The effectiveness and safety of cupping therapy for stroke survivors: A systematic review and meta-analysis of randomized controlled trials ⑤ Results  Ⅲ

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  • 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

3. Meta-analysis and evidence level

2) Effectiveness of cupping therapy as an add-on to conventional treatment

Activities of daily living (ADL) Five studies11,13,15,19,26) assessed the additive effect of cupping therapy using the Barthel index (BI) or modified Barthel index (MBI). Combining the data, the additional implementation of cupping therapy for patients who were receiving conventional treatment was significantly more advantageous than the noncupping condition (SMD 1.23, 95% CI 0.21 to 2.25, P=0.02) (Fig. 4), and the level of evidence supporting this result was low (Supplement 8). The subgroup analysis including only wet cupping studies13,15,26) showed similar results (SMD 0.48, 95% CI 0.23 to 0.72, P=0.0002) (Fig. 4). The heterogeneity detected in the whole synthesis (I2=95%) was resolved in the wet cupping subgroup analysis (I2=0%) (Fig. 4). However, when pooling the two studies involving only dry cupping11,19), the significant benefit of cupping therapy disappeared (SMD 2.44, 95% CI -1.10 to 5.99, P=0.18) (Fig. 4), and the level of evidence was also downgraded (Supplement 8).

② Motor function

  1. General motor function: Only wet cupping study18) and one dry cupping study11) evaluated the change in the motor function subdomain score on the FMA scale. Only the dry cupping study showed a significant benefit of cupping therapy (MD 3.50, 95% CI 0.86 to 6.14, P=0.009) (Fig. 5(A)). However, when combining the two studies, the additional benefits of cupping therapy were not confirmed (MD 1.95, 95% CI -2.42 to 6.31, P=0.38) (Fig. 5(A)), and the level of evidence was still very low (Supplement 8).
  2. Upper limb motor function: Seven studies using wet cupping12-16,22,26) and one study using dry cupping25) reported changes in the upper limb motor function subdomain score of the FMA scale. All studies showed significantly beneficial effects of additive cupping therapy (Fig. 5(B)). Meta-analysis also showed positive results of cupping therapy (MD 6.91, 95% CI 4.36 to 9.46, P<0.00001) (Fig. 5(B)), which was supported by a moderate level of evidence (Supplement 6). The subgroup analysis including only wet cupping studies showed similar results (MD 7.66, 95% CI 4.64 to 10.67, P=0.01) (Fig. 5(B)) (Supplement 8).
  3. Sensory function: Two studies18,32) compared the response rates with and without additional wet cupping therapy in patients with sensory impairment after stroke. Meta-analysis of these studies showed that the benefit of wet cupping therapy was significant and the level of evidence supporting the result was low (OR 4.35, 95% CI 1.42 to 13.32, P=0.010) (Fig. 6) (Supplement 8).
  4. Spasticity: Two studies13,16) assessed the level of spasticity using the MAS before and after wet cupping therapy in patients with upper arm spasticity. The meta-analysis of these two studies showed that the additional effect of wet cupping was significant with a low level of evidence (MD -0.63, 95% CI -0.83 to -0.44, P<0.00001) (Fig. 7(A)) (Supplement 8). Seven studies13-15,20,23,31) investigated the proportion of participants who responded positively in terms of spasticity after cupping therapy. The meta -analysis of these studies showed the significant benefit of cupping therapy (OR 3.28, 95% CI 1.31 to 8.22, P=0.01) (Fig. 7(B)), and a moderate level of evidence supported this result (Supplement 8). The subgroup analysis of the wet cupping studies showed similar results (OR 3.06, 95% CI 1.13 to 8.26, P=0.03), whereas the dry cupping subgroup did not (OR 9.21, 95% CI 0.43 to 198.49, P=0.16) (Fig. 7(B)) (Supplement 8). Changes in biceps brachii muscle detected by integrated electromyography in patients with upper limb spasticity were also more favorable for wet cupping (MD -4.45, 95% CI -6.74 to -2.16, P=0.0001) (Fig. 7(C))12,16). However, the level of evidence supporting this benefit was very low (Supplement 8).
  5. Shoulder pain: Four studies19,22,26,28) reported changes in shoulder pain measured by a VAS after additive cupping therapy for patients with hemiplegic shoulder pain. The meta-analysis of these studies showed that adjuvant cupping therapy had significant benefits in reducing VAS scores (MD -1.67, 95% CI -1.96 to -1.39, P<0.00001) (Fig. 8(A)), although the level of evidence supporting this effect was very low (Supplement 6). Similar results were reproduced in the subgroup analysis including only the wet cupping studies (MD -1.70, 95% CI -2.05 to -1.35) (Fig. 8(A)) (Supplement 8). Two studies22,26) investigated the proportion of hemiplegic shoulder pain patients who responded positively to wet cupping therapy. Combining these studies showed that additive wet cupping therapy had significant benefits in improving shoulder pain, although the level of evidence was very low (OR 4.28, 95% CI 1.91 to 9.60, P=0.0004) (Fig. 8(B)) (Supplement 8).
  6. Shoulder-hand syndrome: Four studies21,27,29,30) assessed the response rates to cupping therapy for patients with poststroke shoulder-hand syndrome. The meta-analysis of these studies showed that cupping therapy had significant benefits in increasing the response rate in patients with poststroke shoulder-hand syndrome (OR 2.73, 95% CI 1.35 to 5.53, P=0.005) (Fig.9). The results of the subgroup analysis of studies involving only wet cupping therapy also reproduced similar results (OR 3.15, 95% CI 1.43 to 6.94, P=0.004) (Fig. 9). However, the level of evidence supporting these findings was very low in all cases (Supplement 8).
  7. Safety: Five studies13,15,21,24,26) mentioned plans for collecting adverse events (AEs) during the study period. All of them were designed to compare the additional effectiveness of cupping therapy with the noncupping control. One24) of the five studies mentioned the AE collection plan in the Methods section of the article but did not provide any information on the safety profile in the Result section. Out of the 4 studies describing the intervention-related AEs in the Results section, one study21) was about dry cupping, and the others13,15,26) were about wet cupping. The dry cupping study21) reported that they did not identify any serious AEs in either cupping or noncupping groups. One of the wet cupping studies reported the occurrence of blistering with pain after cupping therapy, but did not disclose how many cases were identified26). Therefore, we could secure data available for meta-analysis from only two wet cupping studies13,15). One study provided wet cupping therapy every other day for 30 days to patients with upper arm spasticity and reported two cases of subcutaneous bleeding at the cupping site13). These AEs spontaneously disappeared after 1 week, and no AEs were identified in the control group13). Another study provided wet cupping therapy every other day for 3 months to patients with upper arm dysfunction and identified two cases of AEs, including either bleeding or pain15). Combining the AEs identified in these two studies, no significant difference was found in the occurrence of AEs between the additional cupping group and the noncupping control group (OR 6.33, 95% CI 0.74 to 53.99, P=0.09) (Fig. 10), and the level of evidence supporting this result was very low (Supplement 8).

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