Cupping

CUPPING THERAPY

HEALTH TECHNOLOGY ASSESSMENT SECTION MEDICAL DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA 010/2012 i DISCLAIMER Technology review is a brief report, prepared on an urgent basis, which draws on restricted reviews from analysis of pertinent literature, on expert opinion and / or regulatory status where appropriate. It has not been subjected to an external review process. While effort has been made to do so, this document may not fully reflect all scientific research available. Additionally, other relevant scientific findings may have been reported since completion of this review. Please contact: [e-mail], if you would like further information.

Health Technology Assessment Section (MaHTAS), Medical Development Division Ministry of Health Malaysia Level 4, Block E1, Precinct 1 Government Office Complex 62590 Putrajaya Tel Fax : [phone] : 603 8883 1230

Available at the following website: http://www.moh.gov.my

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Prepared by: Dr. Hanin Farhana Kamaruzaman Assistant Director Health Technology Assessment Section (MaHTAS) Ministry of Health Malaysia Reviewed by: Datin Dr Rugayah Bakri Deputy Director Health Technology Assessment Section (MaHTAS) Ministry of Health Malaysia

DISCLOSURE The author of this report has no competing interest in this subject and the preparation of this report is totally funded by the Ministry of Health, Malaysia.

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EXECUTIVE SUMMARY Introduction Cupping therapy is a physical treatment which refers to a technique that uses small glass cups or bamboo jars as suction devices that are placed on the skin. This method is mostly used in Asian and Middle Eastern countries. Cupping is believed to have potential benefit in treating myriad types of disease and conditions. The most common conditions were pain related such as chronic muscle pain, low back pain, neuralgia pain, fibromyalgia and headache. This technology review was requested by the Director of Traditional and Complementary

Citations: and Ovid MEDLINE(R) 1948 to present, EBM Reviews - Cochrane Central Register of Controlled Trials and EBM Reviews - Health Technology Assessment. Other database was PubMed, Cochrane Library, Australia & New Zealand Horizon Scanning Network (ANZHSN) and US Food & Drugs Administration (US FDA). The search terms used can be referred in Appendix 1. 4.2. Selection A reviewer screened the titles and abstracts against the inclusion and exclusion criteria and then evaluated the selected full-text articles for final article selection. The inclusion and exclusion criteria were: Inclusion criteria Population Herpes zoster, facial paralysis, Bell’s palsy, back pain, spondylosis, stroke, cerebrovascular accident, cerebral stroke, brain vascular accident, hypertension, fibromyalgia, bronchitis, asthma, headache Interventions Cupping therapy alone or cupping therapy combined with other therapies (other traditional complementary therapy such as acupuncture, or conventional therapy) Comparators Conventional therapy, medicines, placebo Outcomes Efficacy/effectiveness and safety of cupping therapy Study design Randomized control trials, systematic reviews, metaanalysis, case control, cohort and descriptive studies Type of English publication Exclusion criteria Study design Abstract, animal study Type of Other language than English publication Relevant articles were critically appraised using Critical Appraisal Skills Programme (CASP) and evidence graded according to the US / Canadian Preventive Services Task Force (Appendix 2). 5 5. RESULTS AND DISCUSSION Three full text articles were included in this technology review discussing the efficacy and effectiveness of cupping therapy, with or without comparative treatments. As for safety issues, 2 articles discussed on the adverse effects of cupping therapy. 5.1 EFFICACY / EFFECTIVENESS OF CUPPING THERAPY The three studies included in this technology review were one systematic review and two systematic reviews with meta-analysis. Cao et al conducted a systematic review and meta-analysis to evaluate the therapeutic effect of cupping therapy for specific disease or conditions. The eligible studies were randomized controlled trials (RCT) that examined the effectiveness of cupping therapy, including one or more types of cupping methods, compared with no treatment, placebo, or conventional medication. Cupping combined with other interventions and compared with other interventions alone were also included. However, studies that assessing the effectiveness of cupping therapy combined with other traditional complementary (TCM) therapies, such as acupuncture, compared with nonTCM therapies were excluded. As the result, 135 studies were included in the review and different types of cupping methods were used in the trials that were selected. The six most common diseases or conditions for which cupping was applied were herpes zoster, facial paralysis (Bell’s plasy), , acne, cervical spondylosis, lumbar disc herniation and also cough and dyspnea. Meta-analyses were conducted on the first four of the above listed conditions and due to the heterogeneity of the RCTs of the remaining two diseases- lumbar disc herniation and cough and dyspnea- meta-analyses could not be completed. 4, level I Among the limitations in this study were the inconsistency of the outcome measures that has been used by each and every single RCTs that were included in this systematic review. The included trials used composite non-standardized outcome measures, which categorized treatment efficacy into four grades: “cure”, “markedly effective”, “effective” and “ineffective”. This classification was not internationally recognized and the exact meaning is open to various interpretations. Fifteen RCTs were included to evaluate the efficacy of wet cupping therapy in treating herpes zoster. Wet cupping therapy was found to be superior to pharmaceutical medications, such as antiviral, in providing cure (RR 2.07, CI 1.77 to 2.43, p