Friday, January 11, 2013

Cupping Research


Latest Research on Cupping 

by Romy Lauche


History
Cupping therapy is probably one of the earliest medical techniques used by mankind. First evidence of its use dates back to 3300 BC. Nowadays cupping is mainly used in Asia and in Arab societies; its use in Europe is very limited. But practitioners and researchers show growing interest in this technique, as recently published studies suggest. This article presents some of the current research that has been conducted in Europe.


The Different types of Cupping
  • Dry Cupping uses double-walled glass cups  inverted over an open flame to heat the air inside, after which each glass is placed on an afflicted area. As the air inside the cups cools, vacuums are created, drawing up the skin within each cup. The treatment lasted about 10-15 minutes and after removing of the cup, a cupping mark may be visible. This cupping mark is extravasated blood, i.e. blood drawn from the capillaries into the sub-skin; it will disappear within several days. Traditionally, flame was used to draw air out of the cup, but modern implement now used a mechanical device or a rubber ball to draw air out of the cup to create a vacuum.
  • In Traditional Cupping, the skin is superficially incised before applying the cups, which sucks blood out through the incisions. After some minutes, the bleeding will stop. Traditional cupping is mainly used in conditions that show signs of overabundance, e.g. in inflammation, swelling etc.
  • In Cupping Massage,  the area to be treated is first covered with massage oil. The cup is placed on the skin and a rubber ball at the end of the glass is used to press the air out of the cup, so that negative pressure attaches it to the skin. The glass is held at the base and gently moved over the area to be treated, usually over muscles. The skin reddens and petechial may appear which will fade away after several days.
  • Pulsating Cupping can be applied using a mechanical device such as the Pneumatron® 200S (Pneumed GmbH, Idar-Oberstein, Germany), which generates pulsating suction to glass or silicone cups. Reduction of pressure and atmospheric pressure itself are alternated by a defined frequency leading to an oscillation of skin and subdermal tissues. Cups can be applied stationary or can be moved (with the help of massage oil!) like in cupping massage, the treatment lasts about 10- 15 minutes.


Clinical trials
Several trials have been conducted in Germany in the past couple of years. There was one study (Lüdtke et al., 2006) that investigated the effect of traditional cupping on nocturnal burning pain (German: Brachialgia paraesthetica nocturna). This disease is characterized by feelings of pain, formication, paraesthesia and numbness of the hands. The symptoms mainly occur at night and can be released by massaging and bathing in warm water. Nocturnal burning pain is often assumed to be a pre-stage of the carpal tunnel syndrome.
In this study patients were randomly assigned to traditional cupping or a wait list control group. The patients in the cupping group received one cupping at the trapezius only, while both groups also received standard care in form of analgesics, physical therapy and psychological interventions. The post-intervention observation period was 1 week, the main complaints pain, formication and paraesthesia were assessed using a 100mm visual analogue scale each (0-no complaint, 100-worst imaginable complaint). After 7 days, the patients in the cupping group reported significantly less complaints compared to the control group, formication and paraesthesia were the complaints with the largest improvements.

In another trial from our department (Dept. of Complementary and Integrative Medicine in Essen, Germany) Michalsen et al. (2009) applied traditional cupping in a trial on the treatment of carpal tunnel syndrome, an entrapment syndrome of the median nerve, which is characterised by numbness, tingling, burning, and pain in at least 2 of the 3 digits supplied by the median nerve (i.e., thumb, index finger, or middle finger). Patients received traditional cupping or a local application of heat and 7 days after the treatment, outcomes were assessed. Analysis not only showed significant improvements in the carpal tunnel syndrome score, but also in neck pain, functional disability and physical quality of life.
In 2008 we started several trials on cupping for chronic nonspecific neck pain. This form of neck pain is the most common and it reflects mainly poor microcirculation, increased muscle tension and postural problems rather than inflammatory, traumatic or degenerative causes. We investigated the efficacy of dry cupping* (Lauche et al., 2011), pulsating cupping (Cramer et al., 2011), traditional cupping (Lauche et al., 2012a) and cupping massage (Schumann et al., 2012). The studies were all randomized and they all applied a comparable wait list control group design. Except for traditional cupping, all therapies were utilized 5 times with 2 treatments each week. In the trial of traditional cupping, a single treatment was utilized. Before and 4 days after treatment the outcome measures pain, functional disability and quality of life were assessed. Fifty patients were included in each trial. They had been screened by the study physician to make sure that the right cupping method was chosen for each patient. For example, in traditional cupping, the patient had to show signs of overabundance or so called plethora. This refers to symptoms such as a voluminous gelosis of the subskin, which indicates local blood congestion, swelling and connective tissue adhesions in the neck region. On the other hand patients with blank myogelosis, i.e. hyperirritable muscle areas associated with small palpable nodules in taut bands of muscle fibers together with decreased microcirculation, were included in the studies of dry or pulsating cupping.
After cupping, patients in the treatment groups reported less pain, less impairment and increased aspects of quality of life. The pain reductions were not only statistically significant but they were clinically relevant, i.e. the amount of reduction was meaningful. Despite some minor adverse events, the cupping treatment proved to be a safe therapy.

Trial on traditional cupping and its influence on the body image
In the study of traditional cupping we also investigated the body image before and after therapy (Lauche et al., 2012b). In this context, body image was defined as the perception of the contours of the body. In order to gather data on the body image we used drawings and qualitative interviews.

Body image drawings were adapted from the work by Lorimer Moseley (2008) who had investigated body image in back pain patients and found distortions in those patients. We used a line drawing of the posterior lower and upper back, but with only parts of the body drawn in. The area from the shoulders to the neck was left blank and patients were asked to fill in the contours as they felt them. A previous imagination exercise was used to facilitate the drawing. After the second drawing at the end of the study patients also participated in an interview about the drawings and their body image and perceived changes after cupping. This way it was made sure that patients gave their own pictures meaning instead of a speculative interpretation by a third party.

All patients in the RCT delivered the drawings and six of the patients were included in the qualitative interview study. Figure 1 displays some drawings from one patient before and after cupping therapy. This drawing actually was the inspiration for the following interviews, because the patient reported, that not only had the pain vanished completely, but also had her body shrunk after cupping. The second drawing actually represented improvement in the eyes of the patient, although it did not look like it.

Figure 1. Body image drawing before (left side) and after cupping therapy (right side). The patient reported “My body has shrunk”, which showed in the drawing.



Other drawings before therapy showed distortions of the neck area, some contours were missing, others were very prominent. In most drawings we found images that did not fit the normal body physique with elevated shoulders or shoulders with areal edge. In the end we failed to identify certain patterns within the drawings.

The interviews revealed several topics relevant for the body image. It became clear that the neck, being tense, a burden or heavy like an anvil, and the pain hindered patients to sense non-painful parts of the body. All the attention was drawn to the pain in the neck and the neck felt wrong in terms of its contours. After cupping the tension was relieved and patients felt as if their neck was smaller, their shoulders had rounder edges and the burden was lifted. Some drawings represented that change as figuratively as the drawing in figure 1.
Interestingly not only did cupping affect the body image, but also did the drawing and the interview. Patients were “forced” to draw their attention to their body, the painful area and also the “blind spots”. That was the moment when some of the patients realized how focused they were on the pain.

Altogether this study indicated that pain and body image distortions were also present in patients with chronic neck pain and that cupping might actually reduce pain and influence the body image.

However there is always the discussion about cupping being just placebo and we most certainly do need more placebo controlled clinical trials to be able to distinguish between specific effects and placebo. Lee et al. (2010) have already developed a sham cupping device, which uses a small hole in the glass, so that the vacuum can diminish after attaching the cup to the skin. The cup itself is held by adhesives. We currently are using this paradigm in a clinical study on fibromyalgia with mainly cupping naïve patients and results may provide information if patients believed they got the real treatment. In patients who are very familiar with cupping the use of a placebo might be more challenging.

Summary
Cupping, despite its age (and controversy), seems to be a very effective treatment for a variety of diseases. It might also have the potential to prove effective for body image distortions related to chronic pain conditions. As always, more research – clinical and basic research – will be necessary in order to fully understand its mechanisms and clinical value.

References
Cramer H, Lauche R, Hohmann C, Choi K, Rampp T, Musial F, Langhorst J, Dobos Gj.  Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Forschende Komplementärmedizin, 2011; 18(6):327-34.

Lauche R, Cramer H, Choi K, Rampp T, Saha Fj, Dobos Gj, Musial F. The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain - a randomised controlled pilot study. BMC Complementary and Alternative Medicine, 2011, 11:63.

Lauche R, Cramer H, Haller H, Langhorst J, Musial F, Dobos Gj, Berger B. “My Back Has Shrunk” – The influence of traditional cupping on body image in patients with chronic neck pain. Forsch Komplementmed, 2012b, 19(2): 68-74.

Lauche R, Cramer H, Hohmann C, Choi K, Rampp T, Saha Fj, Musial F, Langhorst J, Dobos Gj. The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: A randomised controlled pilot study. Evidence-Based Complementary and Alternative Medicine 2012a, Vol. 2012, Article Id 429718, 10 Pages.

Lee MS, Kim JI, Kong JC, Lee DH, Shin BC. Developing and validating a sham cupping device. Acupunct Med. 2010;28:200-204.

Lüdtke R, Albrecht U, Stange R, Uehleke B: Brachialgia Paraesthetica Nocturna can be relieved by "Wet Cupping" –Results of a randomised pilot study. Complement Ther Med 2006;14:247–253.

Michalsen A, Bock S, Ludtke R, Rampp T, Baecker M, Bachmann J, Langhorst J, Musial F, Dobos Gj: Effects of traditional cupping therapy in patients with carpal tunnel syndrome: A randomized controlled trial. J Pain 2009;10:601–608.

Moseley Gl: I Can’'t Find It! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain 2008;140:239–243.

Schumann S, Lauche R, Irmisch G, Hohmann C, Rolke R, Saha F, Cramer H, Choi Ke, Langhorst J, Rampp T, Dobos G, Musial F. The effects of 5 sessions of cupping massage on chronic non-specific neck pain: A randomized controlled pilot study. BMC Complementary and Alternative Medicine, 2012, 12 (Supplement 1), 80.


Romy Lauche studied psychology with a focus on neurophysiology and research methods at the University of Jena, Germany. Her PhD thesis studied the influence of cupping therapy on chronic neck pain. Romy is now working as a researcher at the Department for Complementary and Integrative Medicine in Essen, Germany. Her main interests are complementary and integrative medicine in general (traditional medicine, manipulative therapies) and mind/body techniques in particular (mindfulness, meditation, qigong, yoga) for the treatment of chronic conditions. During her PhD study, Romy has also become certified mindfulness instructor and acquired knowledge in fMRI research. She recently published a study evaluating the effectiveness of another traditional East Asian Gua Sha treatment on neck and low back Pain.

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