Cupping therapy versus acupuncture for pain-related conditions: a systematic review of randomized controlled trials and trial sequential analysis

Efficacy of cupping therapy on pain outcomes: an evidence-mapping study

Objective

Cupping therapy is an ancient technique of healing used to treat a variety of ailments. An evidence-mapping study was conducted to summarize the existing evidence of cupping therapy for pain-related outcomes and indicate the effect and the quality of evidence to provide a comprehensive view of what is known.

Methods

PubMed, Cochrane Library, Embase, and Web of Science were searched to collect the meta-analyses investigating the association between cupping therapy and pain-related outcomes. The methodological quality was assessed by using the AMSTAR 2 tool. Significant outcomes (p < 0.05) were assessed using the GRADE system. The summary of evidence is presented by bubble plots and human evidence mapping.

Results

Fourteen meta-analyses covering five distinct pain-related conditions were identified and assessed for methodological quality using the AMSTAR 2, which categorized the quality as critically low (36%), low (50.0%), moderate (7%), and high (7%). In accordance with the GRADE system, no high-quality evidence was found that demonstrates the efficacy of cupping therapy for pain-related outcomes. Specifically, for neck pain, there were two moderate-quality, four low-quality, and two very low-quality evidence, while only one very low-quality evidence supports its efficacy in treating herpes zoster and one low-quality evidence for chronic back pain. Additionally, for low back pain, there were two moderate-quality, one low-quality, and four very low-quality evidence, and for knee osteoarthritis, three moderate-quality evidence suggest that cupping therapy may alleviate pain score.

Conclusion

The available evidence of very low-to-moderate quality suggests that cupping therapy is effective in managing chronic pain, knee osteoarthritis, low back pain, neck pain, chronic back pain, and herpes zoster. Moreover, it represents a promising, safe, and effective non-pharmacological therapy that warrants wider application and promotion.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255879, identifier: CRD42021255879.

Wet cupping with rehabilitation training for upper-limb poststroke spasticity: A systematic review and meta-analysis of randomized controlled trials

Background

Upper-limb poststroke spasticity (PSS) negatively impacts on patients' quality of life. An increasing number of clinical trials have indicated that wet cupping with rehabilitation training is conductive to alleviate spastic muscle tone, thereby to improve upper-limb function. However, related evidence base is insufficient. This study systematically investigates the efficacy and safety of wet cupping with rehabilitation training on stroke patients with upper-limb spasticity.

Methods

Eight separate databases and two clinical trial registries were searched from their inception to December 6, 2022. Two reviewers extracted the data and assessed the quality of the literature, independently. The mean difference (MD) or risk ratio (RR) were used as measure of effect size in meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used for the certainty of evidence.

Results

Eight randomized controlled trials (RCTs) were quantified for meta-analysis. The results indicated that in comparison with the control group, wet cupping with rehabilitation training was more effective in reducing modified Ashworth scale score (MD = -0.60, 95% CI: -0.74, -0.46; P < 0.00001) and the integral electromyography value of biceps muscle (MD = -4.71, 95% CI: -6.74, -2.67; P < 0.00001), but improving effective rate (RR = 1.28, 95% CI: 1.15, 1.41; P < 0.00001), Fugl-Myer Assessment score (MD = 4.84, 95% CI: 3.05, 6.64; P < 0.00001) as well as Barthel Index score (MD = 6.38, 95% CI: 2.20, 10.57; P = 0.003). However, no significant difference was found regarding the integral electromyography value of triceps muscle between groups (MD = 1.72, 95% CI: -2.05, 5.48; P = 0.37).

Conclusion

Wet cupping with rehabilitation training should be included in a comprehensive therapeutic regimen for stroke patients with upper-limb spasticity. However, these results need to be further verified by more RCTs with rigorous design and large sample size.

Acupuncture for mild cognitive impairment: A systematic review with meta-analysis and trial sequential analysis

Background

There is insufficient evidence to support the use of acupuncture for mild cognitive impairment (MCI), and there is no consensus on its efficacy. This review aimed to determine the acupuncture effect in patients with MCI.

Methods

Relevant and potentially eligible randomized controlled trials (RCTs) of acupuncture for MCI were obtained from four Chinese databases, four English databases, and additional resources up to 1 August 2022. The primary outcome was the improvement in overall cognitive function (OCF). Secondary outcomes were improved memory function (MF) and activities of daily living (ADLs). The revised Cochrane collaboration risk of bias (ROB) assessment tool (ROB 2.0) was applied to evaluate their methodological quality. The Review Manager software v 5.4 was used for analyses. Trial sequential analysis (TSA) 0.9.5.10 β software was used to estimate the required sample size and test the reliability of the pooled outcome. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Results

This meta-analysis included 11 RCTs with a total of 602 patients. The methodological quality of all trials was moderate. Low-quality evidence showed that acupuncture significantly improved OCF (Mini-Mental State Examination (MMSE): mean difference (MD) = 1.22, 95% confidence interval (CI): 0.78-1.66; the Montreal Cognitive Assessment Scale (MoCA): MD = 1.22, 95% CI: 0.47-1.97). In subgroup analyses, it was revealed that acupuncture significantly increased OCF in patients with MCI when compared to conventional medicine (CM) and sham acupuncture (SA). TSA's findings indicated that the evidence of improving OCF with acupuncture for patients with MCI was conclusive. Meanwhile, there is no statistical difference in the improvement of MF and ADL between acupuncture and CM. TSA showed that the evidence of improving MF and ADL for patients who had MCI and received acupuncture was inconclusive. The shreds of evidence of improving MF and ADL were ranked from low to critically low.

Conclusion

Acupuncture appears to be an effective clinical application method for improving OCF in patients with MCI. However, due to low-quality evidence, more relevant and high-quality research is needed in this field.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021291284, PROSPERO, No. CRD42021291284.

Efficacy of Moxibustion for Primary Osteoporosis: A Trial Sequential Meta-Analysis of Randomized Controlled Trials

Background

Primary osteoporosis (PO) is a systemic metabolic skeletal disease. Previous studies have shown that moxibustion can reduce pain intensity and enhance response rate, bone mineral density (BMD), and living function of the patients with PO. However, consensus on its efficacy does not exist, and evidence of moxibustion for PO is also insufficient.

Methods

We searched five English and four Chinese databases with various additional sources and published reviews through December 1, 2021, to evaluate potentially concerned randomized controlled trials (RCTs). Two independent researchers addressed selection screening, data extraction, and risk of bias assessment. The data of this meta-analysis were analyzed using the RevMan v.5.4 software. Additionally, the trial sequential analysis v.0.9.5.10 β was used to estimate the sample size. In contrast, the quality of evidence from the RCTs was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool.

Results

The current meta-analysis included 14 RCTs containing 898 participants. The methodological quality of the RCTs was moderate. The review demonstrated that a combination of moxibustion and conventional medicine (CM) significantly reduced pain intensity and improved the BMD compared with CM. Furthermore, it was found that moxibustion plus CM/moxibustion could improve response rates compared with CM. However, it was found that the reduction of pain intensity and improvement of BMD by moxibustion showed no significant difference compared with CM. It was also evident that the sample size of most outcomes was inadequate. Moreover, all evidence obtained in this study was ranked as low to critically low.

Conclusions

In conclusion, it was demonstrated that moxibustion is a potentially effective agent for treating PO. However, high-quality studies should be implemented in the future because this study only obtained low-quality evidence. This study was registered in the PROSPERO platform (CRD42021291310).

An Update on Physical Therapy Adjuncts in Orthopedics

Physical therapy is a necessary part of the recovery process after most orthopedic procedures. Effective treatment, patient satisfaction, and financial reimbursement hinge on the successful implementation of both surgical and nonsurgical interventions. Evidence-based practice and open communication between therapists and orthopedic surgeons continue to form the foundation of patient care. The aim of this paper is to familiarize orthopedic surgeons with the relevant data behind some of the recent advances in rehabilitation adjuncts to better address the needs of our patients. Although each intervention has been found to be relatively safe, high-quality evidence is still sparse. Opportunities exist for improved outcomes with further well-designed studies to investigate the role of these therapy modalities among orthopedic patients.

Acupuncture for breathlessness in advanced cancer: a protocol for systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Breathlessness in advanced cancer, a frequent multicomponent and debilitating disorder, severely reduces function and quality of patients' life. Multiple studies have shown that non-pharmacological therapies can effectively palliate breathlessness in advanced cancer. However, no systematic review has investigated the application of acupuncture, as a non-pharmacological treatment, for breathlessness in advanced cancer. A systematic review will be conducted to summarise evidence supporting the efficacy and safety of acupuncture as a therapeutic option for breathlessness in advanced cancer based on existing randomised controlled trials (RCTs).

METHODS

RCTs will be retrieved from nine scientific databases, including the MEDLINE via PubMed, Web of Science via the Web of Knowledge, Embase via Ovid, the Cochrane Central Register of Controlled Trials via the Cochrane Library, and Allied and Complementary Medicine Database via EBSCO, China National Knowledge Infrastructure, Wanfang Database, VIP Database, Chinese Biomedical Literature Database; three clinical registry platforms, including the WHO International Clinical Trials Registry Platform, NIH Clinical trials.gov and Chinese Clinical Trial Registry, as well as from other sources. Studies published since inception of these databases to 1 August 2021 will be retrieved. Search terms will include breathlessness, cancer, acupuncture and RCT. Two investigators will independently select and extract data from RCTs and assess the risk of bias. The primary outcome, which is alleviation of breathlessness, will be assessed. Meta-analysis will be performed using RevMan V.5.4 and STATA V.15.0. The TSA 0.9.5.10 β software will be used to conduct trial sequential analysis. Finally, the quality of evidence from RCTs will be assessed using the Grading of Recommendations Assessment, Development and Evaluation System tool.

ETHICS AND DISSEMINATION

Results will be disseminated through peer-reviewed journals or conference reports. Since this study involves acquisition of secondary data, ethical approval requirements will be waived.

PROSPERO REGISTRATION NUMBER

CRD42021240085.

Comparison of efficacy and safety of complementary and alternative therapies for scapulohumeral periarthritis: A protocol for Bayesian network meta-analysis

BACKGROUND

Scapulohumeral periarthritis is a disease with high incidence and great pain. The current western treatments with many side effects, poor efficacy cannot fundamentally solve the problem. Complementary and alternative therapies have played an excellent role in the treatment of scapulohumeral periarthritis. However, it is not clear which complementary and alternative therapy is more effective. Therefore, we propose a protocol to compare the efficacy and safety of various complementary and alternative therapies through network meta-analysis (NMA) to provide choice guidance for the therapy.

METHODS

A comprehensive search will be conducted for randomized controlled trials of complementary and alternative therapy for scapulohumeral periarthritis as well as ongoing trials. The time limit is from the establishment of the database until January 2021. Literature and data extraction were completed independently by two researchers. Through pairwise comparison and meta-analysis of Bayesian NMA, all the evidences are evaluated comprehensively. STATA16.0 and WinBUGS1.4.3 software will be used for data processing and analysis, and recommendation evaluation will be used to develop and assess grades to classify the quality of NMA evidence.

RESULTS

Through the analysis, we will obtain the ranking of the efficacy and safety of different complementary and alternative therapies in the treatment of scapulohumeral periarthritis, in order to provide reference for clinical selection of treatment methods.

CONCLUSION

Complementary and alternative therapies of scapulohumeral periarthritis plays a positive role in improving the symptoms of scapulohumeral periarthritis. This study can provide evidence support for clinicians and patients.International Platform of Registered Systematic Review and Meta-Analysis Protocols registration number: INPLASY202140044.

Evidence Map of Cupping Therapy

This study aimed to describe and assess the current evidence in systematic reviews on cupping therapy for various conditions. We searched PubMed, EMBASE, Cochrane Database of Systematic Reviews, China National Knowledge Infrastructure, and six Korean databases for systematic reviews of trials on cupping treatments for any condition published prior to March 2021. We used a bubble plot to graphically display the clinical topics, the number of articles, the number of participants in the total population, confidence, and effectiveness. Thirteen systematic reviews that met the inclusion criteria were included in the evidence map, and 16 bubbles were created. The findings from six reviews showed potential benefits of cupping for conditions such as low back pain, ankylosing spondylitis, knee osteoarthritis, neck pain, herpes zoster, migraine, plaque psoriasis, and chronic urticaria. Cupping has been applied in a variety of clinical areas, and systematic reviews in a few of these areas have demonstrated statistically significant benefits. The evidence map provides a visual overview of cupping research volume and findings. Evidence mapping can facilitate the transfer of knowledge from researchers to policymakers and promote research on musculoskeletal pain (such as low back pain, neck pain, and knee osteoarthritis) and skin disease (plaque psoriasis).

Effects of massage and acupuncture on the range of motion and daily living ability of patients with frozen shoulder complicated with cervical spondylosis

OBJECTIVE

This study was designed to study the effects of massage and acupuncture on patients with frozen shoulder complicated with cervical spondylosis through range of motion (ROM) and daily living ability.

METHODS

A total of 164 patients with frozen shoulder treated in our hospital from June 2016 to April 2019 were recruited and divided into a control group and an observation group. There were 100 cases in the observation group, all of whom were treated with massage combined with acupuncture. Another 64 cases were enrolled in the control group, all of whom were treated with acupuncture alone. The recovery of myodynamia, rating scale of the American Shoulder and Elbow Surgeons (ASES), score of American Spinal Injury Association (ASIA), ROM score, vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1), complication rate, total effective rate, and patient satisfaction were assessed.

RESULTS

After treatment, patients in the observation group had better recovery of myodynamia than the control group. They also had lower VAS scores, higher life function score and total ASES scores, higher ASIA scores, higher ROM scores, lower VCAM-1 and ICAM-1 expression, lower complication rate, higher total effective rate, and higher patient satisfaction.

CONCLUSION

Massage combined with acupuncture can better improve the ROM of joints and daily living ability of patients with frozen shoulder complicated with cervical spondylosis.

Partially randomized patient preference trial: Comparative evaluation of fibromyalgia between acupuncture and cupping therapy (PRPP-FACT)

BACKGROUND

and purpose The aim of this study was to investigate the feasibility of applying a partially randomized patients' preference (PRPP) trial in the clinical evaluation of acupuncture versus cupping therapy for fibromyalgia.

MATERIALS AND METHODS

The final study included 126 participants. Participants without a treatment modality preference were randomly assigned to either the cupping therapy group or the acupuncture group. Patients with strong preferences were assigned to their treatment modality of choice. Ashi points were used for treatment. Outcome measures were both qualitative (patient expectation and satisfaction) and quantitative (drop-out rate, pain intensity, quality of life, depression assessment).

RESULTS

The recruitment of the non-randomized participants was completed 8 months before the randomized participants were recruited. There was no statistical difference related to the grouping method in the adjusted drop-out rate, patient expectation, and satisfaction.

CONCLUSION

The PRPP model is suitable for use in the clinical evaluation of non-pharmaceutical therapies.

Acupuncture methods for allergic rhinitis: a systematic review and bayesian meta-analysis of randomized controlled trials

BACKGROUND

Allergic rhinitis (AR) is a common symptomatic, inflammatory, and immunological disorder of nasal mucosa. Multiple clinical trials and systematic reviews have implicated acupuncture methods as potentially effective treatment strategies for AR, however, considering the great burden of AR, it is crucial to explore the most recent clinical evidence supporting acupuncture in AR. Besides, the methodologies reported in previous studies as well as those commonly applied during clinical practices greatly vary. Herein, we conducted network meta-analysis to compare the effectiveness of diverse acupuncture methods for AR treatment.

METHODS

We conducted a literature search for relevant reports published from inception to 1 July 2020 in several scientific databases, including PubMed, Embase, Cochrane library, Web of Science, CNKI, WF, VIP, CBM, AMED as well as related registration platforms. Primary outcomes as reported in the identified studies were assessed using nasal symptoms. All Meta-analyses were performed with RevMan, ADDIS, and STATA software. To ensure consistency among our reviewers, the intra-class correlation coefficient was used.

RESULTS

Exactly 39 studies with 3433 participants were covered in this meta-analysis. The meta-analysis demonstrated that all acupuncture types were superior to sham acupuncture in terms of total nasal symptom score and rhinoconjunctivitis quality of life questionnaire. Moxibustion was recommended as the most effective intervention as it reduced nasal symptoms in 6 treatments. On the other hand, manual acupuncture plus conventional medicine was recommended as the most effective intervention in improving the quality of life in 9 treatments. Notably, moxibustion was recommended as the most effective intervention that changed the content of IgE in 9 treatments. Moreover, adverse events of these interventions were acceptable.

CONCLUSION

Our findings revealed that all acupuncture methods are effective and safe for AR. Moreover, either moxibustion or manual acupuncture plus conventional medicine are potentially the most effective treatment strategies for AR. Based on these findings, it is evident that acupuncture therapy is not inferior to pharmacologic therapy. Therefore, for AR patients who are either unresponsive to conventional medicine or are intolerant to adverse events, acupuncture therapy should be administered. However, the quality of these included trials was mainly ranked as moderate quality, we recommend additional well-designed RCTs with larger sample sizes to validate these findings.

Spiritual and Religious Healing Practices: Some Reflections from Saudi National Center for Complementary and Alternative Medicine, Riyadh

Traditional practices constituting spiritual and religious (S/R) healing are an important component of the holistic healthcare model and are used in health, well-being, and treating a variety of diseases around the world. The main focus of this review is to summarize the Complementary and Alternative Medicine (CAM) studies that especially target S/R healing practices in Saudi Arabia (SA) and discuss the results in light of relevant international literature. From year 2013-2017, electronic searches of PubMed, OvidSP, Google Scholar, and two publishing housing Web sites (Sciencedomain.com and Dove Medical Press.com) were made using key words and Boolean operators and retrieved thousands of published papers from peer-reviewed journals. Two independent reviewers decided to include a total of 108 articles: 48 from SA and 60 from other international literature. The sociodemographic variables of the participants varied in local studies and were comparable with international data. The frequency and types of religious and spiritual practices reported in local and international zones varied in accordance with religious belief, gender, age, education, and prevalent chronic diseases. Most of professionals and practitioners showed fairly good knowledge and positive attitude toward spiritual and religious practices used in diverse clinical and non-clinical situations across the world. Furthermore, it was observed that in the international scenario, S/R researches using specific religious screening tools have been conducted on different aspects of clinical application including self-care, social cohesion, negative impact, and child development, whereas regional studies targeting varied participants mainly focused on the epidemiological trends of S/R therapies in Saudi Arabia. CAM practitioners and public tend to show great interest in prescribed and self-use of religious and spiritual therapies across the world because of multiple dynamic forces, including positive effects on health, sense of well-being and disease control, cost-effectiveness, easy access to services, and improvement in quality of life. Further studies are needed to assess the effectiveness of different types of religious and spiritual therapies and practices used in specific diseases, their role in promotion of health and well-being, and prevention of diseases nationwide and across the world. Besides integration of S/R into mainstream treatment modalities, medical education curriculum, continuous medical education, and training programs are needed for bridging the knowledge, attitude, and practice gaps concerning CAM in targeted population groups such as medical professionals, CAM practitioners, medical students, public and traditional healers, not only in SA but also around the world.

Cupping for Patients With Chronic Pain: A Systematic Review and Meta-Analysis

There is a growing interest in nonpharmacological pain treatment options such as cupping. This meta-analysis aimed to assess the effectiveness and safety of cupping in chronic pain. PubMed, Cochrane Library, and Scopus were searched through November 2018 for randomized controlled trials on effects of cupping on pain intensity and disability in patients with chronic pain. Risk of bias was assessed using the Cochrane risk of bias tool. Of the 18 included trials (n =1,172), most were limited by clinical heterogeneity and risk of bias. Meta-analyses found large short-term effects of cupping on pain intensity compared to no treatment (standardized mean difference [SMD] = -1.03; 95% confidence interval [CI] = -1.41, -.65), but no significant effects compared to sham cupping (SDM = -.27; 95% CI = -.58, .05) or other active treatment (SMD = -.24; 95% CI = -.57, .09). For disability, there were medium-sized short-term effects of cupping compared to no treatment (SMD = -.66; 95% CI = -.99, -.34), and compared to other active treatments (SMD = -.52; 95% CI = -1.03, -.0028), but not compared to sham cupping (SMD = -.26; 95% CI = -.57,.05). Adverse events were more frequent among patients treated with cupping compared to no treatment; differences compared to sham cupping or other active treatment were not statistically significant. Cupping might be a treatment option for chronic pain, but the evidence is still limited by the clinical heterogeneity and risk of bias. Perspective: This article presents the results of a meta-analysis aimed to assess the effectiveness and safety of cupping with chronic pain. The results suggest that cupping might be a treatment option; however, the evidence is still limited due to methodical limitations of the included trials. High-quality trials seem warranted.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Combined Therapies of Modified Taiyi Miraculous Moxa Roll and Cupping for Patients with Lumbar Intervertebral Disc Herniation

Lumbar intervertebral disc herniation is a kind of syndrome caused by stimulation or pressure of nerve root and cauda equina due to intervertebral disc disorder, fibrous ring rupture, and pulpiform nucleus protrusion. Application of traditional Chinese medicine (TCM) including acupuncture therapy and cupping therapy is unique and effective treatment for lumbar intervertebral disc herniation in China. Hence, we try to investigate the combined clinical efficacy of modified Taiyi miraculous moxa roll and cupping therapy on patients with lumbar intervertebral disc herniation. Seventy patients were randomly assigned into combined treatment group (n = 35) and control group (n = 35). The treatment group received combined therapy of modified Taiyi miraculous moxa roll and cupping therapy, while control group received acupuncture therapy alone. Diagnostic criteria of TCM syndrome, Japanese Orthopedic Association (JOA) score, and simplified McGill pain questionnaire (MPQ) were used to evaluate the therapy. 11 and 13 out of 35 subjects in the combined treatment group had improvement > 75% and between 50% and 75%, respectively. The corresponding number was 2 and 22 of 35 subjects in the acupuncture group. There was significant difference in the clinical efficacy between the treatment group and control group (P = 0.036). The scores of JOA and MPQ detected in the patients of the two groups (P < 0.05) also showed statistically significant differences. Moreover, no serious adverse events occurred in the patients, who received cupping therapy or acupuncture. The combined or alone therapies can effectively improve the treatment efficacy in the patients with lumbar intervertebral disc herniation, while the combined therapies show more comparative effectiveness. Furthermore, the combined therapies are potentially safe and cost-effective and also benefit the improvement of short-term pain. Therefore, the combined therapies of the two ancient TCM deserve further clinical applications.