Tuesday, August 16, 2016

Cupping for Pain, Health & Performance | Must Be Good, if Phelps Does it, Right? Let's See What the 100+ Studies Say

The "cups" come in various forms and sizes... and no, there's no meta-analysis yet that can tell you what the optimal size and form for the treatment of a given disease / problem would be ;-)
"If Phelps does it, it must be good!" I am pretty sure that SuppVersity readers don't think like that this is why I'd like to invite you to join my brief research review on cupping, i.e. the use of cups that are sucked to specific acupuncture points on your back via a simply physics trick: After being heated with fire, the air in the cup expands rapidly only to decrease by the same extent after the pre-heated cup is placed on your back. The rapid reduction of the volume of air in the cup will will create a vacuum that will not just glue the cup to your skin, but literally suck some of your skin into the cup and the capillaries in the skin to rupture - no wonder Phelp's body was plastered with red "cup marks" during the Olympic games ;-)

With Phelps strongly believing in the practice, it is quite obvious that it would have worked its alleged recovery magic irrespective of whether the increased blood flow to the cupped area has any local or systemic health effects whic allegedly range from anti-viral therapy to blood pressure management - you call that "placebo effect".
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From a science perspective, though, there is some preliminary evidence that Phelps' trust is / was not totally misplaced, though - here's an overview of what we know...
  • Initial evidence of cupping to treat chronic neck pain (Lauche. 2013) - Chronic neck pain is a major public health problem with very few evidence-based complementary treatment options.

    It would thus be great, if the positive results of a 2013 study that tested the efficacy of 12 weeks of a partner-delivered home-based cupping massage, and compared it to the same period of progressive muscle relaxation in patients with chronic non-specific neck pain, could be reproduced in a more tightly controlled  setting.
    Figure 1: Cupping vs. PMR home-treatment in a 12-week study in patients w/ chronic neck pain (Lauche. 2013).
    Primary outcome measure was the current neck pain intensity (0-100 mm visual analog scale; VAS) after 12 weeks. Secondary outcome measures included pain on motion, affective pain perception, functional disability, psychological distress, wellbeing, health-related quality of life, pressure pain thresholds and adverse events. Sixty one patients (54.1±12.7 years; 73.8%female) were randomized to cupping massage (n = 30) or progressive muscle relaxation (n = 31).

    After treatment, both groups showed significantly less pain compared to baseline however without significant group differences. Significant effects in favor of cupping massage were only found for wellbeing and pressure pain thresholds.

    "In conclusion, cupping massage is no more effective than progressive muscle relaxation in reducing chronic non-specific neck pain. Both therapies can be easily used at home and can reduce pain to a minimal clinically relevant extent. Cupping massage may however be better than PMR in improving well-being and decreasing pressure pain sensitivity but more studies with larger samples and longer follow-up periods are needed to confirm these results" (Lauche. 2013), the Lauche and colleagues from the University of Duisburg-Essen conclude.
  • Preliminary evidence of a reduction of symptoms of osteoarthritis (Teut. 2012) - Scientists from the Charité University Medical Center in Berlin investigated the effectiveness of cupping in relieving the symptoms of knee osteoarthritis (OA) in a two-group, randomized controlled exploratory pilot study.

    Image 1: Much in contrast to most other studies, the osteoarthritis didn't use "cups" and heating, but this adaptable silicone cup at the knee (Teut. 2012).
    Patients with a clinically and radiological confirmed knee OA (Kellgren-Lawrence Grading Scale: 2-4) and a pain intensity > 40 mm on a 100 mm visual analogue scale (VAS) were included. 40 Patients were randomized to either 8 sessions of pulsatile dry cupping within 4 weeks or no intervention (control). Paracetamol was allowed on demand for both groups. Outcomes were the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the pain intensity on a VAS (0 mm = no pain to 100 mm = maximum intensity) and Quality of Life (SF-36) 4 and 12 weeks after randomization.

    In addition, the subjects' use of Paracetamol was documented within the 4-week treatment period. Analyses were performed by analysis of covariance adjusting for the baseline value for each outcome.
    Figure 2: Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score and Visual Analogue Scale (VAS) for pain intensity after 4 and 12 weeks of cupping or control (Teut. 2012).
    21 patients were allocated to the cupping group (5 male; mean age 68 ± SD 7.2) and 19 to the control group (8 male; 69 ± 6.8). After 4 weeks the WOMAC global score improved significantly more in the cupping group with a mean of 27.7 (95% confidence interval 22.1; 33.3) compared to 42.2 (36.3; 48.1) in the control group (p = 0.001). After 12 weeks the WOMAC global score were still significantly different in favor for cupping (31.0 (24.9; 37.2) vs. 40.8 (34.4; 47.3) p = 0.032), however the WOMAC subscores for pain and stiffness were not significant anymore. Significantly better outcomes in the cupping group were also observed for pain intensity on VAS and for the SF-36 Physical Component Scale compared to the control group after 4 and 12 weeks. No significant difference was observed for the SF-36 Mental Component Scale and the total number of consumed Paracetamol tablets between both groups (mean 9.1, SD ± 20.0 vs. 11.5 ± 15.9).

    "In this exploratory study dry cupping with a pulsatile cupping device relieved symptoms of knee OA compared to no intervention. Further studies comparing cupping with active treatments are needed," Teut et al. conclude and forget to mention that everything could be placebo... after all, simply not doing anything is not a valid / significant "treatment" to evaluate the effects of cupping. This and the fact that the dosage of pain-killers are things you should keep in mind when evaluating the study results. 
"Wet" = bloody cupping - Geez!
"Wet cupping" is gorier than you'd expect: What doesn't sound like much is in fact a completely different way of cupping. While the previously described procedure (see introduction) may be a bit painful, it is totally non-invasive. That's in contrast to the so-called "wet-cupping" process aka "Hijamat bilshurt" in Unani medicine, which involves "the incising of skin either before the cup is placed or during the process of suctioning with needles placed at the base of the cup being used" (Akhtar. 2008). Overall a rather gory practice as the image to the left is one of the rather harmless photos you will find online.
  • Promising effects in chronic low back pain, systematic review says (Huang. 2016) - It's just published as a letter, but the systematic review Huang and colleagues from Taiwan argue that "the research results show that cupping therapy is promising for pain control and improvement of quality of life, and minimises the potential risks of treatment" (ibid.). Huang et al. base this assessment on their review of one randomised controlled trial (RCT, level I evidence), six non-RCTs (level II evidence), 20 case reports (level IV evidence) and two mechanism-based reasoning studies (see Table 1):
    Table 1: Overview of studies with levels I and II evidence Huang et al. (2016) included in their review.
    In the RCT, the effective rate of the wet-cupping (see red box!) group was similar to that of the waiting-list group (p>0.05). Interventions in both groups decreased pain, disability and acetaminophen dosage, but a significant decrease in pain intensity according to the McGill pain questionnaire (p<0.01) and reduced consumption of acetaminophen (p=0.09) were seen in the wet-cupping group. Similarly promising were the results of the six non-RCTs: one showed that the visual analogue scale (VAS) score and the Oswestry disability index in the balance-cupping group were significantly lower than in the group with cupping with retention and diclofenac (p<0.05), but there was no difference between the cupping with retention group and the diclofenac-only group (p>0.05). The other studies individually showed that the effectiveness of cupping in decreasing VAS,  reducing recurrence rate and improving quality of life, was better than Western medication.

    It should not be forgotten, though, that the evidence is rather preliminary than water-tight. Accordingly, Huang et al. are 100% right, when they demand that "further studies are needed to determine the potential role of cupping therapy in the treatment of low back pain" (Huang. 2016).
Table 2: Estimate effect of cupping for pain management (all types of diseases) from 16 included trials (Cao. 2014).
Pain management appears to be the best proven area of application (Cao. 2014) - As the overview of studies from Cao et al.'s 2014 review in Table 2 indicates, the effect of cupping for pain management (regardless of type of diseases) from 16 included trials is mostly, but not exclusively positive (meaning the pain was reduced), albeit not always significant and in many cases potentially influenced by confounding factors / treatments and thus far from being convincing evidence.
  • A plethora of additional possible benefits (Cao. 2012) - While pain management appears to be the closest to being a proven benefit of cupping, the literature that was reviewed among others by Cao, Li and Liu lists other purported benefits.

    The scientists from the University of Western Sydney and the Beijing University of Chinese Medicine managed to identify the impressive number of 135 RCTs published from 1992 through 2010; studies that were generally of low methodological quality, but investigated diseases ranging from herpes zoster, facial paralysis (Bell palsy), cough and dyspnea, over acne, lumbar disc herniation, to cervical spondylosis.
    Figure 3: Types of cupping therapy used in the studies in the meta-analysis (Cao. 2012).
    Unlike Phelps, most researchers used the "bloody" wet cupping - when all is said end done, not without negative effects as Cao et al. point out: "Meta-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" (Cao. 2012 | check out the Figures for free). 
Figure 3: While it turned out to be a failure in this follow up study (data from Aleyeidi. 2015), wet, i.e. bloody, cupping aka "Hijama" is traditionally used in Indian medicine to treat hypertension (=elevated blood pressure), too - and guess what: initial evidence from other studies suggested that it works (Lee. 2010; Zarai. 2012).
Bottom line: Thanks to the placebo effect and its very likely effects on practitioners pain threshold, it does not seem appropriate to laugh about Michael Phelps or anyone else who uses (dry!) cupping to promote recovery and/or control back, knee or whatever other pain (cf. Cao. 2014).

In the absence of bulletproof evidence from sensibly controlled human trials, it would yet be similarly misguided to think of cupping as a decisive factor in Phelps' recent Olympia success and/or a traditional medicine technique that doesn't just cure pain but also high blood lipid levels, which was the goal of an inaccessible doctoral thesis Abeer Mohammed Kawthar announced at the King Abdulaziz University - for blood pressure, Kawthar, this time working with Aleyeidi & Aseri has, after all, only recently failed to replicate the results of previous studies that suggested a blood pressure lowering effect of wet, i.e. bloody, cupping (Aleyeidi. 2015) | Comment!
  • Akhtar, Jamal, and M. Khalid Siddiqui. "Utility of cupping therapy Hijamat in Unani medicine." Indian J Trad Knowl 7.4 (2008): 572-4.
  • Cao, Huijuan, Xun Li, and Jianping Liu. "An updated review of the efficacy of cupping therapy." PLoS One 7.2 (2012): e31793.
  • Cao, Huijuan, et al. "Cupping therapy for acute and chronic pain management: a systematic review of randomized clinical trials." Journal of Traditional Chinese Medical Sciences 1.1 (2014): 49-61.
  • Huang, Chia-Yu, Mun-Yau Choong, and Tzong-Shiun Li. "Effectiveness of cupping therapy for low back pain: a systematic review." Acupuncture in Medicine (2013): acupmed-2013.
  • Kawthar, Abeer Mohammed. "Effect of compining antilipids drugs with wet cupping on lipid blood level." (2007).
  • Lauche, Romy, et al. "Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain—A randomized controlled trial." PloS one 8.6 (2013): e65378 [FFT]
  • Lee, Myeong Soo, et al. "Cupping for hypertension: a systematic review." Clinical and experimental hypertension 32.7 (2010): 423-425.
  • Teut, Michael, et al. "Pulsatile dry cupping in patients with osteoarthritis of the knee–a randomized controlled exploratory trial." BMC complementary and alternative medicine 12.1 (2012): 1.
  • Zarei, Mohammad, et al. "The efficacy of wet cupping in the treatment of hypertension." ARYA Atheroscler (2012): S145-S148.