An Updated Review of the Efficacy of Cupping Therapy

Abstract

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.

Methods

The flow diagram for this review and supporting CONSORT checklist are available as supporting information; see Checklist S1 and Protocol S1.

Results

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).

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Figure 1

Constituent ratios of types of cupping therapy.

Estimate Effects of RCTs with Cupping

Due to insufficient number of RCTs and the variations in study quality, participants, intervention, variable control, and outcome measures, results of most of the studies could not be synthesized by quantitative methods. Though 133 of the 135 included studies showed that cupping therapy as well as cupping combined with other treatment were significantly effective for certain diseases (Table S6), interpretation of the positive findings from the individual studies needs to be incorporated with the clinical characteristics of the included studies and evidence power. Therefore, the beneficial effect of cupping therapy needs to be confirmed through large and rigorously-designed RCTs.

We conducted meta-analyses to evaluate therapeutic effect of cupping therapies for herpes zoster, facial paralysis, acne, and cervical spondylosis (Tables 2–5).

Table 2

Effect of estimates of wet cupping treatment for herpes zoster in 15 RCTs.

Trials	Comparisons	Effect estimates ([95%CI])	P
Numbers of cured patients
Wet cupping plus other interventions versus other interventions alone
Wet cupping plus medication versus medications alone
Guo L 2006 [32]	Wet cupping plus aciclovir, VitB1, VitB12 versus aciclovir, VitB1, VitB12	RR 1.48 [1.05, 2.09]
Liu L 2003 [61]	Wet cupping plus aciclovir, VitB1, VitB12 and aciclovir cream versus aciclovir, VitB1, VitB12, and aciclovir cream	RR 3.83 [2.07, 7.06]
Long W 2003 [64]	Wet cupping plus ultraviolet radiation versus ultraviolet radiation alone	RR 1.30 [1.06, 1.59]
Xu L 2004 [104]	Wet cupping plus aciclovir cream, aciclovir 0.5 g and glucose 250 ml intravenous drip versus aciclovir cream, aciclovir 0.5 g and glucose 250 ml intravenous drip	RR 1.35 [0.93, 1.97]
Zhang Q 2008 [126]	Wet cupping and bloodletting on ear apex plus aciclovir and acupuncture versus aciclovir and acupuncture	RR 4.17 [1.92, 9.05]
Subgroup		RR 1.93 [1.23, 3.04]*	0.005
Wet cupping plus acupuncture versus acupuncture alone
Huang J 2008 [37]	Wet cupping plus acupuncture versus acupuncture alone	RR 2.38 [1.10, 5.13]
Zhang H 2009 [122]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 1.29 [0.95, 1.76]
Zuo R 2010 [145]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 1.91 [1.07, 3.42]
Subgroup		RR 1,65 [1.08, 2.53]	0.02
Overall (Random, I2  = 76%)		RR 1.81 [1.33, 2.45]	0.0001
Wet cupping versus medications
Ci H 2010 [20]	Wet cupping versus aciclovir	RR 1.60 [1.24, 2.06]
Jin M 2008 [45]	Wet cupping versus aciclovir, cimetidine, indomethacin, mecobalamin, calamine, and aciclovir cream	RR 2.15 [1.54, 3.00]
Liu L 2003 [61]	Wet cupping versus aciclovir, VitB1, VitB12, and aciclovir cream	RR 2.83 [1.47, 5.46]
Liu Q 2004 [63]	Wet cupping versus aciclovir and poly I-C injection	RR 2.90 [1.71, 4.91]
Wang Y 2009 [94]	Wet cupping versus valaciclovir	RR 2.34 [1.66, 3.30]
Overall (Fixed, I2  = 43%)		RR 2.07 [1.77, 2.43]	<0.00001
Numbers of patients with postherpetic neuralgia after treatment
wet cupping versus medications alone
Jin M 2008 [45]	Wet cupping versus acyclovir, cimetidine, indomethacin, mecobalamin, 23acyclovir, andacyclovir cream	RR 0.09 [0.01, 1.60]
Liu L 2003 [61]	Wet cupping versus acyclovir, VitB1, VitB12, and acyclovir cream	RR 0.06 [0.00, 1.09]
Wang Y 2009 [94]	Wet cupping versus valaciclovir	RR 0.23 [0.08, 0.64]
Xiong Z 2007 [103]	Wet cupping versus acyclovir plus normal saline 250 ml intravenous drip	RR 0.05 [0.01, 0.38]
Overall (Fixed, I2  = 0%)		RR 0.12 [0.06, 0.28]	<0.00001
Numbers of patients with effective symptoms after treatment
Wet cupping plus other interventions versus other interventions alone
Wet cupping plus medication versus medication alone
Guo L 2006 [32]	Wet cupping plus aciclovir, VitB1, VitB12 versus aciclovir, VitB1, VitB12	RR 1.00 [0.92, 1.08]
Liu L 2003 [61]	Wet cupping plus aciclovir, VitB1, VitB12 and aciclovir cream versus aciclovir, VitB1, VitB12, and aciclovir cream	RR 1.00 [0.95, 1.05]
Xu L 2004 [104]	Wet cupping plus aciclovir cream, aciclovir 0.5 g and glucose 250 ml intravenous drip versus aciclovir cream, aciclovir 0.5 g, and glucose 250 ml intravenous drip	RR 1.00 [0.95, 1.05]
Zhang Q 2008 [126]	Wet cupping and blood-letting on auditive apex plus aciclovir and acupuncture versus aciclovir and acupuncture	RR 1.00 [0.95, 1.05]
Subgroup		RR 1.00 [0.97, 1.03]	0.99
Wet cupping plus acupuncture versus acupuncture alone
Huang J 2008 [37]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.09 [0.83, 1.43]
Zhang H 2009 [122]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 1.20 [0.97, 1.48]
Zuo R 2010 [145]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 1.11 [0.98, 1.27]
Subgroup		RR 1.13 [1.02, 1.25]	0.02
Overall (Random, I2  = 52%)		RR 1.02 [0.98, 1.06]	0.41
Wet cupping versus medications
Ci H 2010 [20]	Wet cupping versus aciclovir	RR 1.22 [1.07, 1.40]
Jin M 2008 [45]	Wet cupping versus aciclovir, cimetidine, indomethacin, mecobalamin, calamine, and aciclovir cream	RR 1.07 [0.98, 1.17]
Liu L 2003 [61]	Wet cupping versus aciclovir, VitB1, VitB12 and aciclovir cream	RR 1.00 [0.94, 1.06]
Liu Q 2004 [63]	Wet cupping versus aciclovir and poly I-C injection	RR 1.27 [1.05, 1.54]
Wang Y 2009 [94]	Wet cupping versus valaciclovir	RR 1.08 [0.99, 1.17]
Overall (Random, I2  = 82%)		RR 1.11 [1.00, 1.23]	0.06
Average cure time
Wet cupping plus other interventions versus other interventions alone
Guo L 2006 [32]	Wet cupping plus aciclovir, VitB1, VitB12 versus aciclovir, VitB1, VitB12	MD −2.10 [−3.55, −0.65]
Liu L 2003 [61]	Wet cupping plus aciclovir, VitB1, VitB12, and aciclovir cream versus aciclovir, VitB1, VitB12,and aciclovir cream	MD −5.08 [−8.04, −2.12]
Overall (Fixed, I2  = 68%)		MD −2.67 [−3.97, −1.37]	<0.0001
Wet cupping versus medications
Liu L 2003 [61]	Wet cupping versus aciclovir, VitB1, VitB12, and aciclovir cream	MD −3.14 [−6.45, 0.17]
Overall (Fixed, I2  = 0%)		MD −3.14 [−6.45, 0.17]	0.06

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Table 5

Effect of estimates of cupping for cervical spondylosis in 6 RCTs.

Trials	Comparisons	Effect Estimates ([95%CI])	P
Numbers of cured patients
Cupping plus other interventions versus other interventions alone
Cupping plus acupuncture versus acupuncture alone
Wan XW 2007 [86]	Needling cupping plus acupuncture versus acupuncture alone	RR 1.59 [1.14, 2.22]
Subgroup		RR 1.59 [1.14, 2.22]	0.007
Wet cupping plus acupuncture versus acupuncture alone
Shao M 2003 [79]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.64 [1.04, 2.58]
Wang PL 2010 [90]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.15 [0.63, 2.12]
Subgroup		RR 1.46 [1.01, 2.09]	0.04
Wet cupping plus electroacupuncture versus electroacupuncture alone
Wang XM 2004 [93]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 1.59 [0.72, 3.53]
Subgroup		RR 1.59 [0.72, 3.53]	0.25
Wet cupping plus traction versus traction alone
You Y 2006 [116]	Wet cupping plus traction versus traction alone	RR 1.55 [0.83, 2.91]
Subgroup		RR 1.55 [0.83, 2.91]	0.17
Overall (Fixed, I2  = 0%)		RR 1.52 [1.20, 1.92]	0.0005
Numbers of effective patients
Cupping plus other interventions versus other interventions alone
Cupping plus acupuncture versus acupuncture alone
Wan XW 2007 [86]	Needling cupping plus acupuncture versus acupuncture alone	RR 10.36 [0.53, 201.45]
Subgroup		RR 10.36 [0.53, 201.45]	0.12
Wetcupping plus acupuncture versus acupuncture alone
Shao M 2003 [79]	Wet cupping plus acupuncture versus acupuncture alone	RR 2.90 [1.14, 7.38]
Wang PL 2010 [90]	Wet cupping plus acupuncture versus acupuncture alone	RR 6.83 [0.79, 59.48]
Subgroup		RR 3.43 [1.47, 8.01]	0.004
Wet cupping plus electroacupuncture versus electroacupuncture alone
Wang XM 2004 [93]	Wet cupping plus electroacupuncture versus electroacupuncture alone	RR 7.22 [0.72, 72.56]
Subgroup		RR 7.22 [0.72, 72.56]	0.09
Wet cupping plus warm acupuncture versus warm acupuncture alone
Zeng HW 2007 [117]	Wet cupping plus acupuncture and moxibustion versus acupuncture and moxibustion alone	RR 3.86 [1.12, 13.26]
Subgroup		RR 3.86 [1.12, 13.26]	0.03
Wet cupping plus traction versus traction alone
You Y 2006 [116]	Wet cupping plus traction versus traction alone	RR 3.24 [1.04, 10.05]
Subgroup		RR 3.24 [1.04, 10.05]	0.17
Overall (Fixed, I2  = 0%)		RR 3.84 [2.19, 6.75]	<0.00001
Wet cupping versus medications
Zeng HW 2007 [117]	Wet cupping versus flunarizine	RR 1.18 [0.60, 2.32]
Overall		RR 1.18 [0.60, 2.32]	0.63

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Table 3

Effect of estimates of cupping for facial paralysis in 15 RCTs.

Trials	Comparisons	Effect Estimates ([95%CI])	P
Numbers of cured patients
Cupping plus other interventions versus other interventions alone
Flash cupping plus acupuncture versus acupuncture alone
Cao R 2009 [12]	Flash cupping plus acupuncture versus acupuncture alone	RR 2.00 [1.09, 3.66]
Fu C 2004 [25]	Flash cupping plus acupuncture versus acupuncture alone	RR 1.73 [1.30, 2.30]
Huang L 2009 [39]	Flash cupping plus acupuncture versus acupuncture alone	RR 1.33 [0.95, 1.86]
Li K 2009 [49]	Flash cupping plus acupuncture versus acupuncture alone	RR 1.50 [1.02, 2.21]
Zhao N 2010 [133]	Flash cupping plus acupuncture versus acupuncture alone	RR 1.33 [1.04, 1.68]
Subgroup		RR 1.51 [1.29, 1.76]	<0.00001
Wet cupping plus acupuncture versus acupuncture alone
Gao B 2010 [28]	Wet cupping plus acupuncture and mecobalamine versus acupuncture and mecobalamine alone	RR 1.68[0.62, 4.53]
Huang L 2010 [40]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.60 [0.79, 3.23]
Lü J 2010 [71]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.29 [0.95, 1.76]
Ren Y 2006 [77]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.91 [1.32, 2.76]
Sun H 2010 [80]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.71 [1.23, 2.36]
Wang L 2010 [89]	Wet cupping plus acupuncture versus acupuncture alone	RR 1.41 [0.85, 2.35]
Subgroup		RR 1.60 [1.33, 1.93]	<0.0001
Medicinal cupping plus medication versus medications
Qiu J 2003 [76]	Medicinal cupping plus neurotrophic drugs versus neurotrophic drugs alone	RR 1.44 [1.11, 1.87]
Subgroup		RR 1.44 [1.11, 1.87]	0.006
Wet cupping plus TDP and medications versus TDP and medications
Li W 2005 [51]	Wet cupping plus TDP, antivirus and neurotrophic drugs versus TDP and drugs alone	RR 1.18 [0.89, 1.57]
Subgroup		RR 1.18 [0.89, 1.57]	0.25
Flash cupping plus herbal medicine and acupuncture versus herbal medicine and acupuncture
Ou X 2009 [75]	Flash cupping plus herbal decoction and acupuncture versus herbal decoction and acupuncture	RR 1.37 [1.05, 1.80]
subgroup		RR 1.37 [1.05, 1.80]	0.02
Overall (Fixed, I2  = 0%)		RR 1.49 [1.35, 1.65]	<0.00001
Wet cupping versus medications
Zhu F 2009 [141]	Wet cupping versus antivirus and neurotrophic drugs	RR 1.33 [0.83, 2.14]
Overall		RR 1.33 [0.83, 2.14]	0.23

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Table 4

Effect of estimates of cupping for acne in 6 RCTs.

Trials	Comparisons	Effect Estimates ([95%CI])	P
Numbers of cured patients
Wet cupping plus other interventions versus other interventions alone
Wet cupping plus herbal medicine versus herbal medicine alone
Huang J 2010 [38]	Wet cupping plus herbal preparation, topical cream versus herbal preparation and external cream	RR 2.06 [1.33, 3.18]
Subgroup		RR 2.06 [1.33, 3.18]	0.001
Wet cupping plus acupuncture versus acupuncture alone
Liu H 2009 [59]	Flash cupping plus acupuncture versus acupuncture alone	RR 1.91 [0.99, 3.72]
Wang Q 2007 [91]	Moving and wet cupping plus acupuncture versus acupuncture alone	RR 1.67 [0.87, 3.20]
Subgroup		RR 1,79 [1.12, 2.86]	0.01
Overall (Fixed, I2  = 0%)		RR 1.93 [1.40, 2.65]	<0.0001
Wet cupping versus medications
Wu F 2010 [95]	Wet cupping versus tanshinone	RR 1.07 [0.45, 2.56]
Wu Y 2008 [97]	Wet cupping versus tetracycline and ketoconazole cream	RR 2.50 [1.31, 4.77]
Zhang K 2008 [125]	Wet cupping versus tetracycline	RR 2.75 [1.38, 5.48]
Overall (Fixed, I2  = 37%)		RR 2.14 [1.42, 3.22]	0.0003
Average cure time
Cupping plus other intervention versus other interventions alone
Li W 2005 [51]	Wet cupping plus TDP, antivirus and neurotrophic drugs versus TDP and drugs alone	MD −4.14 [−5.74, −2.54]
Qiu J 2003 [76]	Medicinal cupping plus neurotrophic drugs versus neurotrophic drugs alone	MD −8.00 [−9.78, −6.22]
Overall (Random, I2  = 90%)		MD −6.05 [−9.83, −2.27]	0.002
Wet cupping versus medications
Zhu F 2009 [141]	Wet cupping versus antivirus and neurotrophic drugs	MD −7.20 [−14.27, −0.13]
Overall		MD −7.20 [−14.27, −0.13]	0.05

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Meta-analysis of 15 RCTs [20], [29], [32], [37], [45], [61], [63], [64], [94], [102]–[104], [122], [126], [145] to evaluate the efficacy of wet cupping therapy for herpes zoster (2 trials [13], [123] were excluded due to insufficient data), wet cupping was found to be superior to pharmaceutical medications, such as antiviral, in effecting a cure (RR 2.07, 95%CI 1.77 to 2.43, p<0.00001, 5 trials, random model) (Figure 2), and in lowering the incidence rate of post-herpetic neuralgia (RR 0.12, 95%CI 0.06 to 0.28, p<0.00001, 4 trials, fixed model). But no difference was identified in the number of patients with improved symptoms (RR 1.11, 95%CI 1.00 to 1.23, p = 0.06, 5 trials, random model). Wet cupping in combination with pharmaceutical medications was significantly better than medications alone in effecting a cure (RR 1.93, 95%CI 1.23 to 3.04, p = 0.005, 5 trials, random model), but no difference in symptom improvement was observed (RR 1.00, 95%CI 0.97 to 1.03, p = 0.99, 4 trials, random model) (Figure 3). Wet cupping combined with acupuncture was superior to acupuncture alone both in effecting a cure (RR 1.65, 95%CI 1.08 to 2.53, p = 0.02, 3 trials, random model) (Figure 3) and in improving symptoms (RR 1.13, 95%CI 1.02 to 1.25, p = 0.02, 3 trials, random model).

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Figure 2

Effect of estimates of wet cupping versus medication on numbers of cured patients with herpes zoster.

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Figure 3

Effect of estimates of combination of wet cupping and other interventions versus other interventions alone on numbers of cured patients of herpes zoster.

There were 17 RCTs [12], [15], [39], [40], [47], [49]–[51], [71], [75]–[77], [80], [89], [133], [141] that assessed the therapeutic effect of cupping therapy for facial paralysis. Two of the trials [47], [50] were excluded from the meta-analysis due to the incomparability between treatment and control groups. Six trials used flash cupping therapy, 8 trials used wet cupping, and 1 trial used medicinal cupping as the main intervention. Meta-analysis showed flash cupping combined with acupuncture (RR 1.51, 95%CI 1.29 to 1.76, p<0.00001, 5 trials, fixed model) and wet cupping combined with acupuncture (RR 1.60, 95%CI 1.33 to 1.93, p<0.0001, 6 trials, fixed model) were markedly better than acupuncture alone in effecting a cure (Figure 4). In addition, cupping in combination with medications, such as neurotrophic drugs, was superior to medications alone in reducing average cure time (MD −6.05, 95%CI −9.83 to −2.27, p = 0.002, 2 trials, random model).

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Figure 4

Effect of estimates of cupping combined with other interventions versus other interventions alone on numbers of cured patients with facial paralysis.

Six trials [38], [59], [91], [95], [97], [125] evaluated the efficacy of cupping therapy for acne. Meta-analysis showed that, for improving the cure rate, wet cupping therapy was significantly better than medications, such as tanshinone, tetracycline, and ketokonazole (RR 2.14, 95%CI 1.42 to 3.22, p = 0.0003, 3 trials, fixed model). Furthermore, cupping therapy combined with other interventions was superior to other interventions alone (RR 1.93, 95%CI 1.40 to 2.65, p<0.0001, 3 trials, fixed model). As each comparison had less than five trials, it was not meaningful to conduct a funnel plot analysis.

For cervical spondylosis, 6 trials [79], [86], [90], [93], [116], [117] evaluated the efficacy of cupping therapy on this condition. Cupping therapy, especially wet cupping on GV-14 and Ashi points, combined with other treatment, including acupuncture and traction, was better than other treatments alone in effecting a cure (RR 1.52, 95%CI 1.20 to 1.92, p = 0.0005, 5 trials, fixed model) and in ameliorating symptoms (RR 3.84, 95%CI 2.19 to 6.75, p<0.00001, 6 trials, fixed model). One trial [117] compared wet cupping with flunarizine for symptom improvement, and found no difference between the two groups (RR 1.18, 95%CI 0.60 to 2.32, p = 0.63, 1 trial).

A funnel plot analysis of 39 trials was performed to examine outcome for the number of cured patients irrespective of disease. The result showed potential asymmetry (Figure 5).

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Figure 5

Funnel plot assessing outcomes of cured patients reported in 39 randomized controlled trials on 4 diseases.

Serious adverse effects were not reported in any of the 135 included trials.

Discussion

In our previous review [3], we focused on the characteristics of the RCTs on cupping therapy. This review aimed to ascertain whether or not cupping therapy is efficacious for several conditions, especially when combined with other treatments. With this review, we expanded our search to include articles published from 2008 through 2010. The 62 new studies indicate that the ancient TCM practice of cupping remains an important therapeutic modality in China and is gaining recognition elsewhere. For diseases/conditions that are commonly treated by cupping, we conducted meta-analyses by synthesizing data from homogeneous studies to assess the therapeutic effect of cupping in treating these diseases/conditions. For studies whose data were inappropriate for synthesis, we used qualitative methods to evaluate their findings. This is the first instance that quantitative and qualitative methods were used in a systematic review to evaluate the efficacy of cupping therapy.

Despite the large number of studies on cupping therapy, including the 62 new ones, there remains a lack of well-designed investigations. Of the 135 RCTs included in this review, 84.44% were high risk of bias. One issue is adherence to the Consolidated Standards of Reporting Trials (CONSORT) [146] in which randomization methods should be clearly described and fully reported. Another issue is blinding, which continues to be a challenge for studies involving manual healing therapies, such as acupuncture, massage, and cupping therapy. Lee et al [147] report developing a sham cupping device with a tiny opening that in effect reduces the negative pressure in the cup once it is attached to the skin. The RCT they conducted showed that the device appears to be tenable as a control for actual cupping, though confirmatory studies are needed. While blinding during studies on cupping therapy may be difficult to achieve, at the very least, blinding of outcome assessors and statistics should be attempted to minimize performance and assessment biases. Another area that researchers should be attentive to is adapting STRICTA [148] standards when designing and reporting studies. Similar to acupuncture, cupping therapy is based on energy channels (meridians) and acupoints. Therefore, methodology details should be reported, including types of cups, acupoints used and their TCM rationale, practitioner background, number of treatment sessions and frequency, among other STRICTA-recommended information. Standardization can also be achieved by registering with and following the protocol of international organizations [149], such as WHO International Clinical Trials Registry Platform (ICTRP) [150].

As in our previous review, we continue to emphasize the importance of using standard outcome measures for specific diseases/conditions. As mentioned, 80.74% of the included trials used composite outcome measures, which categorized treatment efficacy into four grades. The classifications of “cure,” “markedly effective,” “effective,” and “ineffective” are not internationally recognized with their exact meaning open to interpretation. This can increase clinical heterogeneity. We suggest that researchers comply with international standards, such as the House Brackmann score for facial nerve paralysis (Bell palsy), in the evaluation of treatment efficacy to give credibility to their work.

The potential asymmetry of the overall funnel plot test (Figure 5) of 39 RCTs that examined the outcome of the number of cured patients for 4 diseases (herpes zoster, facial paralysis, acne, and cervical spondylosis) may be caused by, small study effects, or even heterogeneity in intervention effects. Furthermore, as we did not include unpublished studies, there is high potential that our review may have publication bias. We strongly recommend that researchers plan their sample size for randomized controlled trials to ensure adequate statistical power. Furthermore, sample size calculation and analysis of outcomes should be based on the principle of intention-to-treat.

Finally, our meta-analysis revealed that cupping therapy combined with other treatments, such as acupuncture or medications, showed significant benefit over other treatments alone in effecting a cure for herpes zoster, acne, facial paralysis, and cervical spondylosis. This appears to support the common practice in China of combining TCM therapeutic modalities, either TCM with TCM, or TCM with routine western medicine, to enhance efficacy. The effect of cupping therapy over time is not known, but use of cupping is generally safe based on long-term clinical application and outcomes reported in the reviewed trials.

In conclusion, the results of this systematic review suggest that cupping therapy appears to be effective for various diseases/conditions, in particular herpes zoster, acne, facial paralysis, and cervical spondylosis. However, the main limitation of our analysis was that nearly all included trials were evaluated as high risk of bias. As such, it is necessary to conduct further RCTs that are of high quality and larger sample sizes in order to draw a definitive conclusion.

Supporting Information

Acknowledgments

Footnotes

References