry cupping had a significant effect on pain
relief (Table 2).
3.4.2. Effects of dry cupping vs. no treatment on functional status
for non-specific neck pain
Four trials including 191 participants were analysed for the ef-
fect of dry cupping on functional status in non-specific neck pain,
measured by the neck disability index. All 4 trials reported a sig-
nificant effect on disability, in favour of dry cupping Cramer et al.,
(2011); Lauche et al., (2011); Lauche et al., (2013); Saha et al.,
(2017). Meta-analysis of the 4 trials (Fig. 3) displayed a statisti-
cally significant effect on functional status in favour of dry cupping,
with a MD of
4.65 (95%CI,
6.44,
2.85; I2 ¼ 14%); though, only a
medium effect was observed (SMD,
0.77; 95%CI,
1.07,
0.48). For
functional status in chronic neck pain, there was moderate-quality
evidence (downgraded due to imprecision) that dry cupping had a
significant effect (Table 2).
3.4.3. Effects of dry cupping vs. no treatment on pressure pain
sensitivity for non-specific neck pain
Four trials including 191 participants were analysed for the ef-
fect of dry cupping on pressure pain sensitivity in non-specific neck
pain, measured by pressure algometry. All 4 trials reported a sig-
nificant effect on pressure pain thresholds, in favour of dry cupping
(Cramer et al., 2011; Lauche et al 2011, 2013; Saha et al., 2017).
Meta-analysis of the 4 trials (Fig. 4) displayed a statistically sig-
nificant effect on pressure pain thresholds in favour of dry cupping,
with a SMD of
0.40 (95%CI,
0.69,
0.11; I2 ¼ 0%); however, only a
small effect was observed. For pressure pain sensitivity in chronic
neck pain, there was moderate-quality evidence (downgraded due
to imprecision) that dry cupping had a significant effect (Table 2).
3.5. Dry cupping therapy for low back pain
3.5.1. Effects of dry cupping vs. comparative or control group on low
back pain
Two trials including 196 participants were analysed for the ef-
fect of dry cupping for pain relief in non-specific low back pain
(Akbarzadeh et al., 2014; Teut et al., 2018). The trials compared
cupping therapy to routine care (Akbarzadeh et al., 2014), minimal
cupping (low vacuum suction) and medication (Teut et al., 2018).
Both trials reported a significant effect on pain, in favour of dry
cupping. Meta-analysis of the trials (Fig. 5) displayed a statistically
significant effect on pain relief in favour of dry cupping, with a MD
of
19.38 (95%CI,
28.09,
10.66) and a large effect was found with
a SMD of
1.08 (95%CI,
2.04,
0.12). Moderate heterogeneity was
observed between the two trials, I2 ¼ 59%. The mean difference
of
19.38 mm on the VAS was found to exceed the clinically
important range of 15 mm (Ostelo et al., 2008). For low back pain,
there was low-quality evidence (downgraded due to inconsistency
Fig. 2. Effects of dry cupping vs. no treatment on pain for non-specific neck pain (Outcome Measure: Visual Analogue Scale 100 mm).
511
and imprecision) that dry cupping had a significant effect on pain
relief (Table 3).
3.5.2. Effects of dry cupping vs. comparative or control group on
low back pain
Two trials including 160 participants were analysed for the ef-
fect of dry cupping for pain relief in non-specific low back pain
(Akbarzadeh et al., 2014; El Rahim et al., 2017). The trials compared
cupping therapy to routine care (Akbarzadeh et al., 2014), inter-
ferential therapy and traditional physical therapy (El Rahim et al.,
2017). Both trials reported a significant effect on pain, in favour of
dry cupping. Meta-analysis of the trials (Fig. 6) displayed a statis-
tically significant effect on pain relief in favour of dry cupping, with
a MD of
11.20 (95%CI,
13.76,
8.64) and a large effect was found
with a SMD of
2.60 (95%CI,
3.48,
1.72); however, considerable
heterogeneity was observed between the two trials, I2 ¼ 76%. For
low back pain, there was low-quality evidence (downgraded due to
inconsistency and imprecision) that dry cupping had a significant
effect on pain relief (Table 3).
3.5.3. Effects of dry cupping therapy on pressure pain sensitivity
3.5.3.1. Effects of dry cupping on pressure pain sensitivity in partic-
ipants with symptomatic musculoskeletal conditions. Six trials
including 306 participants were analysed for the effect of dry
cupping on pressure pain sensitivity in symptomatic participants,
measured by pressure algometry. The 6 trials used dry cupping
therapy for the treatment of chronic neck pain (Cramer et al., 2011;
Lauche et al 2011, 2013; Saha et al., 2017), plantar fasciitis (Ge et al.,
2017) and fibromyalgia (Lauche et al., 2016). Meta-analysis of the 6
trials (Fig. 7) displayed a statistically significant effect on pressure
pain thresholds in favour of dry cupping, with a SMD of
0.40 (95%
CI,
0.63,
0.17; I2 ¼ 0%); however, only a small effect was
observed. For pressure pain sensitivity in symptomatic participants,
there was moderate-quality evidence (downgraded due to impre-
cision) that dry cupping had a significant effect (Table 4).
3.5.3.2. Effects of dry cupping on pressure pain sensitivity in partic-
ipants without symptomatic musculoskeletal conditions (healthy
controls). Two trials including 66 participants were analysed for
the effect of dry cupping on pressure pain sensitivity in asymp-
tomatic participants, measured by pressure algometry. The 2 trials
compared dry cupping therapy to passive stretching (Kim et al.,
2017) and active stretching (Yim et al., 2017). Meta-analysis of the
2 trials (Fig. 8) displayed a statistically significant effect on pressure
pain thresholds in favour of dry cupping, with a SMD of
0.63 (95%
CI,
1.13,
0.14; I2 ¼ 0%); however, only a medium effect was
observed. For pressure pain sensitivity in asymptomatic partici-
pants, there was low-quality evidence (downgraded due to limi-
tations and imprecision) that dry cupping had a significant effect
(Table 5).
512 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

Fig. 3. Effects of dry cupping vs. no treatment on functional status for non-specific neck pain (Outcome Measure: Neck Disability Index).

Fig. 4. Effects of dry cupping vs. no treatment on pressure pain sensitivity for non-specific neck pain (Outcome measure: Pressure Pain Threshold).

Fig. 5. Effects of dry cupping vs. comparative or control group on low back pain (Outcome Measure: Visual Analogue Scale 100 mm).

Fig. 6. Effects of dry cupping vs. comparative or control group on low back pain (Outcome Measure: Short Form McGill Pain Questionnaire).

Fig. 7. Effects of dry cupping on pressure pain sensitivity in symptomatic participants (Outcome Measure: Pressure Pain Threshold).

3.6. Effects of dry cupping on range of motion
3.6.1. Dry cupping vs. active control
Three trials including 126 participants were analysed for the
effect of dry cupping on range of motion, measured by active range
of motion using a goniometer. The 3 trials compared dry cupping
therapy to an active control group, including interferential therapy
and traditional physical therapy (El Rahim et al., 2017), passive
stretching (Kim et al., 2017) and active stretching (Yim et al., 2017).
Meta-analysis of the 3 trials (Fig. 9) displayed no significant effect
on range of motion with a SMD of
1.13 (95%CI,
2.57, þ0.31), with
considerable heterogeneity observed between the two trials,
I2 ¼ 92%. For range of motion, there was very low-quality evidence
(downgraded due to limitations, inconsistency and imprecision)
that dry cupping had no significant effect (Table 6).
 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518 513

Fig. 8. Effects of dry cupping on pressure pain sensitivity in asymptomatic participants (Outcome Measure: Pressure Pain Threshold).

Fig. 9. Dry cupping vs. active control (Outcome Measure: Range of Motion).

Fig. 10. Dry cupping vs. no treatment (Outcome Measure: Range of Motion).

Table 2
Dry cupping therapy vs. no intervention, standard care, wait-list and usual care for chronic non-specific neck pain.

No. of Quality assessment No. of patients Treatment Effect Quality of the evidence
studies (95%CI) (GRADE)
Limitations Inconsistency Indirectness Imprecision Other Intervention Control
considerations

Pain measured with: VAS from 0 to 100 (worse pain)

5 no serious seriousa no serious seriousb none 118 121 MD,
21.67 44OO
limitations indirectness [-36.55,
6.80] LOW
Functional status measured with: neck disability questionnaire
4 no serious no serious no serious seriousb none 93 98 MD -4.65 444O
limitations limitations limitations [-6.44,
2.85] MODERATE
Pressure pain sensitivity measured with: pressure algometry
4 No serious no serious no serious seriousb none 93 98 SMD -0.40 444O
limitations limitations limitations [-0.69,
0.11] MODERATE

Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a 2
I ¼ 94%.
b
Sample size<400.

3.6.2. Dry cupping vs. no treatment
Two trials including 88 participants were analysed for the effect
of dry cupping on range of motion, measured by active range of
motion using a goniometer. The 2 trials compared dry cupping
therapy to no treatment. Meta-analysis of the 2 trials (Fig. 10) dis-
played a statistically significant effect on range of motion with a
SMD of
0.75 (95%CI,
1.19,
0.32; I2 ¼ 0%; however, only a me-
dium effect was observed. For range of motion, there was low-
quality evidence (downgraded due to limitations and impreci-
sion) that dry cupping had a significant effect versus no treatment
(Table 7).
3.6.3. Adverse events
Of the 21 RCTs included in this review, an adverse event state-
ment was reported in 11 trials; the remaining 10 trials failed to
mention adverse events. Of the 11 trials that reported on adverse
events, 2 trials reported that no adverse events occurred during the
trial duration and 9 trials reported a total of 47 adverse events
occurred in the dry cupping group, with an overall relative risk ratio
of 1.88 (95%CI, 1.11, 3.20).All adverse events are summarised in
Table 8. Most symptoms were of mild to moderate severity,
resolving within 48-h, and included mild muscular soreness
(18.9%), increase in pain (13.79%), and an onset of a headache
(3.45%). Mild hematomas were also reported, as was blister for-
mation e often associated with fire cupping.
There were 2 serious adverse events reported in the dry cupping
group; however, both authors concluded was not a consequence of
the intervention (Lauche et al., 2013; Saha et al., 2017). Firstly,
Lauche et al. (2013) reported a participant was diagnosed with a
prolapsed intervertebral disc in the home-based cupping massage
514 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

Table 3
Dry cupping therapy vs. routine care, minimal cuppingd and medication for non-specific low back pain.

No. of Quality assessment No. of patients Treatment Effect Quality of the evidence
studies (95%CI) (GRADE)
Limitations Inconsistency Indirectness Imprecision Other Intervention Control
considerations

Pain measured with: VAS from 0 to 100 (worse pain)

2 no serious seriousa no serious seriousb None 115 81 MD -19.38 44OO

limitations limitations [-28.09,
10.66] LOW
Pain measured with: Short Form McGill Pain Questionnaire
4 no serious seriousc no serious seriousb none 90 70 MD -11.20 44OO
limitations limitations [-13.76,
8.64] LOW

Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a 2
I ¼ 59%.
b
Sample size<400.
c b
I ¼ 76%.
d
minimal cupping (low vacuum suction).

Table 4
Effects of dry cupping therapy on pressure pain sensitivity in symptomatic participants.

No. of Quality assessment No. of patients Treatment Effect Quality of the evidence
studies (95%CI) (GRADE)
Limitations Inconsistency Indirectness Imprecision Other Intervention Control
considerations

Pressure pain sensitivity measured with: pressure algometry

6 no serious no serious no serious seriousa none 155 151 SMD -0.40 444O
limitations limitations limitations [-0.63,
0.17] MODERATE

Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a
Sample size<400.

Table 5
Effects of dry cupping therapy on pressure pain sensitivity in asymptomatic participants.

No. of Quality assessment No. of patients Treatment Effect Quality of the evidence
studies (95%CI) (GRADE)
Limitations Inconsistency Indirectness Imprecision Other Intervention Control
considerations

Pressure pain sensitivity measured with: pressure algometry

2 seriousa no serious no serious seriousb none 33 33 SMD -0.63 44OO

limitations limitations [-1.13,
0.14] LOW

Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a
Serious risk of bias.
b
Sample size<400.

Table 6
Effects of dry cupping therapy vs. active control on range of motion.

No. of Quality assessment No. of patients Treatment Effect (95% Quality of the evidence
studies CI) (GRADE)
Limitations Inconsistency Indirectness Imprecision Other Intervention Control
considerations

Range of motion measured with: goniometer

3 seriousa seriousb no serious seriousc none 53 7b SMD -1.13 4OOO

limitations [-2.57, þ0.31] VERY LOW

Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a
Serious risk of bias.
b 2
I ¼ 92%.
c
Sample size<400.

group. Secondly, a participant from the Saha et al. (2017) trial was
diagnosed with a lipoma after the first cupping session that
required surgical removal. The authors concluded that it was un-
likely the cupping massage caused the lipoma, although, it may
have elicited the visibility. A case-study report is available; how-
ever, it is only available in German (Schumann et al., 2012). Overall,
the adverse events were mild to moderate, with 2 serious events e
not directly resulting from the dry cupping treatment.
4. Discussion
The purpose of this study was to evaluate the efficacy and safety
of dry cupping therapy for the treatment of musculoskeletal pain
and range of motion. To our knowledge, this review is the first
systematic review and meta-analysis specifically examining the
effects of dry cupping therapy for musculoskeletal pain and range
of motion.
 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518
Table 7
Effects of dry cupping therapy vs. no treatment on range of motion.
Quality assessment
No. of Limitations Inconsistency Indirectness Imprecision Other
studies
Range of motion measured with: goniometer
2 seriousa no serioua no serious seriousb
limitations limitations
Abbreviations: CI Confidence Interval, MD Mean Difference, SMD Standard Mean Difference, VAS Visual Analogue Scale.
a
Serious risk of bias.
b
Sample size<400.
Meta-analyses were conducted for 15 trials. When the included
trials were pooled and analysed, a significant large effect was
observed for dry cupping therapy on pain intensity in chronic neck
pain and non-specific low back pain. A significant medium effect
was found for dry cupping therapy on neck function. Despite the
significant effect, the quality of evidence to support the use of dry
cupping for chronic neck pain and low back pain was low-quality,
due to high heterogeneity and small sample sizes (<400 accord-
ing to the GRADE recommendations (Ryan and Hill, 2016)). The
analysis for chronic neck pain revealed high heterogeneity; when
an outlying trial (Chi et al., 2016) was omitted from the analysis,
heterogeneity was low. This trial reported high baseline VAS scores
with little to no improvement in the control group, resulting in a
large effect and variability in the meta-analysis data (Chi et al.,
2016). For changes in pressure pain sensitivity and functional sta-
tus, the quality of evidence was moderate, due to serious limita-
tions associated with small sample sizes. For pressure pain
sensitivity, there were different effects between symptomatic and
asymptomatic participants, with moderate-level evidence of a
small effect in symptomatic patients and low-level evidence of a
medium effect in asymptomatic participants. Most of the symp-
tomatic participants were diagnosed with chronic neck pain; when
a separate analysis was conducted for chronic neck pain only, a
similar small effect was observed.
The reported minimal important change for low back pain on a
visual analogue scale (VAS) is 15 mm on a 100 mm scale (Ostelo et al.,
2008). A change of over 20 mm, as seen in the results for low back
pain in this review, exceeds the clinically important range. This
suggests that the changes in pain from the dry cupping treatment
were clinically meaningful; however, these results do not take into
consideration patient perspectives, risks and costs; therefore,
cannot be deemed clinically important until further research with
high-quality trials has been undertaken (Ferreira, 2012). A previous
review by Lauche et al. (2013) reanalysed 4 cupping trials to assess
the minimal clinical important differences (MCID) for chronic neck
pain patients. Lauche et al. (2013) observed comparable results in
pain reduction to other conventional therapies. Results revealed a
MCID of -8mm (
21%) on the VAS and substantial clinical benefit
(SCB) of
26.5 mm (
66.8%). For a clinical benefit, a percentage
change of over 50% for SCB is recommended (Dworkin et al., 2008).
The number of dry cupping session and duration of treatment
varied among trials. Most of the trials investigating the efficacy of
dry cupping on non-specific neck pain conducted a total of 5 ses-
sions over a 2-week period, with the session duration lasting
10e15 min. For low back pain, there were no standardised treat-
ment duration or number of sessions; however, El Rahim et al.,
(2017) and Teut et al., (2018) both conducted their trials over 4
weeks, with a total of 8e10 sessions. Further studies are required to
standardise the optimal number of sessions required in the treat-
ment of musculoskeletal conditions.
This current systematic review assessed the risks and safety of
dry cupping therapy for the treatment of musculoskeletal pain, thus
515
No. of patients Treatment Effect Quality of the evidence
(95%CI) (GRADE)
Intervention Control
considerations
none 44 4b SMD -0.75 44OO
[-1.19,
0.32] LOW
providing important information when judging an intervention as
clinically meaningful. A total of 11 trials included an adverse event
statement, with a total of 47 adverse events reported for the dry
cupping group. Most of the events were mild to moderate and
abated within 48-h. Two serious events were reported but were not
associated with the treatment (Lauche et al., 2013; Saha et al.,
2017). The most frequent events reported in the dry cupping
groups were mild muscular soreness, increased pain, headache, and
blister formation. Dry cupping can be performed with either a
manual handheld pump (or mechanical device) or heat from an
ignited cotton ball and glass cups (fire cupping). Blister formations
and burns have been associated with fire cupping, and numerous
severe adverse events have been documented through case reports
(Seifman et al., 2017). This current review found no reports of burns
in the included trials that used fire cupping (Akbarzadeh et al.,
2014; Chi et al., 2016; El Rahim et al., 2017; Khan et al., 2013; Kim
et al., 2017; Lauche et al., 2011); however, blister formation was
reported by Khan et al. (2013). Vacuum cupping using a manual
handheld pump has far less risks than the use of fire cupping;
however, it is unknown whether the benefits of heat outweigh the
risks associated with fire cupping; therefore, caution is warranted
in the use of fire cupping.
Previous systematic reviews and meta-analysis have examined
the efficacy of all cupping methods, rather than dry cupping alone.
Cao et al. (2014) conducted a meta-analysis on 2 dry cupping trials
that produced a significant effect for reducing pain and improving
quality of life. The analysis combined data from two separate
musculoskeletal conditions, knee osteoarthritis and chronic neck
pain, and therefore may not be generalisable to a specific condition.
Recent systematic reviews have investigated cupping therapy on
chronic neck pain (Azizhani et al., 2018; Kim et al., 2018) and
chronic back pain (Moura et al., 2018); however, the recent reviews
included all types of cupping therapy. Nonetheless, Kim et al. (2018)
reported similar results in their meta-analysis to this current re-
view for the effects of cupping on chronic neck pain and function.
Kim et al. (2018) observed a significant reduction in pain and
improved function in patients treated with cupping compared to no
treatment. Additionally, when compared to active treatment, there
was also a significant reduction in pain and improved quality of life.
The results reported by Kim et al. (2018) were not limited to dry
cupping therapy; however, they do concur with the results pro-
duced from this current review.
From this review, 8 trials investigated the use dry cupping as a
form of myofascial release to increase range of motion (Barger,
2016; Biehl, 2017; Doozan, 2015; El Rahim et al., 2017; Kim et al.,
2017; LaCross, 2014; Smith, 2015; Yim et al., 2017). Meta-analysis
of dry cupping compared to an active control group did not
display significant differences. Dry cupping was found to have a
medium effect when compared to no treatment; however, the
quality of evidence was low. The individual trials found dry cupping
to be just as effective as passive stretching (Kim et al., 2018) and
self-myofascial release with the use of a foam roller (LaCross, 2014),
516 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518

Table 8
Reported adverse events for dry cupping in musculoskeletal conditions.

Study ID Sample No. of events Details of the reported adverse events

Size T ¼ Treatment
group
C ¼ Control
group

Chi et al. (2016) (n ¼ 60) T: (n ¼ 2) T: mild low back pain related to the seated position (n ¼ 2)
Cramer et al. (n ¼ 50) T: (n ¼ 5) T: muscle soreness for 1e2 days (n ¼ 2); minor hematoma at the treated site for 2 days (n ¼ 1); increased neck pain for 1e5 h
(2011) (n ¼ 2)
Khan et al. (n ¼ 62) T: (n ¼ 11) T: blister formation (n ¼ 5); ecchymosis (n ¼ 6)
(2013) C: (n ¼ 8) C: GI symptoms (n ¼ 8)
Lauche et al. (n ¼ 50) T: (n ¼ 1) T: symptoms temporarily worsened (n ¼ 1)
(2011)
Lauche et al. (n ¼ 61) T: (n ¼ 3) T: increased muscular tension and pain (n ¼ 1); pain in shoulder (n ¼ 1); prolapsed intervertebral disc (n ¼ 1)
(2013)
Lauche et al. (n ¼ 141) T: (n ¼ 4) T: severely increased pain (n ¼ 1); bruised ribs (n ¼ 1); flu (n ¼ 1); acute torticollis (n ¼ 1)
(2016) C: (n ¼ 3) C: torn meniscus (n ¼ 1); persistent pain after spinal operation (n ¼ 1); flu (n ¼ 1)
Saha et al. (n ¼ 50) T: (n ¼ 5) T: headache <1hr (n ¼ 2); upper back pain <48hrs (n ¼ 1); vertigo <48hrs (n ¼ 1); lipoma (n ¼ 1)
(2017)
Teut et al. (n ¼ 40) T: (n ¼ 6) T: mild hematoma (n ¼ 3); self-limiting light tingling sensations for a few minutes in the legs after cupping the knee (n ¼ 2);
(2012) increased LBP <24hrs (n ¼ 1)
Teut et al. (n ¼ 110) T: (n ¼ 10) T: aggravation of LBP <24hrs (n ¼ 2); light muscular backache (n ¼ 8)
(2018)

Abbreviations: GI Gastrointestinal; LBP Low back Pain.

with both trials reporting no significant differences between the
interventions. Furthermore, dry cupping was found to be more
effective than the Mc Kenzie's cervical stretch protocol (Yim et al.,
2017) for increasing cervical range of motion and traditional
physical therapy (El Rahim et al., 2017) for increasing lumbar range
of motion.
D&B scores varied greatly between 21 RCTs, ranging from
excellent to poor quality, with almost half the trials found to be
good quality. For internal validity, many trials suffered due to lack of
blinding of participants and outcome assessors. Most trials did not
perform any blinding of the intervention to participants; however,
a sham cupping device was used in 2 trials (Biehl, 2017; Lauche
et al., 2016). The reliability of the sham device was tested in a pi-
lot study (Lee et al., 2011) and it was reported that the device was
valid; however, in contrast, Lauche et al. (2016) observed a lack of
success in their trial, with 73.2% of patients correctly identifying the
sham treatment, resulting in questionable validity of the sham
device for blinding participants.
External validity was weak for more than half of the trials
examined, with most of the trials using convenient samples or
healthy college athletes that are not generalisable to the population
at large. Treatment representation was weak for many studies, as
dry cupping is not representative of a usual intervention to treat
musculoskeletal conditions in the facilities where participants were
treated. Other domains of limitations included statistical power,
with less than half of the included trials including a power analysis
in the methodology. Small sample sizes due to underpowered trials
can lead to an overestimation of the treatment effects or fail to
detect a clinically important effect (Akobeng, 2005).
There were several limitations associated with this current re-
view. A language restriction of English resulted in the exclusion of
19 trials and may have resulted in a possible selection bias. Many of
the included trials had small sample sizes which may lead to sta-
tistical heterogeneity and overestimation of the effect size. Addi-
tional sources of heterogeneity may have been from multiple
interventions performed, variation in comparison groups between
trials, and patient characteristics, including pain duration. This
study only investigated the short-term (less than 3 months) effects
of cupping and the long-term effects remain unknown.
The specific physiological mechanisms underpinning dry
cupping remain unclear; however, proposed theories prevail within
the literature (Aboushanab and Ravalia, 2017; Emerich et al., 2014;
Larsson et al., 1990; Pomeranz and Stux, 2001; Tham et al., 2006).
Future trials should continue to investigate the mechanisms of dry
cupping therapy and how the application of cupping may benefit
musculoskeletal pain conditions, additional to the clinical impor-
tance of dry cupping therapy from the perspectives of patients to
assess the MCID. Cost analysis should be conducted to determine
the benefits of dry cupping treatment compared to other in-
terventions currently used for the treatment of musculoskeletal
conditions. Adverse event statements should continue to be re-
ported to monitor the safety and risks of dry cupping therapy.
Furthermore, future trials should examine the long-term effects of
dry cupping and ensure the sample size is appropriate, and the trial
is considerably powered.
5. Conclusion
To our knowledge, this current systematic review is the first to
analyse western dry cupping methods in the treatment of muscu-
loskeletal pain and range of motion. The results suggest that dry
cupping may be effective in reducing pain and improving func-
tional status in patients with chronic neck pain when compared
with no intervention. A significant reduction in pain for non-
specific low back pain was observed, although the quality of evi-
dence was found to be moderate to low. The adverse events asso-
ciated with dry cupping were typically mild to moderate and
resolved within 48 h. Considering the low quality of evidence,
further higher-quality RCTs with larger sample sizes and long-term
outcomes are warranted to provide definitive conclusions
regarding the effectiveness and safety of dry cupping for the
treatment of musculoskeletal pain and range of motion.
CRediT authorship contribution statement
Sarah Wood: conceived the study, Formal analysis, Validation,
Writing - original draft, Methodology, results and discussion, All
authors critically reviewed, edited and approved the final manu-
script. Gary Fryer: conceived the study. Liana Lei Fon Tan: Vali-
dation. Caroline Cleary: Formal analysis.
 S. Wood et al. / Journal of Bodywork & Movement Therapies 24 (2020) 503e518
Declaration of competing interest
GF is a member of the journal's International Advisory Board but
had no role in reviewing this article. The authors declare that they
have no other competing interests.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jbmt.2020.06.024.
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