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Journal of Back and Musculoskeletal Rehabilitation 30 (2017) 1187–1195 1187
DOI 10.3233/BMR-169736
IOS Press
Review Article
The effect of cupping therapy for low back
pain: A meta-analysis based on existing
randomized controlled trials
Yun-Ting Wanga,1, Yong Qib,1, Fu-Yong Tanga,1, Fei-Meng Lic,1, Qi-Huo Lid, Chang-Peng Xub,
Guo-Ping Xiedand Hong-Tao Sunb,∗
aGuangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
bDepartment of Orthopaedics, Guangdong No.2 Provincial People’s Hospital, Guangzhou, Guangdong, China
cGuangdong Traditional Medical and Sports Injury Rehabilitation Research Institute, Guangdong No.2 Provincial
Peopie’s Hospital, Guangzhou, Guangdong, China
dThe First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
Abstract.
BACKGROUND: LBP is one of the most common symptoms with high prevalence throughout the world. Conflicting conclu-
sions exist in RCTs on cupping for LBP.
OBJECTIVE: To assess the effects and safety of cupping for the patients with LBP.
METHODS: Pubmed, Cochrane Library databases, and Embase database were electronically researched. RCTs reporting the
cupping for the patients with LBP were included. The meta-analysis was conducted using Review Manager software (version 5.3,
Nordic Cochrane Centre). The primary outcome was VAS scores. The secondary outcomes included ODI scores, MPPI scores
and complications.
RESULTS: Six RCTs were included in this synthesized analysis. The results showed that cupping therapy was superior to the
control management with respect to VAS scores (SMD: −0.73, [95% CI: −1.42 to −0.04]; P=0.04), and ODI scores (SMD:
−3.64, [95% CI: −5.85 to −1.42]; P=0.001). There was no statistical significant difference as regard to MPPI scores. No
serious adverse event was reported in the included studies.
CONCLUSIONS: Cupping therapy can significantly decrease the VAS scores and ODI scores for patients with LBP compared
to the control management. High heterogeneity and risk of bias existing in studies limit the authenticity of the findings.
Keywords: Low back pain, cupping therapy, meta-analysis
1Yun-Ting Wang, Yong Qi, Fu-Yong Tang and Fei-Meng Li con-
tributed equally to this study and should be considered co-first au-
thors. Hong-tao Sun and Guo-ping Xie are co-corresponding au-
thors.
∗Corresponding author: Hong-Tao Sun, Department of Or-
thopaedics, Guangdong No.2 Provincial People’s Hospital, No. 466
courtyard, Xing Gang Middle Road, Haizhu District, Guangzhou
510317, Guangdong, China. Tel.: +86 20 8916 8085; Fax: +86 20
8916 8085; E-mail: ht_sun177@163.com.
1. Introduction
Low back pain (LBP) is one of the most common
symptoms affecting innumerable individuals through-
out the world. A global review of the prevalence of
LBP in the general adult population has shown its point
prevalence to be approximately 12%, with a one-month
prevalence of 23%, a one-year prevalence of 38%, and
a lifetime prevalence of approximately 40% [1]. It is a
generic term of kinds of back pains characterized by no
ISSN 1053-8127/17/$35.00 c
2017 – IOS Press and the authors. All rights reserved
1188 Y.-T. Wang et al. / Cupping therapy for LBP
identified histopathological changes and cannot clear
its etiology from objective determinations. The symp-
toms of LBP could be acute/chronic lumbosacral pain
accompanied with/without pain or numbness of legs.
Female or older workers were at increased risk of ex-
periencing LBP [2], students who sat with the spine
positioned wrongly, or stood incorrectly, were more
likely to present with LBP [3]. The risk factors of LBP
included postmenopausal female, work-family imbal-
ance, exposure to a hostile work environment, job in-
security, long work hours, certain occupation groups,
unemployment, and sleep disturbances [4–6].
The current therapeutics of LBP consist of absolute
bed rest at acute phase, analgesic or anti-inflammatory
medications, physiotherapy, traction, alternative treat-
ments and education regarding the prevention of LBP.
Cupping therapy is a common therapy in Traditional
Chinese Medicine (TCM) field with a long history,
which could be used to reduce the local chronic pain
symptoms. Nowadays, more and more patients have
shown an interest in using cupping therapy for the
treatment of LBP due to their belief that it is more
effective and safe than the current therapeutics. Al-
though the cupping is safe ussually, it would leave lo-
cal site skin pigmentation which would gradually van-
ish in a few days, and has been reported a complica-
tion of anaemia after excessive cupping therapy by an
unqualified therapist in Korea in a case report [7].
There are many types of cupping including dry cup-
ping, wet cupping, cupping with retention, moving
cupping, shaking cupping, quick cupping and balance
cupping. All of these types of cupping were frequently
used in China, while dry cupping and wet cupping
were widely used in Asian and Middle Eastern coun-
tries [8]. Dry cupping is using the negative pressure
conditions of the cup to suck the skin into the cup with-
out drawing blood. Wet cupping should prick the skin,
so that blood of local site could be drawn into the cup.
Cupping with retention is that cup is retained for a pe-
riod of time on the skin after the dry cupping process
completed. Moving cupping is characterized by mov-
ing on the skin by pre-daubing lubricating oil on the
skin. Shaking cupping is a kind of cupping that after
the cup sucked on the skin, the manipulator hold the
body of cup to shake it. Quick cupping is character-
ized by quickly removing the cup once it sucks on the
skin, which is on the contrary to cupping with reten-
tion. Balance cupping is a combination of cupping with
retention, shaking cupping, quick cupping and moving
cupping with established procedures.
Although cupping therapy has been used for LBP for
a long time, it has been limited to assess its efficacy due
to lack of high-quality, well-designed randomized con-
trolled trials (RCTs). Nowadays, more and more RCTs
concerning cupping therapy for LBP written in Chi-
nese or English have been published. At present, there
were 5 studies published in English were searched con-
taining a description of systematic review on this topic.
In 2011, a systematic review conducted by Kim of
South Korea drew a conclusion that the current RCTs
were few and showed low methodological quality [9].
In 2013 and 2015, there were two systematic reviews
drew a conclusion that cupping therapy is promising
for pain [10,12]. In 2014, a systematic review of tra-
ditional medicine in east asian countries weakly rec-
ommended cupping therapy for both sub-acute and
chronic LBP [11]. In 2015, a review about all aspects
of TCM for neck pain (NP) and LBP indicated that
cupping could be efficacious in pain and disability for
chronic NP or chronic LBP in the immediate term [13].
Since there is no consensus on cupping therapy for
LBP, we searched the existing RCTs published in En-
glish or Chinese language to make a synthesized anal-
ysis to test its effectiveness in patients with LBP.
2. Materials and methods
We conducted this meta-analysis according to the
PRISMA (Preferred reporting items for systematic re-
views and meta-analyses) statement [14].
2.1. Literature search strategy
The strategy of literature search was according to
the guidance of the Cochrane Handbook. We electroni-
cally searched the Pubmed database, Cochrane Library
databases, and Embase database from their inception
up to 31st August 2016 to identify studies meeting the
inclusion criteria. RCTs concerning cupping therapy
for subacute or chronic LBP were searched in elec-
tronic databases by two authors independently. The
search terms were as follows: ((Low back pain*) OR
(back pain*, low) OR (pain*, low back) OR (lumbago)
OR (lower back pain*) OR (back pain*, lower) OR
(pain*, lower back) OR (low back ache*) OR (ache*,
low back) OR (back ache*, low) OR (low backache*)
OR (backache*, low) OR (recurrent low back pain*)
OR (low back pain*, postural) OR (postural low back
pain*) OR (low back pain*, mechanical) OR (mechan-
ical low back pain*) OR (low back pain*, posterior
compartment) OR (lumbar sprain) OR (lumbar my-
ofasciitis) OR (lumbosacral pain*)) AND (cupping OR
Y.-T. Wang et al. / Cupping therapy for LBP 1189
(cupping therapy) OR (dry cupping) OR (wet cupping)
OR (cupping with retention) OR (moving cupping) OR
(shaking cupping) OR (quick cupping) OR (balance
cupping)). To ensure retrieval comprehensive, we man-
ually searched the reference lists of all retrieved studies
and published systematic reviews/meta-analysis, and
included all identified relevant articles.
2.2. Eligibility criteria
2.2.1. Inclusion criteria
(1) Randomized controlled trial. (2) Participants en-
rolled in trials were diagnosed as nonspecific subacute
or chronic LBP. (3) Intervention in experimental group
was a kind of cupping therapy, which could be dry
cupping, wet cupping, cupping with retention, moving
cupping, shaking cupping, quick cupping or balance
cupping. (4) Intervention in control group was medi-
cation or usual care. (5) The interested outcomes in-
cluded one of the VAS (visual analogue scale) scores,
ODI (Oswesty pain disability index) scores and MPPI
(McGill present pain index) scores. (6) Language of
included trials were published in English or Chinese.
2.2.2. Exclusion criteria
(1) Comorbid factors such as fracture, dislocation,
tumor of lumbar spine which directly deduce the LBP
symptom in participants. (2) non-RCT. (3) Sample size
less than 15. (4) Studies without available data for
statistics were excluded.
2.3. Study identification
Firstly, all titles of searched articles were viewed by
two investigators independently. At this step, articles
obviously unrelated to the topic were removed. Sec-
ondly, full articles were reviewed to remove the non-
RCTs and articles without comparison group. Thirdly
articles were removed due to the lack of interested out-
come. The third investigator was involved in the study
when there existed divergence on eligibility of enrolled
studies.
2.4. Methodological quality assessment
The methodological scores of eligible studies were
assessed by using Jadad scale [15]. Two indepen-
dent investigators performed the methodological eval-
uation. The third investigator was consulted to resolve
it once divergence occurs.
Fig. 1. Flow diagram of study selection.
2.5. Outcome measures
The primary outcome was VAS scores. The Sec-
ondary outcomes included ODI scores, MPPI scores
and complications.
2.6. Data extraction
The following data from each study were extracted
independently by two authors: first author’s family
name, year of publication, diagnosis, interventions,
sample size, mean age, interested outcomes, follow-
up times, lost follow or withdraw, adverse events, the
baseline of interested outcome before interventions,
the interested outcomes at the chosen time point and
end of follow-up period. Any disagreements were re-
solved by consensus.
2.7. Statistical analysis
Data analyses were conducted by using the Re-
view Manager statistical software (version 5.3, Nordic
Cochrane Centre). Standard Mean Difference (SMD)
with 95% confidence intervals (CIs) was selected to
describe the mean differences between cupping group
and control group. A P-value less than 0.05 was
judged as statistically significant. The potential hetero-
geneity among studies was examined via Cochran’s Q-
statistic [16] and I2statistics [17]. When there was
no statistically significance on heterogeneity test of
outcomes (I2<50% and P > 0.1), a fixed-effect
model was adopted in the meta-analysis. Otherwise, a
random-effect model was used.
1190 Y.-T. Wang et al. / Cupping therapy for LBP
Table 1
The demographic characteristics of the patients of the included studies (cupping vs. control)
Study Diagnosis Intervention Sample Mean age Outcomes Follow Lost Adverse
Cupping Control size up time follow events
Hong et al.
2006 [18]
NLBP Moving cupping,
q.o.d, for 11 days
Dexibuprofen,
0.15 g, po, tid for
12 days
37/33 38.89 ±11.03/
36.0 ±10.21
VAS After treat-
ment
0/0 NR
Liu et al.
2008 [19]
NLBP Dry cupping, qd,
21 days
Diclofenac
sodium, po, qd
25/25 38.6 ±18.5/
35.2 ±14.3
VAS; ODI 3 weeks 0/0 NR
Li and Chen
2009 [20]
NLBP Dry cupping,
q.o.d, for
3 weeks
Diclofenac
sodium, po, qd
30/30 31.7 ±9.7/
30.9 ±9.3
VAS; ODI 9.2 ±2.5
(months)
0/0 NR
Farhadi et al.
2009 [21]
NLBP Wet-cupping; 0,
3, and 6 days
Usual care 48/50 44.0 ±14.8/
41.8 ±13.9
MPPI; ODI 3 months 7/5 3/0
Akbarzadeh et
al. 2014 [22]
PLBP Dry cupping; qd;
for 4 days
Usual care 50/50 25.0 ±4.2/
27.0 ±3.8
VAS; MPPI 2 weeks 0/0 None
AlBedah et al.
2015 [23]
NLBP Wet-cupping, 3
times per weeks
for 2 weeks
Usual care 40/40 36.48 ±9.3/
36.43 ±9.4
MPPI; ODI 2, 4 weeks 0/0 None
Abbreviations: NLBP, nonspecific low back pain; PLBP, postpartum low back pain; VAS, visual analogue scale; ODI, Oswesty pain disability
index; MPPI, McGill present pain index; NR, not report.
Table 2
Comparisons of interested outcomes (cupping vs. control)
Study VAS score MPPI score ODI score
Baseline Post-treatment Baseline Post-treatment Baseline Post-treatment
Hong 2006 6.11 ±2.08/
5.86 ±1.99
1.29 ±1.62/
3.57 ±2.96
NA NA NA NA
Liu 2008 5.97 ±1.5/
5.86 ±1.64
1.79 ±0.53/
1.88 ±0.41
NA NA 28.69 ±9.57/
29.72 ±9.43
14.69 ±5.57/
15.72 ±4.43
Li 2009 5.6 ±2.0/
5.9 ±2.1
2.1 ±1.1/
2.3 ±1.4
NA NA 30.2 ±6.3/
29.8 ±6.1
14.6 ±3.2/
15.7 ±3.8
Farhadi 2009 NA NA 2.7 ±0.8/
2.7 ±0.9
3 months
0.7 ±0.9/
2.8 ±1.3
31.4 ±6.6/
30.9 ±9.8
3 months
15.6 ±6.7/
30.6 ±11.6
Akbarzadeh 2014 7.8 ±2.7/
7.6 ±2.7
3.7 ±1.8/
6.4 ±2.3
24 hrs:
2.5 ±1.7/
5.0 ±2.0
2 weeks:
1.4 ±1.4/
3.7 ±1.5
31.8 ±10.8/
31.8 ±9.8
9.0 ±6.7/
29.2 ±8.0
24 hrs:
7.5 ±6.6/
21.7 ±6.2
2 weeks:
4.1 ±3.6/
14.0 ±5.2
NA NA
AlBedah 2015 NA NA 2.35 ±1.2/
2.13 ±0.96
2 weeks:
1.17 (0.96–1.4)/
2.3 (2.1–2.7)
4 weeks:
0.98 (0.7–1.2)/
2.3 (2.1–2.6)
38.33 ±19.2/
32.05 ±15.9
2 weeks:
19.6 (16.5–22.7)/
35.4 (32.3–38.5)
4 weeks:
15.2 (11.6–18.8)/
35.9 (32.3–39.5)
Abbreviations: VAS, visual analogue scale; ODI, Oswesty pain disability index; MPPI, McGill present pain index; NA, not available.
3. Results
3.1. Literature search and study selection
A total of 87 studies were searched from electronic
and manual searching. Specifically, 14 from Pubmed,
21 from Cochrane library, 38 from Embase, and 14
were manually searched from the reference lists of
published systematic review or meta-analysis. After
duplicated, 39 studies were removed and 48 studies re-
mained for screening. Then 29 studies were excluded
for obviously unrelated to the research topic after re-
view the titles and abstracts, 19 studies remained for
next full-text review. After full-text articles assessed
for eligibility, 13 articles were excluded for reasons as
follows: cupping combined with acupuncture (n=7),
conference abstract (n=1), without comparison group
Y.-T. Wang et al. / Cupping therapy for LBP 1191
Table 3
Jadad scores of the enrolled studies
Study Study Random Appropriate Blinding of Blinding of Withdrawl Sum
type sequence randomization participants outcomes and dropouts
generation or personnel assessors
Hong 2006 RCT 1 0 0 0 1 2
Liu 2008 RCT 1 0 0 0 1 2
Li 2009 RCT 1 0 0 0 1 2
Farhadi 2009 RCT 1 1 0 0 1 3
Akbarzadeh 2014 RCT 1 1 0 0 1 3
AlBedah 2015 RCT 1 1 0 0 1 3
Abbreviations: RCT, randomized controlled trial.
(n=2), sample size <15 (n=1), and acute LBP
(n=2). Finally 6 RCTs [18–23] accorded with eli-
gibility criteria were included qualitative synthesis, 3
published in Chinese, 3 published in English (See flow
diagram of study selection, Fig. 1).
3.2. Study characteristics
Six RCTs were included in this meta-analysis,
3 RCTs [18–20] published in Chinese were from
China, 2 RCTs [21,22] published in English were from
Iran, 1 RCT [23] published in English was from Saudi
Arabia. All the trials included were RCTs.
A total of 458 participants enrolled in this study,
including 230 participants in cupping groups and
228 participants in control (medication or usual care)
groups respectively. The participants in 4 RCTs [18–
21,23] were diagnosed as nonspecific low back pain
(NLBP), and participants in 1 RCT [22] were diag-
nosed as low back pain among postpartum women (Ta-
ble 1).
As for the intervention aspect, there are many types
of cupping therapy reported in cupping groups. Three
RCTs [19,20,22] adopted dry cupping, 2 RCTs [21,23]
using wet cupping, and 1 RCTs [18] applied mov-
ing cupping. As for control groups, 3 RCTs [18–20]
adopted oral medications (diclofenac sodium in 2
RCTs [19,20] and dexibuprofen in 1 RCT [18]), and
3 RCTs [21–23] applied usual care. The treatment ses-
sions were from 11 days to 3 weeks with different fre-
quencies (Table 1).
All the included RCTs at least reported one of the
interested outcomes. Four RCTs [18–20,22] reported
VAS score as their important indicator to evaluate the
level of pain. Four RCTs [19–21,23] adopted ODI
score to evaluate the degree of limitation of daily life
and activity ability. And 3 RCTs applied the McGill
pain index to assess the present pain level. But among
these 3 RCTs [21–23], there was 1 RCT [22] adopted
the short-form McGill pain questionnaire which is
quite different to the McGill present pain index. The
data at baseline and each point of follow-up were ab-
stracted in Table 2. There was no report of serious ad-
verse event in the included RCTs.
3.3. Methodological quality assessment
As for the randomization aspect, all RCTs reported
the method of random sequence generation, but only
3 RCTs [21–23] reported the appropriate randomiza-
tion or allocation concealment process. Thus other 3
RCTs [18–20] existed a moderate degree of selection
bias. Considering the specialization of the cupping pro-
cess, all the RCTs did not use blinding of participants
or personnel. So there exists high performance bias in
all trials. Blinding of outcomes assessors was not ap-
plied in all these RCTs, so all the trials exist a high de-
tection bias. Due to the relative short term of follow up,
all the studies reported the situation of withdrawl and
dropouts, and achieved high follow up rate. So there
exists low risk of withdraw bias in all trials. The spe-
cific Jadad score of the enrolled studies were listed in
Table 3.
3.4. Meta-analysis of interested outcomes
3.4.1. VAS scores
Four RCTs including 280 participants reported the
follow-up end VAS scores. The results of pooled anal-
ysis showed that cupping therapy was superior to the
control (medication or usual care) on decreasing VAS
score (SMD: −0.73, [95% CI: −1.42 to −0.04]; P=
0.04) with high heterogeneity (I2=87%, P <
0.0001) [18–20,22] (Fig. 2).
3.4.2. ODI scores
Four RCTs [19–21,23] adopted ODI score to eval-
uate the degree of limitation of daily life and activity
ability. 1 RCT [23] reported the ODI scores in the form
of median and range. So we estimated the mean and
1192 Y.-T. Wang et al. / Cupping therapy for LBP
Fig. 2. Forest plot of VAS score.
Fig. 3. Forest plot of ODI score.
Fig. 4. Forest plot of MPPI score.
variance from the median, range, and the sample size
according to the calculation method reported by Hozo
et al. [24]. The sample of this trial was 40, so the mean
was equal to the median, and the variance is equal to
the quarter of range [24]. The results of meta-analysis
involving 288 participants revealed that the cupping
therapy showed significant advantages over the con-
trol (medication or usual care) on reducing the follow-
up end ODI score (SMD: −3.64, [95% CI: −5.85 to
−1.42]; P=0.001) with high heterogeneity (I2=
98%, P < 0.00001) [19–21,23] (Fig. 3).
3.4.3. MPPI scores
Three RCTs applied the McGill pain index to assess
the present pain level. But among these 3 RCTs [21–
23], there was 1 RCT [22] adopted the short-form
McGill pain questionnaire which is quite different to
the McGill present pain index. So only 2 RCTs [21,23]
were included in meta-analysis. Albedah’s study [23]
reported MPPI scores in the form of median and range,
we also used Hozo’s method [24] to calculate the data
in the form of mean and variance. The results of meta-
analysis found that there was no significant difference
between two groups on MPPI scores (SMD: −6.12,
[95% CI: −14.54 to 2.31]; P=0.15) with high het-
erogeneity (I2=98%, P < 0.00001) [21,23] (Fig. 4).
3.5. Sensitivity analysis
Statistical tests of heterogeneity revealed that there
were high heterogeneity with respect to all the in-
terested outcomes. So we performed the sensitivity
analysis to explore the source of high heterogene-
ity. We found that when we remove the trial of Ak-
barzadeh et al. [22], the heterogeneity of VAS score
was turned to moderate (I2=68%, P=0.05) accom-
panying with pooled-P value turning to un-significance
(Fig. 5). As for ODI score aspect, when we removed
the trial of Albedah et al. [23], the heterogeneity was
decreased accompanying with pooled-P value turning
to un-significance (Fig. 6).
4. Discussion
The main findings of this study are that cupping ther-
apy can significantly decrease the VAS scores and ODI
Y.-T. Wang et al. / Cupping therapy for LBP 1193
Fig. 5. Forest plot of sensitivity analysis of VAS score.
Fig. 6. Forest plot of sensitivity analysis of ODI score.
scores compared to the control management (usual
care/medication) for patients with LBP. And there is
no significant difference between cupping therapy and
the control management on MPPI scores for patients
with LBP. However the results of VAS scores and ODI
scores are unstable according to the results of sensitiv-
ity analysis.
The VAS scores is a scale with 10 numbers, and elu-
cidated as follows: no pain (0), mild (1 to 3), moder-
ate pain (4 to 6), severe pain (7 to 9), and the worst
pain possible (10), and is frequently used in patients
with chronic musculoskeletal pain [25]. In this study,
we found cupping therapy was superior to the control
management on decreasing VAS scores. That means
cupping therapy shows advantages on alleviating pain
over the control management (medication or usual
care) for patients with LBP. In the included RCTs,
there were 2 RCTs’s results showed a negative results
as regards to VAS scores between dry cupping and di-
clofenac sodium for LBP [19,20]. And there were 2
RCTs’s results reported cupping therapy can signifi-
cantly decrease the VAS scores compared to the con-
trol management [18,22]. The trial of Hong et al. [18]
reported moving cupping was superior to dexibupro-
fen on decreasing the VAS scores. The moving cupping
therapy method might be the key factor contributing to
the positive result. The trial of Akbarzadeh et al. [22]
reported dry cupping was superior to usual care on de-
creasing the VAS scores.
The ODI scores is an important tool to measure a pa-
tient’s permanent functional disability in the manage-
ment of spinal disorders [26]. The test is considered
the “gold standard” of low back functional outcome
tools [27]. In our study, the result revealed that cup-
ping therapy showed more advantages over the con-
trol management on decreasing ODI scores. It is sug-
gested that in the aspect of improving the disability
condition induced by LBP, cupping therapy is better
than the control management. In the included RCTs,
there were 2 RCTs’s results showed a negative results
as regards to ODI scores between dry cupping and di-
clofenac sodium for LBP [19,20]. And there were 2
RCTs’s results reported wet cupping therapy can sig-
nificantly decrease the ODI scores compared to the
usual care [21,23]. The advantage of dry cupping com-
pared to diclofenac sodium on decreasing ODI scores
didn’t show a significant difference.
The MPPI scores is a standard and well-used index
of current pain. Patients rate their current pain on a 6-
point scale from “no pain” to “excruciating” [28]. Al-
though there exists significant advantages of cupping
therapy on down-regulating the MPPI scores compared
to the usual care in both 2 included RCTs, the result of
meta-analysis showed no statistical significance. The
Hozo’s calculation method [24] and the high hetero-
geneity between 2 RCTs might contribute to this result.
There were high heterogeneity in the results of all
interested outcomes. Although, sensitivity analysis can
find the main source of the heterogeneity, there still
exists statistical significant difference in heterogene-
ity. We noted possible causes as follows: firstly, al-
though all the included participants were patients with
1194 Y.-T. Wang et al. / Cupping therapy for LBP
LBP, the patients enrolled in the study of Akbarzadeh
et al. [22] were postpartum women with nonspecific
LBP. Generally postpartum women have higher preva-
lence and level of pain compared to the normal [29,30].
Secondly, as for experimental interventions, there were
many types of cupping therapy, and the treatment ses-
sion and frequency were not the same in trials (see Ta-
ble 1). Thirdly, as for the control interventions, there
also existed different types of medication and usual
care (see Table 1). Fourthly, the drawback of design
of RCTs (such as without blinding of participants or
personnel due to the cupping therapy was well-known
by participants and particularity of the cupping for the
personnel) also contributed to the high heterogeneity.
Fifthly, the calculation method used on the data of
MPPI scores and ODI score in Albedah’s study might
create heterogeneity.
There existed different degrees of risk of bias in tri-
als. According to the situation of methodological qual-
ity assessment, moderate degree of selection bias in
some trials, high performance bias, high detection bias,
and low risk of withdraw bias in all trials were found.
All trials did not involve independent examiners, which
may have contributed some observer bias, a distortion,
conscious or unconscious, in the perception or report-
ing of measurements [31]. And at the process of cal-
culation on the data of MPPI scores and ODI score in
Albedah’s study, calculation bias might exist.
The findings need to be further confirmed by sub-
group analysis based on different types of cupping
and control management, and meta-regression to find
the source of high heterogeneity based on more well-
designed and high-quality RCTs.
There also exist some limitations in this meta-
analysis. Firstly, many types of cupping therapy and
different control managements were included in cup-
ping groups and control groups respectively, and it is
difficult to conduct subgroup analysis or Meta regres-
sion due to the lack of enough trials. Secondly, the
frequency of cupping, duration of each session, loca-
tion of acupoints, experience of manipulators in each
trial were different. These factors might strongly in-
fluence the clinical effects of cupping. Thirdly, the in-
cluded Chinese RCTs [18–20] showed low-scoring of
Jadad scores, and the inlcuded English RCTs [21–23]
showed fair-scoring of Jadad scores. The qualities of
original trials may potentially impact results of each
trial and meta-analysis. Additionally, we did not test
the publication bias due to the limitation of number of
RCTs.
5. Conclusion
Cupping therapy is a promisingly effective and safe
therapy method for subacute or chronic low back pain.
Cupping therapy can significantly decrease the VAS
scores and ODI scores compared to the control man-
agement (usual care/medication). High heterogeneity
and risk of bias existing in trials limited the authentic-
ity of the findings.
Acknowledgments
This work was supported by Guangdong province
natural science foundation of China (Grant No. 2015A
030313724), and Production, study and research pro-
ject of Guangdong province department of science of
China (Grant No. 2013B090600144).
Conflict of interest
The authors declare that they have no conflict of in-
terest.
References
[1] Manchikanti L, Singh V, Falco FJ, Benyamin RM, Hirsch JA.
Epidemiology of low back pain in adults. Neuromodulation.
2014; 17(Suppl 2): 3.
[2] Yang H, Haldeman S, Lu ML, Baker D. Low back pain preva-
lence and related workplace psychosocial risk factors: A study
using data from the 2010 national health interview survey.
Journal of Manipulative & Physiological Therapeutics. 2016;
39(7): 459-472.
[3] Minghelli B, Oliveira R, Nunes C. Postural habits and weight
of backpacks of Portuguese adolescents: Are they associated
with scoliosis and low back pain? Work. 2016; 54(1).
[4] Homaid MB, Abdelmoety D, Alshareef W, Alghamdi A, Al-
hozali F, Alfahmi N, Hafiz W, Alzahrani A, Elmorsy S. Preva-
lence and risk factors of low back pain among operation room
staff at a Tertiary Care Center, Makkah, Saudi Arabia: A
cross-sectional study. Annals of Occupational and Environ-
mental Medicine. 2016; 28(1): 1-8.
[5] Wáng YXJ, Wáng JQ, Káplár Z. Increased low back pain
prevalence in females than in males after menopause age: Ev-
idences based on synthetic literature review. Quant Imaging
Med Surg. 2016; 6(2): 199-206.
[6] Shmagel A, Foley R, Ibrahim H. Epidemiology of chronic low
back pain in US adults: National health and nutrition exam-
ination survey 2009–2010. Arthritis Care & Research. 2016;
68(11): 1688-1694.
[7] Kim KH, Kim TH, Hwangbo M, Yang GY. Anaemia and
skin pigmentation after excessive cupping therapy by an un-
qualified therapist in Korea: A case report. Acupuncture in
Medicine. 2012; 30(3): 227-228.
Y.-T. Wang et al. / Cupping therapy for LBP 1195
[8] Yoo SS, Francisco T. Cupping: East meets west. International
Journal of Dermatology. 2004; 43(9): 664-665.
[9] Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for
treating pain: A systematic review. The American Journal of
Chinese Medicine. 2010; 38(5): 829-838.
[10] Huang CY, Choong MY, Li TS. Effectiveness of cupping
therapy for low back pain: A systematic review. Acupuncture
in Medicine Journal of the British Medical Acupuncture So-
ciety. 2013; 31(3): 336.
[11] Cho HW, Hwang EH, Lim B, Heo KH, Liu JP, Tsutani K,
Lee MS, Shin BC. How current clinical practice guidelines for
low back pain reflect traditional medicine in east asian coun-
tries: A systematic review of clinical practice guidelines and
systematic reviews. Plos One. 2014; 9(2): e88027.
[12] Cao H, Han M, Zhu X, Liu J. An overview of systematic re-
views of clinical evidence for cupping therapy. Journal of Tra-
ditional Chinese Medical Sciences. 2015; 2(1): 3-10.
[13] Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional chi-
nese medicine for neck pain and low back pain: A systematic
review and meta-analysis. Plos One. 2015; 10(2): e0117146.
[14] Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP.
Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. Revista Española De Nu-
trición Humana Y Dietética. 2009; 18(3): 889-896.
[15] Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ.
Assessing the quality of reports of randomized clinical trials:
Is blinding necessary? Controlled Clinical Trials. 1996; 17(1):
1-12.
[16] Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in sys-
tematic reviews. Annals of Internal Medicine. 1997; 127(9):
820-826.
[17] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measur-
ing inconsistency in meta-analyses. British Medical Journal,
2003; 327(7414): 557-560.
[18] Hong YF, Wu JX, Wang B. The effect of moving cupping
therapy on nonspecific low back pain. Chinese Journal of Re-
habilitation Medicine. 2006; 21(4): 340--343. (Chinese)
[19] Liu BX, Xu M, Huang CG. Therapeutic effect of balance cup-
ping therapy on non-specific low back pain. Chin J Rehabil
Theory Pract. 2008; 14(6): 572-573. (Chinese)
[20] Li JY, Chen WT. Clinical observation of cupping therapy on
low back pain. Nei Mongol Journal of Traditional Chinese
Medicine. 2009; 7: 31-32. (Chinese)
[21] Farhadi K, Schwebel DC, Saeb M, Choubsaz M, Mohammadi
R, Ahmadi A. The effectiveness of wet-cupping for nonspe-
cific low back pain in Iran: A randomized controlled trial.
Complementary Therapies in Medicine. 2009; 17(1): 9-15.
[22] Akbarzadeh M, Ghaemmaghami M, Yazdanpanahi Z, Zare N,
Azizi A, Mohagheghzadeh A. The effect dry cupping ther-
apy at acupoint BL23 on the intensity of postpartum low back
pain in primiparous women based on two types of question-
naires, 2012; A randomized clinical trial. International Jour-
nal of Community Based Nursing & Midwifery. 2014; 2(2):
112-120.
[23] Albedah A, Khalil M, Elolemy A, Hussein AA, Alqaed M.
The use of wet cupping for persistent nonspecific low back
pain: Randomized controlled clinical trial. Journal of Alterna-
tive & Complementary Medicine. 2015; 21(8): 504-508.
[24] Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and
variance from the median, range, and the size of a sample.
Bmc Medical Research Methodology. 2005; 5(1): 13.
[25] Boonstra AM, Preuper HRS, Balk GA, Stewart RE. Cut-off
points for mild, moderate, and severe pain on the visual ana-
logue scale for pain in patients with chronic musculoskeletal
pain. Pain R
. 2014; 155(12): 2545-2550.
[26] Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry
low back pain disability questionnaire. Physiotherapy. 1980;
66(66): 271-273.
[27] Fairbank JC, Pynsent PB. The Oswestry Disability Index.
Spine. 2000; 25(22): 2940-2953.
[28] Melzack R. The short-form McGill pain questionnaire. Pain.
1987; 30(2): 191-197.
[29] Louw QA, Morris LD, Grimmer-Somers K. The prevalence
of low back pain in Africa: A systematic review. BMC Mus-
culoskelet Disord. 2007; 8(1): 105.
[30] Mousavi SJ, Parnianpour M, Vleeming A. Pregnancy related
pelvic girdle pain and low back pain in an Iranian population.
Spine. 2007; 32(3): 100-104.
[31] Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup
DF. Improving the quality of reports of meta-analyses of ran-
domised controlled trials: The QUOROM statement. Qual-
ity of Reporting of Meta-analyses. Lancet. 1999; 354: 1896-
1900.
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