The effectiveness and safety of cupping therapy for stroke survivors: A systematic review and meta-analysis of randomized controlled trials ③ Results

• Mikyung Kim(1Department of Internal Medicine, College of Korean Medicine, Sangji University), Chang-ho Han(Department of Internal Medicine, College of Korean Medicine, Dongguk University)
• J Korean Med. 2021;42(4):75-101

Study selection

A total of 374 articles were identified through the database search, and 3 articles were identified through hand searching, and of these, 50 were excluded due to duplication.

The titles and abstracts of the remaining 327 articles were screened, and 271 articles not suitable for this study were excluded. Full texts of the remaining 56 articles were read and 24 articles that did not meet the eligibility criteria of this study were excluded.

Out of the remaining 32 articles, 22 articles providing data suitable for quantitative synthesis were finally selected for meta-analysis and methodological quality assessment.

The study selection process is summarized in Fig. 1, and a list of articles excluded during the process from full text reading to the final selection is presented in Supplement 4.

1. Characteristics of the included studies

1) Study design and sample size
A total of 22 studies^11-32) with 1653 participants published in China from 2001 to 2020 were included in the final analysis. Most of them were studies with a 2-arm design with the exception of three studies^14,19,31) with 3 arms. The number of participants included in the posttreatment evaluation ranged from 40 to 135 (Table 1).

2) Participants
The participants of all included studies were patients with stroke, and none of the studies limited the stroke subtype of the patients. There was no study that recruited only patients in the acute stage within one week of stroke onset, but most of the participants were patients within 6 months of stroke onset. Of the exceptions, 4 studies included patients with more than 6 months since stroke onset,^15,18,30,31) and 3 studies did not provide any information regarding the time from onset (Table 1)^22,23,32).
The most commonly treated stroke condition was spasticity, which was reported in 9 studies ^{12-14,16,17,20,23,24,31)}. Six12-^14,16,17,24) of these studies targeted patients with upper limb spasticity, of which 4^12,14,16,17) were about elbow spasticity.
There were three studies each on spasticity in lower limbs²³⁾, four limbs,³¹⁾ and nonspecified parts²⁰⁾. The most commonly studied stroke conditions after spasticity were hemiplegic shoulder pain (5 studies)^{19,22,25,26,28)} and poststroke shoulder-hand syndrome (4 studies).^21,27,29,30) The remaining studies targeted sensory dysfunction^18,32), upper limb dysfunction¹⁵⁾, and neglect syndrome (Table 1)¹¹⁾.
Two studies considered the type of syndrome differentiation based on traditional Chinese medicine.^15,20) One enrolled patients with spasticity and qi deficiency with blood stasis type15) and the other enrolled patients with upper limb dysfunction
with phlegm and blood stasis obstructing collaterals type (Table 1)²⁰⁾.

3) Intervention, control and outcome measures

• A versus B type studies
  Two studies^17,24) compared the effects of wet cupping and Western medication (baclofen, a muscle relaxant) in patients with upper limb spasticity. In both studies, the treatment period was 4 weeks, the treatment group received wet cupping on the center of the biceps brachii belly twice a week, and the control group was orally administered 10 mg of baclofen three times a day.
  These two studies evaluated changes in upper limb motor function and spasticity. In terms of the safety of the cupping therapy, one study²⁴⁾ described the plan for adverse event monitoring in the methods session but did not report the results. Another study¹⁷⁾ did not provide any information on the safety of cupping therapy ^{(Table 1 & 2)}.
• A+B versus B type studies
  Twenty studies^{11-16,18-23,25-32)} were designed as an A+B versus B form, comparing the add-on effect of cupping therapy with the noncupping control in patients receiving standard treatment for stroke. Three of them^14,19,23) were 3-arm studies, and the other 18 were 2-arm studies. No studies used sham devices or placebo controls (Table 1).
  Of the 20 studies, 5^{11,19,21,25,31)} used dry cupping and 15^{12-16,18,20,22,23,26-30,32)} used wet cupping. The retention time for cupping was between 5 and 15 minutes in both dry and wet cupping studies. The amount of blood drawn by wet cupping therapy ranged from a few drops to 10 ml. Ten^{13,15,18-20,22, 25-27,32)} of the included studies performed cupping therapy once every other day. The next most common protocols were once a day^14,28,30,31) and twice a week12,16,23). The treatment period was most frequently 4 weeks^{11,12,16,18,21)} and ranged between at least 2 weeks and at most 6 months.
  The most common sites for cupping were the pain site of the affected shoulder for patients with hemiplegic shoulder pain or shoulder-hand syndrome and the center of the biceps brachii belly for patients with upper limb spasticity (Table 1).
  The therapeutic effects of cupping therapy for stroke patients was evaluated on various scales. Most of the studies presented the response rates for the main outcomes in stroke survivors. In addition, many other studies measured upper limb motor function using the Fugl-Meyer assessment (FMA) scale, and there were also studies that evaluated overall motor function or sensory function. Some studies assessed the intensity of shoulder pain using a visual analog scale (VAS) or numeric rating scale. There were also studies that assessed the activities of daily living using the Barthel or modified Barthel index. There was only one study¹⁵⁾ that assessed neurological deficits using an internationally accepted stroke scale, such as the National Institute Health stroke scale, and no study reported mortality, disability, or recurrence of stroke (Table 1 & 2).
  Most studies did not mention safety. One study on dry cupping²¹⁾ reported that any serious adverse events were observed, and three studies on wet cupping^13,15,25) described the adverse events identified during the study period (Table 1 & 2).

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