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Background
Since 1950, traditional Chinese medicine (TCM) cupping therapy has been applied as a formal modality in hospitals throughout China and elsewhere in the world. Based on a previous systematic literature review of clinical studies on cupping therapy, this study presents a thorough review of randomized controlled trials (RCTs) to evaluate the therapeutic effect of cupping therapy.
Method
Six databases were searched for articles published through 2010. RCTs on cupping therapy for various diseases were included. Studies on cupping therapy combined with other TCM treatments versus non-TCM therapies were excluded.
Results
135 RCTs published from 1992 through 2010 were identified. The studies were generally of low methodological quality. Diseases for which cupping therapy was commonly applied were herpes zoster, facial paralysis (Bell palsy), cough and dyspnea, acne, lumbar disc herniation, and cervical spondylosis. Wet cupping was used in most trials, followed by retained cupping, moving cupping, and flash cupping. ****-analysis showed cupping therapy combined with other TCM treatments was significantly superior to other treatments alone in increasing the number of cured patients with herpes zoster, facial paralysis, acne, and cervical spondylosis. No serious adverse effects were reported in the trials.
Conclusions
Numerous RCTs on cupping therapy have been conducted and published during the past decades. This review showed that cupping has potential effect in the treatment of herpes zoster and other specific conditions. However, further rigorously designed trials on its use for other conditions are warranted.
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Introduction
Cupping is a traditional Chinese medicine (TCM) therapy dating back at least 2,000 years. Types of cupping include retained cupping, flash cupping, moving cupping, wet cupping, medicinal cupping, and needling cupping [1]. The actual cup can be made of materials such as bamboo, glass, or earthenware. The mechanism of cupping therapy is not clear, but some researchers suggest that placement of cups on selected acupoints on the skin produces hyperemia or hemostasis, which results in a therapeutic effect [2].
In our previous study, we conducted a systematic literature review based on available clinical studies published from 1958 through 2008 [3]. We concluded that the majority of the 550 included studies showed that cupping is of potential benefit for pain conditions, herpes zoster, and cough and dyspnea. Five other systematic reviews [4]–[8] on cupping therapy have also been published, focusing on pain conditions, stroke rehabilitation, hypertension, and herpes zoster, respectively. The numbers of included trials in these reviews were quite small (between 1and 8 trials). Lee et al. [9] conducted an overview of these five reviews and concluded that cupping is only effective as a treatment for pain, and even for this indication doubts remain. Extensive search did not find further related reviews.
Though the quality of included randomized controlled trials (RCTs) in the aforementioned reviews was generally poor according to the Cochrane risk of bias tool, we felt that it was still worth conducting an overview systematic review to further evaluate the therapeutic effect of cupping therapy for specific disease/conditions due to the paucity of evidence in this subject.
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Methods
The flow diagram for this review and supporting CONSORT checklist are available as supporting information; see Checklist S1 and Protocol S1.
Inclusion Criteria
Eligible studies were randomized controlled trials (RCTs) that examined the therapeutic effect of cupping therapy, including one or more types of cupping methods, compared with no treatment, placebo, or conventional medication. Cupping combined with other interventions and compared with other interventions alone were also included. Studies that looked at cupping therapy combined with other TCM therapies, such as acupuncture, compared with non-TCM therapies were excluded. Multiple publications reporting the same patient data set were also excluded. There was no restriction on ******** and publication type.
Identification and Selection of Studies
Based on our previous review [3], an updated search of publications was performed using China Network Knowledge Infrastructure (CNKI) (2009 through 2010), Chinese Scientific Journal Database (VIP) (2009 through 2010), Chinese Biomedical Database (CBM) (2009 through 2010), Wanfang Database (2009 through 2010), PubMed (1966 through 2010), and the Cochrane Central Register of Controlled Trials (CENTRAL, 1800 through 2010). All searches ended at December 2010. The search terms included cupping therapy, bleeding cupping, wet cupping, dry cupping, flash cupping, herbal cupping, moving cupping, needling cupping and retained cupping. Two authors (HC and XL) independently identified and checked each study against the inclusion criteria.
Data Extraction and Quality Assessment
Two authors (HC and XL) independently extracted the data from the included trials. The extracted data included authors and title of study, year of publication, type of disease, study size, age and gender of participants, and methodological information. Other extracted data included type of cupping therapy, treatment process, control interventions, outcomes (for example, overall efficacy rate), and adverse effects.
Quality of included trials was evaluated. Methodological quality of RCTs was assessed using criteria from the Cochrane Handbook for Systematic Reviews of Interventions [10]. Trials were appraised according to the risk of bias for each important outcome, including adequacy of generation of the random al******** sequence, al******** concealment, blinding, and outcome reporting. Quality of each trial was categorized into low/unclear/high risk of bias. Trials that met all criteria were categorized into low risk of bias, trials that met none of the criteria were categorized into high risk of bias, and the remaining trials were categorized into unclear risk of bias if there was insufficient information to make a judgment.
Data Analysis and Statistical Methods
Data were extracted using Microsoft Access and transferred into Microsoft Excel spreadsheets to be calculated for frequency. Outcome data were summarized using risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI for continuous outcomes. RevMan 5.0.20 software was used for data analyses. ****-analysis was used if the trials had good homogeneity, which was assessed by examining I2 (an index that describes the percentage of variation across studies that is due to heterogeneity rather than chance), on study design, participants, interventions, control, and outcome measures. Funnel plot analysis was done to determine publication bias.
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Results
Basic Information of Studies
Searches of six databases identified 1,294 citations, the majority of which were deemed ineligible from reading title and abstract (Protocol S1). Full-text papers of 108 trials were retrieved. In addition to the 73 trials from our previous review, 62 new trials were included in this study. Of the 135 included trials [11]–[145], 132 were published in Chinese, including 3 unpublished dissertations [16], [27], [72].The remaining 3 trials [69], [73], [86] were published in English. All included studies were published from 1992 through 2010, with more than half from 2008 through 2010 (Table S1).
Description of Interventions
Among the included trials, 78 (57.78%) used wet cupping as the main intervention, 23 (17.04%) used retained cupping, 12 (8.89%) used moving cupping, 10 trials (7.40%) used flash cupping, 6 (4.44%) used medicinal cupping, and 1 (0.74%) used needle cupping. Combined cupping in which at least two types of cupping methods were applied, was used in 5 trials (3.70%) (Figure 1).
Figure 1
Figure 1
Constituent ratios of types of cupping therapy.
Distribution of Diseases/Conditions
In the included trials, 56 diseases or symptoms were treated by cupping therapy. Diagnostic criteria varied, some authors used international criteria, such as ICD-10, others used Chinese criteria, such as those issued by government health agencies, or criteria from Chinese ******** medical textbooks. Some authors did not report any sources for their diagnostic criteria. The 6 most common diseases/conditions for which cupping was applied were herpes zoster (17 trials), facial paralysis (Bell palsy) (17 trials), cough and dyspnea (8 trials), acne (6 trials), lumbar disc herniation (6 trials) and cervical spondylosis (6 trials) (Table 1). ****-analyses were conducted on 4 diseases/conditions – herpes zoster, facial paralysis (Bell palsy), acne and cervical spondylosis (characteristics of the RCTs involving these 4 diseases are presented in Tables S2, S3, S4 and S5). Due to the heterogeneity of the RCTs of the remaining 2 diseases/conditions – lumbar disc herniation and cough and dyspnea – ****-analyses could not be completed.
Table 1
Table 1
Reporting of quality components in 135 included randomized clinical trials on cupping therapy.
Of the 6 diseases/conditions, 3 were related to pain, including herpes zoster, an inflammatory pain of the nerve; and lumbar disc herniation and cervical spondylosis, pain caused by nerve compression. Relieving pain was the main purpose of cupping therapy in these studies. Retained cupping or wet cupping was typically applied.
Facial paralysis (Bell palsy) falls under nerve, nerve root, and plexus disorders. In the studies we reviewed, flash cupping and moving cupping were commonly applied.
Respiratory diseases, such as pneumonia, bronchitis, and asthma, for which the main purpose of treatment is to alleviate the symptoms of cough and dyspnea are also treated by cupping therapy. Retained cupping or wet cupping therapy on EX-B1, a so-called extra acupoint (acupuncture point not located on one of the traditional channels), was mostly used in the studies for treating cough and dyspnea symptoms.
Acne is a skin condition that affects the face, neck, shoulders, chest, and back. In the studies we evaluated, wet cupping was primarily used to relieve the skin breakouts.
The remaining 50 diseases/conditions are presented in Table S1.
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2014-09-20, 10:24
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