**5.1 Low back pain**

Low back pain (LBP) is a common clinical problem which has an estimated one-year prevalence of 38% in the general population [33]. The current management options include bed rest during the acute phase, analgesia, physiotherapy, traction, alternative treatments, and health education on prevention of future episodes [34]. Cupping therapy has been used for a long time for both acute and chronic low back pain. Studies have shown significant reduction in pain intensity scores and improvement in functional outcome tools with cupping compared to other modalities of treatment like usual care or medications [34, 35]. Wang *et al* conducted a meta-analysis of six randomized controlled trials (RCTs). The total number of participants was 458 (230 received cupping *versus* 228 who received usual care). Five RCTs included patients with non-specific low back pain and a single RCT included post-partum women with low back pain. Different types of cupping were used in these trials (3 dry cupping, 2 wet cupping, 1 moving cupping). Pain was measured by different tools (1 visual analogue scale (VAS), 2 VAS + Oswestry pain disability index (ODI), 2 the McGill pain index (MPPI) + ODI, 1 VAS + MPPI). The meta-analysis concluded that cupping therapy was more effective compared to other modalities on reducing the VAS scores, and ODI scores. However, this positive effect was not captured on the MPPI.

Teut *et al* conducted a three-armed RCT in patients with chronic LBP to investigate the effectiveness of two different forms of cupping (dry pulsatile and minimal) compared to medication (paracetamol) on demand alone. A total of 110 subjects were enrolled in the study. Both forms of cupping were found to be effective compared to the control group after 4 weeks of therapy based on VAS scores. After 12 weeks, subjects who were in the pulsatile cupping group only reported beneficial effects as documented by the VAS scores and the physical component scale of the health quality of life short-form questionnaire (SF-36) [36]. Most of the studies which included patients with LBP investigated the short-term effects of cupping and were conducted for 2 to 12 weeks only [34, 37]. In addition, all of these studies suffered from major limitations which included high heterogeneity, small sample size, different inclusion criteria, different assessment tools, different types of cupping therapy, and different number of treatment sessions. Despite these limitations, the available literature supports the use of cupping therapy in patients with LBP but high-quality randomized clinical trials of longer duration and utilizing standardized assessment tools are needed to confirm these short-term beneficial effects.

### **5.2 Neck pain**

The lifelong prevalence of neck pain varies from 14.2% to 71% and it is more dominant in the high activity age groups, mainly individuals aged 35 to 49 years [38]. It was found to be associated with increased medical costs and adverse effects on personal productivity [39]. The commonly used therapies for neck pain include the use of analgesics and physiotherapy. In addition, surgery might be of help in some specific situations. However, these options are not always effective, and sometimes are associated with serious side-effects. Therefore, people have been always looking for other alternative options which include traditional medicine [40]. Cupping is one of the methods used commonly by people to relieve neck pain especially for the non-specific types. Studies conducted in patients with this condition investigated the effectiveness of cupping by measuring the following outcomes: pain intensity, disability scores, and quality of life [41]. The current available evidence indicates that cupping is effective for patients with chronic non-specific neck pain in terms of reduction in pain scores, improvement in disability scores, and quality of life indices compared to no treatment or active controls (physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), heat pack therapy, and acupuncture) [41]. Kim *et al* conducted a systematic review and meta-analysis which included 18 studies, out of which 7 studies used wet cupping while 11 studies used dry cupping as an intervention [41]. The number of subjects in each study ranged between 40 to 240 [41]. The subjects in the cupping group were reported to have significant reduction in pain scores, and significant improvement in terms of function and quality of life compared with no intervention or active control groups [41]. Leem *et al* studied the effects of cupping in patients with chronic neck pain for up to 2 years and reported sustainable positive effects on physical function and quality of life for the whole period of time unlike the effects on pain intensity which were not maintained [42]. In conclusion, the current evidence supports the use of cupping therapy to treat neck pain but it is not conclusive because of the low quality of available studies. Future better designed studies are required to confirm the beneficial effects of cupping in this group of patients.

## **5.3 Arthritis**

Arthritis is a commonly seen clinical problem in medical practice. It is a manifestation of many joint disorders like osteoarthritis, gout, rheumatoid arthritis

**225**

*The Role of Cupping Therapy in Pain Management: A Literature Review*

and others. Cupping therapy has been used to reduce the joint pain associated with osteoarthritis (OA), gout and ankylosing spondylitis. OA is a common chronic degenerative joint disease. The commonly affected joints are knees, hips and shoulders. It may present with pain, stiffness, and decreased mobility due to the effects on joint function and stability [43]. Li J *et al* concluded that the use of a combination of cupping therapy and Western medicine (physical therapy and use of analgesics) is more effective compared to Western medicine alone in patients with knee OA in terms of pain and stiffness reduction and improvement in physical function domains of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [44]. Yet, the use of cupping therapy alone compared to Western medicine therapy was not superior in decreasing pain

Gout is an inflammatory arthritis which results from deposition of monosodium

In conclusion, there is a weak evidence which supports the use of cupping therapy for pain management in different types of arthritis. Further research is required with better designed clinical trials to overcome the methodological problems, and the risk

Post-Herpetic Neuralgia (PHN) is a persistent neuropathic type of pain which

develops as a complication of herpes zoster infection. It may occur in 20% of herpes zoster patients and it can persist for 90 days after the acute phase of the rash [49]. The aim of the treatment of PHN is to control the pain by using topical and systemic drugs like topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic anti-depressants [50]. Cao *et al* conducted a systematic review of RCTs to evaluate the effects of wet cupping therapy in patients with PHN. Wet cupping therapy was found to be significantly better than medications, on rash healing (RR 2.49, 95%CI 1.91 to 3.24, p < 0.00001), pain reduction (RR 1.15, 95%CI 1.05 to 1.26, p = 0.003) and reduction in the incidence rate of post-herpetic neuralgia (RR 0.06, 95%CI 0.02 to 0.25, p = 0.0001) [51]. Tian *et al* reported that the use of wet cupping was significantly superior to pregabalin in terms of reduction in pain and reduction in peripheral and local serum substance P level [52]. A study by Wu *et al* found that the use of wet cupping was significantly more effective than herbal thermal compressing therapy and vitamin B12 intra-muscular injections in relieving the PHN pain [53]. Findings from these studies should be taken with caution because of the major limitations which included small sample size, methodological issues, and possibility of publication bias since all of the studies were conducted in a single

urate crystals in the joint space. It typically presents with painful joint inflammation, mainly in the first metatarsophalangeal joint [45]. A single study which was conducted in China investigated the combined effects of cupping and herbal medicine in comparison to the use of NSAIDs in acute gouty arthritis. The investigators reported that the therapeutic effects of both cupping and herbal medicine were comparable to NSAIDs but the differences were not statistically significant [46]. Ankylosing spondylitis (AS) is a chronic inflammatory disorder which causes chronic back pain. The common presenting symptoms are back pain and stiffness due to spinal fusion and ankylosis [47]. Ma *et al* conducted a systematic review and meta-analysis which included 5 RCTs, each with a sample size for each trial ranging from 42 to 280. Most of these trials were of low methodological quality [48]. It was concluded that the use of a combination therapy of cupping and Western medicine was more effective compared to Western medicine alone in terms of pain and stiffness reduction, improvement in physical function, disease activity, and serum

levels of inflammatory markers (ESR and CRP) [48].

of bias with the present studies.

**5.4 Post-herpetic neuralgia**

*DOI: http://dx.doi.org/10.5772/intechopen.93851*

intensity [44].

#### *The Role of Cupping Therapy in Pain Management: A Literature Review DOI: http://dx.doi.org/10.5772/intechopen.93851*

*Pain Management - Practices, Novel Therapies and Bioactives*

these short-term beneficial effects.

beneficial effects of cupping in this group of patients.

Arthritis is a commonly seen clinical problem in medical practice. It is a manifestation of many joint disorders like osteoarthritis, gout, rheumatoid arthritis

**5.2 Neck pain**

Teut *et al* conducted a three-armed RCT in patients with chronic LBP to investigate the effectiveness of two different forms of cupping (dry pulsatile and minimal) compared to medication (paracetamol) on demand alone. A total of 110 subjects were enrolled in the study. Both forms of cupping were found to be effective compared to the control group after 4 weeks of therapy based on VAS scores. After 12 weeks, subjects who were in the pulsatile cupping group only reported beneficial effects as documented by the VAS scores and the physical component scale of the health quality of life short-form questionnaire (SF-36) [36]. Most of the studies which included patients with LBP investigated the short-term effects of cupping and were conducted for 2 to 12 weeks only [34, 37]. In addition, all of these studies suffered from major limitations which included high heterogeneity, small sample size, different inclusion criteria, different assessment tools, different types of cupping therapy, and different number of treatment sessions. Despite these limitations, the available literature supports the use of cupping therapy in patients with LBP but high-quality randomized clinical trials of longer duration and utilizing standardized assessment tools are needed to confirm

The lifelong prevalence of neck pain varies from 14.2% to 71% and it is more dominant in the high activity age groups, mainly individuals aged 35 to 49 years [38]. It was found to be associated with increased medical costs and adverse effects on personal productivity [39]. The commonly used therapies for neck pain include the use of analgesics and physiotherapy. In addition, surgery might be of help in some specific situations. However, these options are not always effective, and sometimes are associated with serious side-effects. Therefore, people have been always looking for other alternative options which include traditional medicine [40]. Cupping is one of the methods used commonly by people to relieve neck pain especially for the non-specific types. Studies conducted in patients with this condition investigated the effectiveness of cupping by measuring the following outcomes: pain intensity, disability scores, and quality of life [41]. The current available evidence indicates that cupping is effective for patients with chronic non-specific neck pain in terms of reduction in pain scores, improvement in disability scores, and quality of life indices compared to no treatment or active controls (physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), heat pack therapy, and acupuncture) [41]. Kim *et al* conducted a systematic review and meta-analysis which included 18 studies, out of which 7 studies used wet cupping while 11 studies used dry cupping as an intervention [41]. The number of subjects in each study ranged between 40 to 240 [41]. The subjects in the cupping group were reported to have significant reduction in pain scores, and significant improvement in terms of function and quality of life compared with no intervention or active control groups [41]. Leem *et al* studied the effects of cupping in patients with chronic neck pain for up to 2 years and reported sustainable positive effects on physical function and quality of life for the whole period of time unlike the effects on pain intensity which were not maintained [42]. In conclusion, the current evidence supports the use of cupping therapy to treat neck pain but it is not conclusive because of the low quality of available studies. Future better designed studies are required to confirm the

**224**

**5.3 Arthritis**

and others. Cupping therapy has been used to reduce the joint pain associated with osteoarthritis (OA), gout and ankylosing spondylitis. OA is a common chronic degenerative joint disease. The commonly affected joints are knees, hips and shoulders. It may present with pain, stiffness, and decreased mobility due to the effects on joint function and stability [43]. Li J *et al* concluded that the use of a combination of cupping therapy and Western medicine (physical therapy and use of analgesics) is more effective compared to Western medicine alone in patients with knee OA in terms of pain and stiffness reduction and improvement in physical function domains of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [44]. Yet, the use of cupping therapy alone compared to Western medicine therapy was not superior in decreasing pain intensity [44].

Gout is an inflammatory arthritis which results from deposition of monosodium urate crystals in the joint space. It typically presents with painful joint inflammation, mainly in the first metatarsophalangeal joint [45]. A single study which was conducted in China investigated the combined effects of cupping and herbal medicine in comparison to the use of NSAIDs in acute gouty arthritis. The investigators reported that the therapeutic effects of both cupping and herbal medicine were comparable to NSAIDs but the differences were not statistically significant [46].

Ankylosing spondylitis (AS) is a chronic inflammatory disorder which causes chronic back pain. The common presenting symptoms are back pain and stiffness due to spinal fusion and ankylosis [47]. Ma *et al* conducted a systematic review and meta-analysis which included 5 RCTs, each with a sample size for each trial ranging from 42 to 280. Most of these trials were of low methodological quality [48]. It was concluded that the use of a combination therapy of cupping and Western medicine was more effective compared to Western medicine alone in terms of pain and stiffness reduction, improvement in physical function, disease activity, and serum levels of inflammatory markers (ESR and CRP) [48].

In conclusion, there is a weak evidence which supports the use of cupping therapy for pain management in different types of arthritis. Further research is required with better designed clinical trials to overcome the methodological problems, and the risk of bias with the present studies.

#### **5.4 Post-herpetic neuralgia**

Post-Herpetic Neuralgia (PHN) is a persistent neuropathic type of pain which develops as a complication of herpes zoster infection. It may occur in 20% of herpes zoster patients and it can persist for 90 days after the acute phase of the rash [49]. The aim of the treatment of PHN is to control the pain by using topical and systemic drugs like topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic anti-depressants [50]. Cao *et al* conducted a systematic review of RCTs to evaluate the effects of wet cupping therapy in patients with PHN. Wet cupping therapy was found to be significantly better than medications, on rash healing (RR 2.49, 95%CI 1.91 to 3.24, p < 0.00001), pain reduction (RR 1.15, 95%CI 1.05 to 1.26, p = 0.003) and reduction in the incidence rate of post-herpetic neuralgia (RR 0.06, 95%CI 0.02 to 0.25, p = 0.0001) [51]. Tian *et al* reported that the use of wet cupping was significantly superior to pregabalin in terms of reduction in pain and reduction in peripheral and local serum substance P level [52]. A study by Wu *et al* found that the use of wet cupping was significantly more effective than herbal thermal compressing therapy and vitamin B12 intra-muscular injections in relieving the PHN pain [53]. Findings from these studies should be taken with caution because of the major limitations which included small sample size, methodological issues, and possibility of publication bias since all of the studies were conducted in a single

country [51]. Further research with better designed studies and longer follow-up periods is warranted.

### **5.5 Carpel tunnel syndrome**

Carpal tunnel syndrome (CTS) is a peripheral nerve entrapment due to the compression of the median nerve in the carpal tunnel of the wrist joint. It usually manifests as numbness and burning pain in the palm and the first three fingers (sensory involvement), and reduction in the grip strength (motor involvement) [54]. The beneficial effects of cupping therapy were observed when used in combination with physiotherapy or alone. Mohammadi *et al* studied the effects of cupping in combination with physiotherapy compared to physiotherapy alone on CTS patients. Modified cups were used in this study to accommodate the anatomical shape of the wrist joint. The pressure level used during the treatment sessions was 50 mmHg and the cups were applied for 4 minutes. A total of 10 sessions were done and the effects were assessed after completion of all the sessions. Four CTS-related parameters were measured: symptom severity, functional status, distal sensory latency, and distal motor latency. The study concluded that there was a significant improvement in the symptom severity scale and reduction in the distal sensory latency in the cupping group compared to the control group. In addition, subjects in the cupping group had an improvement in the functional status scale and reduction in the distal motor latency but the differences were not statistically significant. The limitations of the study included the lack of regular time intervals to assess the effects, and the uneven distribution of patients with severe disease between the two arms of the study [55]. Furthermore, two case reports had documented the beneficial effects of cupping in CTS patients [56, 57]. The first case report used wet cupping and reported profound reduction in pain, numbness and paresthesia. These clinical findings were confirmed by significant improvement in the electrophysiological measures as demonstrated by both nerve conduction velocity and electromyography [56]. The second case report used self-applied cupping at least once daily for 3 to 5 minutes for a period of 3 months in a patient with mild CTS symptoms. The patient reported an improvement in the symptoms after 1 week of treatment and complete resolution of all symptoms after 6–8 weeks. The nerve conduction study showed that median distal latency had returned back to the normal range after 3 months [57].

## **5.6 Fibromyalgia**

Fibromyalgia is a disorder characterized by chronic generalized pain, fatigue, cognitive disturbances, sleep disorder, and pronounced somatic and psychological distress [58]. The main aim of treatment for fibromyalgia patients is to relieve pain and to improve the patients' quality of life [59]. Few studies were conducted to investigate the effects of cupping in fibromyalgia. Lauche *at al* reported that cupping therapy was more effective than usual care in patients diagnosed with the fibromyalgia syndrome after 18 days from treatment in terms of reduction in pain intensity and improvement in quality of life [60]. Moreover, the other studies were conducted to evaluate the effectiveness of a combination therapy of cupping and acupuncture together with conventional medications (anti-depressants) compared to medications alone [61, 62]. A total of 242 patients were included in both studies. Significant reduction in pain scores (MD −1.65, 95%CI −2.10 to −1.31, < 0.00001) were reported in the combination group compared to the control group [29]. Further research with better quality studies is needed to determine the effectiveness of cupping in this group of patients.

**227**

**Table 1.**

*The Role of Cupping Therapy in Pain Management: A Literature Review*

cautions [5]. The contraindications are summarized in **Table 1**.

Cupping therapy is a process where suction with or without scarification is done as a treatment for different types of pain and medical problems. Direct application of cupping on specific sites of the body is contraindicated as the negative pressure created during cupping therapy might be harmful [23]. These sites are veins, arteries, nerves, inflamed and injured skin, body orifices, eyes, lymph nodes, varicose veins, bone fractures, and sites of deep vein thrombosis [23]. Ahmedi et *al* classified the contraindications into absolute, relative and with

Prevention of infection by following strict infection control measures is an essential aspect of clinical care. In cupping therapy, such measures are of paramount importance since the therapy necessitates direct contact with the skin and body fluids. Several infection control measures should be considered. These measures include hand hygiene and washing, and wearing personal protective equipment like gloves, masks, protective eyewear and gowns. Disinfection of the patient's skin with approved disinfectants is required before starting the procedure. Also, disinfection of the patient's bed or use of disposable bed covers is needed. It is recommended to use disposable cups, vacuum pumps, and surgical blades to avoid cross-transmission of infection. Lastly, adhering to proper medical waste segrega-

**Absolute contraindication Relative contraindication Caution** Cancer Acute infection Active psoriasis

Patients using pacemaker Pregnancy, puerperium Children Bleeding disorders like hemophilia Anti-coagulant therapy Anti-platelet

Undiagnosed/suspicious lump Menstruation Anemia

disease)

recent blood donation

recent blood donation

Keloid scars

therapy

disease

Peripheral vascular

Organ failure (heart, renal, hepatic) Severe chronic disease (e.g. heart

Active cellulitis/erysipelas/abscess Recent wet cupping session or

Ulcer Recent wet cupping session or

Thrombophlebitis Medical emergencies

*Contraindications to cupping therapy (adapted from Ahmedi* et al *[5]).*

*DOI: http://dx.doi.org/10.5772/intechopen.93851*

**6. Contraindications**

**7. Infection control measures**

tion system is crucial [63, 64].

Deep vein thrombosis Cauda equina

Life threatening asthma

Fracture site

Chemotherapy

Stroke — unstable or evolving

Suspected osteomyelitis or septic arthritis
