By Jong-In Kim1, 2, Myeong Soo Lee1,3, Dong-Hyo Lee14, Kate Boddy3 and Edzard Ernst3
1Korea Institute of Oriental Medicine, Daejeon 305-811, Republic of Korea
2College of Oriental Medicine, Kyung Hee University, Seoul, Republic of Korea
3Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK
4College of Oriental Medicine,Wonkwang University, Hospital, Sanbon, Republic of Korea
Evidence-Based Complementary and Alternative Medicine Volume 2011, Article ID 467014, 7 pages
1. Introduction
Pain is the most common reason for seeking therapeutic alternatives to conventional medicine [1] and the more severe the pain, themore frequent is the use of such therapies [1, 2]. Frequently used treatments include acupuncture, massage and mind-body therapies [1, 2]. Cupping is a physical treatment used by acupuncturists or other therapists, which utilize a glass or bamboo cup to create suction on the skin over a painful area or acupuncture point [3]. It is mostly used in Asian and Middle Eastern countries and has been claimed to reduce pain as well as a host of other symptoms [4]. There are two types of cupping. Dry cupping pulls the skin into the cup without drawing blood. In wet cupping the skin is lacerated so that blood is drawn into the cup.
A recent systematic review included five trials (two randomized clinical trials (RCTs) and three controlled clinical trials (CCTs)) on the effects of wet cupping on musculoskeletal problems [5]. Its findings suggested that wet cupping is effective for treating low back pain. However, the review lacked a comprehensive search, included language restrictions and only searched a limited number of databases. Another limitation is that all of the trials compared cupping in combination with other therapies with either acupuncture or another type of cupping. Furthermore, this review pooled the results regardless of their design which raises the possibility of biased results. The aim of this systematic review therefore, was to summarize and critically evaluate the evidence for or against the effectiveness of cupping as a singular treatment of pain.
2.Methods
2.1. Data Sources. The following databases were searched from inception through to January 2009: MEDLINE, AMED, EMBASE, CINAHL, five Korean Medical Databases (Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, KoreaMed, and Research Information Center for Health Database), four Chinese Medical Databases (China National Knowledge Infracture: China Academic Journal, Century Journal Project, China Doctor/MasterDissertation Full Text DB and China Proceedings Conference Full Text DB) and The Cochrane Library 2008, Issue 4. The search terms used were based on two concepts. First concept included terms for cupping and the other concept included terms for pain. The two concepts
were combined using the Boolean operator AND. In the English databases it was unnecessary to use synonyms for cupping as the only term used to describe this therapy is cupping. The term “cupping” would also capture dry cupping, wet cupping, cupping therapy, and so forth. Korean and Chinese terms for cupping and pain were used in the Korean and Chinese databases.We also performed electronic searches of relevant journals (FACT (Focus on Alternative and Complementary Therapies), and Research in Complementary Medicine (Forschende Komplementar medizin) up to January 2009). Reference lists of all obtained papers were searched in addition. Furthermore, our own personal files were manually searched. Hardcopies of all articles were obtained and read in full.
2.2. Study Selection. RCTs testing cupping with or without drawing blood as sole or adjunctive treatment, in patients of either sex or any age diagnosed as having any type of pain and assessing clinically relevant outcomes, were included. The RCTs were included whether placebo controlled or controlled against another active treatment or no treatment. Cupping was defined as pulling the skin into the cup with or without drawing blood for therapeutic. Trials with designs that did not allow an evaluation of efficacy of the test intervention (e.g., by using treatments of unproven efficacy in the control group or comparing two different forms of cupping) were excluded. Trials with cupping as concomitant treatment together with other treatments of unproven efficacy were excluded. Trials published in the forms of dissertation and abstract were included. No language restrictions were imposed.
2.3. Data Extraction and Quality Assessment. Hard copies of all articles were obtained and read in full. All articles were read by three independent reviewers (J.-I. K., M . S. L. and D.-H. L.) and data from the articles were validated and extracted according to pre-defined criteria (Table 1). No language limitations were imposed. Risk of bias was assessed using the Cochrane classification in four criteria: randomization, blinding, withdrawals and allocation concealment [6]. Considering that it is very
hard to blind therapists to the use of cupping, we assessed patient and assessor blinding separately. We admitted assessor
blinding if pain was assessed by another person (not the patient himself) who did not know the group assignment. Disagreements were resolved by discussion among the three reviewers (J.-I. K., M. S. L. and D.-H. L.). There were no disagreements among the three reviewers about risk of biases.
2.4. Data Synthesis. The mean change of out come measures compared to baseline was used to assess the differences between the intervention groups and the control groups. The mean difference (MD) and 95% confidence intervals (CIs) were calculated using the Cochrane Collaboration’s software (Review Manager version 5.0 for Windows, Copenhagen: The Nordic Cochrane Center) for continuous data. For studies with insufficient information, we contacted the primary authors to acquire and verify data where possible. The χ2 test was used for statistical analysis for trials which reported response rate (RR) using dBSTAT program (http://www.dbstat.com/).
References
[1] J. A. Astin, “Why patients use alternative medicine: results of a national study,” Journal of the American Medical Association, vol. 279, no. 19, pp. 1548–1553, 1998.
[2] S. Fleming, D. P. Rabago, M. P. Mundt, and M. F. Fleming, “CAM therapies among primary care patients using opioid therapy for chronic pain,” BMC Complementary and Alternative Medicine, vol. 7, Article ID 15, 2007.
[3] I. Z. Chirali, Cupping Therapy, Elservier, Philadelphia, Pa, USA, 2007.
[4] S. S. Yoo and F. Tausk, “Cupping: East meets West,” International Journal of Dermatology, vol. 43, no. 9, pp. 664–665, 2004.
[5] Y. D. Kwon and H. J. Cho, “Systematic review of cupping including bloodletting therapy for musculoskeletal diseases in Korea,” Korean Journal of Oriental Physiology & Pathology, vol.21, pp. 789–793, 2007.
[6] P. T. H. Julian and G. A. Douglas, “Assessing risk of bias in included studies,” in Cochrane Handbook for Systematic Reviews of Interventions, P. T. H. Julian and S.Green, Eds., pp.187–241,Wiley-Blackwell,West Sussex, UK, 2008.
