- Email: [email protected]
The effect of traditional wet cupping on shoulder pain and neck pain: A pilot study
Complementary Therapies in Clinical Practice 23 (2016) 30e33
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
The effect of traditional wet cupping on shoulder pain and neck pain: A pilot study € kgo € z a, S¸enol Dane b Müzeyyen Arslan a, *, Nurcan Go a b
Turgut Ozal University, School of Nursing, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey € Turgut Ozal University, Medical Faculty, Department of Physiology, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 December 2015 Received in revised form 14 February 2016 Accepted 24 February 2016
Objectives: Wet cupping therapy (WCT) is a traditional complementary method recommended to decrease the symptoms of a lot of diseases and used in the treatment of pain syndromes. In this pilot study, the possible effects of wet cupping therapy on nonspecific neck and upper shoulder pain were investigated. Methods: Sixty one eligible volunteer participants with nonspecific neck and upper shoulder pain for at least 3 months were allocated. The Numeric Rating Scale (NRS) was used to assess pain scores. Pain scores were recorded before and after wet cupping therapy. Results: The mean scores of neck pain in study group were 7.02 (SD ¼ 1.8) before and 3.70 (SD ¼ 2.2) after cupping therapy. The decrease of pain scores between pre- and post-test was statistically significant (p < 0.05). Discussion: It can be stated that WCT has potential therapeutic effect in nonspecific neck and upper shoulder pain. Future full-scale randomized controlled trials will be needed to provide firm evidence of the effectiveness of this intervention. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Cupping Neck Shoulder Pain
1. Background In modern world, neck and upper shoulder pain is a very common health problem. The incidence of neck and shoulder muscle pain is increased in recent years. The rate of shoulder pain in general population may be 6%e11% under the age of 50 years and 16%e25% in elderly people [1]. The neck and shoulder pain may be due to different factors. Excessive physical strain may cause micro traumas in connective tissues, and psychosocial stress may lead to increased muscular tension [2]. There are different treatment alternatives such as nonsteroidal anti-inflammatory drugs, physical therapy or exercise, but these have only limited evidence for the neck and shoulder pain treatment [3e5]. In the literature and treatment guidelines, drug, manual or massage therapies cannot be recommended [3,4,6]. Different therapeutic exercises have moderate effects in neck and shoulder pain relief in the long term [6]. Therefore, physicians and patients look for traditional, alternative or complementary
* Corresponding author. E-mail addresses: [email protected] (M. Arslan), nurcan.hilalay55@ €kgo €z), [email protected] (Dane). gmail.com (N. Go http://dx.doi.org/10.1016/j.ctcp.2016.02.003 1744-3881/© 2016 Elsevier Ltd. All rights reserved.
treatment applications [7e9]. Cupping therapy is mostly used in Asian and Middle Eastern countries and has been suggested to reduce pain as well as many other symptoms [10]. Cupping therapy are already used for shoulder and neck pain as a complementary medicine [11]. ]. There are two types of cupping. Dry cupping pulls the skin into a cup without drawing blood. In wet cupping, the skin is lacerated so that blood is drawn into a cup. Traditional dry or wet cupping has been utilized to treat many complaints for thousands of years [12e14]. A glass or plastic cup is used to generate suction on the painful area or point before lacerations are made on the skin. This process gets the body rid of the congested blood and therefore blood and lymphatic circulation increases which relieves painful muscle tension [12,15,16]. The main purpose of this therapy is to precipitate the circulation of blood and qi and to remove blood-stasis and waste from the body [17]. Recently, there is growing evidence that cupping might be effective in various painful conditions [11,18e21]. Recent systematic reviews and findings suggested that wet cupping is effective for musculoskeletal problems [17,22]. The aim of this pilot study was to retest the efficacy of a
M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33
traditional wet cupping treatment in patients with non-specific neck and shoulder pain. 2. Methods 2.1. Participants A one-group, pre-test and post-test quasi experimental design was utilized to measure the change in neck and shoulder pain scores before and after wet cupping therapy intervention. We recruited participants through advertisements on notice board of a university hospital in Ankara. After a telephone interview, potential participants were invited to be assessed on whether they were eligible for the study. Participants visited the Turgut Ozal University Medical School. The physicians conducting the study informed them about the study details. Their eligibility was determined by a physician through physical exams, and relevant questionnaires. Men and women aged 20e60 years were eligible to participate. Patients with traumatic neck pain, inflammatory or malignant diseases, congenital malformation of the spine, radicular symptoms such as radiating pain, paresis, prickling, or tingling, invasive treatments within the last 4 weeks, who had surgery to the spine within the last year, and who were on corticosteroid, opioid or any other similar treatments were excluded. Further exclusion criteria were pregnancy, serious acute or chronic organic diseases such as diabetes or cancer, mental disorders, and hemorrhagic tendency or anticoagulation treatment.
31
10e15 min, and the skin was disinfected and a plaster was applied. However, since bleeding generally stopped during the treatment, this was only a precaution. Patients were asked not to take a bath or go swimming within the next 24 h to prevent delays in wound healing. After some minutes of rest patients were free to leave. No adverse events were reported throughout the study. 2.5. Statistical analysis The data were analyzed using the Statistical Package for Social Sciences 16.0 (SPSS). Paired samples T-test was used for analysis. 3. Results Our study population consisted of 61 volunteers with nonspecific neck and upper shoulder pain, 43 females (70.5%) and 18 males (29.5%); aged 20e60 years (mean age 45.59 ± 10.9 years). The mean body mass index (BMI) of the subjects was 29 (SD ¼ 5.5). The mean scores of neck and upper shoulder pain in study group were 7.02 (SD ¼ 1.8) before and 3.70 (SD ¼ 2.2) after cupping therapy (see Fig. 1). The decrease of pain scores between pre- and post-test was statistically significant (p < 0.05). There were no serious adverse events in study group. A regular minor adverse effect was a hematoma on the site of application of a cupping glass. All scarified wounds healed without any complications.
2.2. Ethical consideration
4. Discussion
The study protocol was approved by the Turgut Ozal University ethics committee. Signed informed consent was obtained from every participant before beginning the study.
In the present study, the decrease in pain scores secondary to wet cupping therapy was walloping and the mean scores of neck pain decreased from 7.02 to 3.70. It can be stated that wet cupping must be accepted as a complementary therapy in clinical practice for patients with chronic and tenacious neck and upper shoulder pain. Pain in the upper neck and shoulder is highly prevalent in many countries [26,27]. Since conservative options for treatment are limited, new therapeutic approaches need to be noted. It has lately been proposed that cupping, a traditional method of treatment, may be beneficial in neck and shoulder pain when applied to the referred shoulder-neck region. A recent randomized study and systematic review suggested that cupping alleviates lower back pain [28,29]. The mechanism of action of wet cupping is still not clear; theories and many studies have been sectional. Different modes of actions might explain the effect of traditional cupping on chronic neck pain. They involve hematological [30], neural [31], antioxidant
2.3. Data collection The data were collected using a questionnaire, The Numeric Rating Scale (NRS) [23]. NRS is a simple and frequently used method for the assessment of variations in the subjective intensity of pain. In clinical practice, as a measure of the efficacy of the treatment, NRS segmented numeric version is often used in which respondents select a whole number (integers 0e10) that best reflects the intensity of their pain [24]. The NRS is used to assess pain in general in the previous week on a scale ranging from 0 to 10, where 0 represents ‘‘no pain’’ and 10 represents ‘‘extreme pain’’. Participants stated their pain level on the scale. This ensured that statistical evaluation of the effects of the wet cupping treatment was not influenced by alterations in medications or physiotherapy during the study. 2.4. Intervention Cupping was performed by the study physician and two certified nurses. For the cupping therapy, sterile disposable cups of 5 cm in diameter were used. Treatment points were selected to be five points of the posterior neck, bilateral perispinal areas of the neck and scapula according to the WHO Guideline for Acupuncture [25]. Same points were applied to all participants. The cupping procedure involved the following steps: Application areas were cleaned with antiseptic solution. Disposable cups were placed onto these points and negative pressure was applied by the cupping pump. After two to 3 min, cups were removed. The skin was disinfected; superficial incisions were made with a disposable micro lancet on the areas of pain; the cups were placed on the same incision points. The glasses were removed after
Fig. 1. The mean pain scores before and after cupping therapy.
32
M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33
[32], and psychological effects [11]. By taking pressure off the tissues of the affected area, traditional cupping therapy evacuates the neck and shoulder from the toxic congestions and inflammatory agents which also increase blood and lymph flows. This could help clarify the local effects on pressure pain thresholds [11]. The result of this study supports the use of wet cupping in reducing neck and upper shoulder pain for at least one week after the wet cupping. In a recent review, both dry and wet cupping therapies were suggested for various musculoskeletal pain conditions [28]. In a recent study, it has been reported that dry cupping therapy can be confidently used to reduce the upper shoulder and neck pain in office workers as a therapeutic application and possibly as a preventative method [21]. Lauche and et al. [11] reported that the effects of traditional cupping are already present on the day after cupping treatment. This conforms to clinical observations, in which traditional cupping often showed immediate effects on pain and other complaints. Michalsen et al. presented [18] the results of a randomized trial on the clinical effects of traditional cupping therapy in patients with carpal tunnel syndrome. Cupping of segmentally related shoulder zones appears to alleviate the symptoms of carpal tunnel syndrome. Cupping (both dry and wet) therapy has been asserted to drain accumulated fluids, toxins and other chemical compounds such as lipids from interstitial fluid to blood and lymphatic capillaries [33,34]. The possible curative effects of wet cupping therapy in reducing non-specific neck and shoulder pain can be due to two its three mechanisms: (1) by stimulating the peripheral nervous system [14] and (2) removing oxidants and decreasing oxidative stress [32] and (3) by excreting toxic heavy metals [35]. Wet cupping therapy decreased the psychological stress conditions by restoring the sympathovagal imbalances and by decreasing static electric [14]. It can be accepted that the decrease in stress is important in relieving of pain. Oxidants or oxidative stress causes pain via lipid peroxidation injury in cell membranes. Therefore, the wet cupping therapy can be suggested as an antioxidant application in clinical practice [32]. Also, it is well known that the accumulation of heavy metals is the most toxic and hazardous factors for all body tissues. The excretion of heavy metals via wet cupping [35] from the body can be effective in the relieving of neck and upper shoulder pain. Also, in a recent study, all sleep quality parameters were positively affected after wet cupping therapy in healthy subjects. They concluded that the increase in sleep quality may be secondary to decrease in different pains and stresses and also the removal of some macromolecules and heavy metals accounts for the improved sleep quality [36]. The studies in future must be focused the effectiveness of wet cupping therapy on other pains such as headache, back pain and cancer pain. Also, wet cupping therapy can be compared to the other medical and physical therapies in future studies. In addition to the evaluation of effectiveness, safety issues are very important in wet cupping practice and must be paid attention. In conventional wet-cupping, non-sterile, reusable cups and lancets are used without any consideration of the possibility of an infection. 5. Conclusion The result of this study supports the use of wet cupping in reducing non-specific neck and shoulder pain. But, these results must be supported by randomized and placebo controlled trials. A single application of traditional wet cupping might be effective in the treatment of chronic non-specific neck pain. It should be considered for other musculoskeletal pain conditions, as a complement to medical treatment.
Conflict of interests All authors disclose any commercial association that might create a conflict of interest in connection with the paper. There is no competing financial interest for any of the authors. References [1] D.A. van der Windt, E. Thomas, D.P. Pope, A.F. de Winter, G.J. Macfarlane, L.M. Bouter, A.J. Silman, Occupational risk factors for shoulder pain: a systematic review, Occup. Environ. Med. 57 (2000) 433e442. €, T. Pohjolainen, S.[2] J. Ylinen, E.-P. Takala, M. Nyk€ anen, A. H€ akkinen, E. M€ alkia L. Karppi, H. Kautiainen, O. Airaksinen, Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial, JAMA 289 (2003) 2509e2516. [3] P.M.J. Peloso, A. Gross, T. Haines, K. Trinh, C.H. Goldsmith, S.J. Burnie, Medicinal and Injection Therapies for Mechanical Neck Disorders, The Cochrane Library, 2007. [4] J. Ezzo, B.G. Haraldsson, A.R. Gross, C.D. Myers, A. Morien, C.H. Goldsmith, G. Bronfort, P.M. Peloso, C.O. Group, Massage for mechanical neck disorders: a systematic review, Spine 32 (2007) 353e362. [5] A. Gross, T.M. Kay, J.P. Paquin, S. Blanchette, P. Lalonde, T. Christie, G. Dupont, N. Graham, S.J. Burnie, G. Gelley, Exercises for Mechanical Neck Disorders, The Cochrane Library, 2015. [6] J. Albright, R. Allman, R.P. Bonfiglio, A. Conill, B. Dobkin, A.A. Guccione, S.M. Hasson, R. Russo, P. Shekelle, J.L. Susman, Philadelphia Panel evidencebased clinical practice guidelines on selected rehabilitation interventions for neck pain, Phys. Ther. 81 (2001) 1701e1717. [7] S.K. Ndao-Brumblay, C.R. Green, Predictors of complementary and alternative medicine use in chronic pain patients, Pain Med. 11 (2010) 16e24. [8] K.J. Sherman, A.J. Cook, R.D. Wellman, R.J. Hawkes, J.R. Kahn, R.A. Deyo, D.C. Cherkin, Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain, Ann. Fam. Med. 12 (2014) 112e120. [9] R. Lauche, M. Schuth, M. Schwickert, R. Lüdtke, F. Musial, A. Michalsen, G. Dobos, K.E. Choi, Efficacy of the Alexander Technique in treating chronic non-specific neck pain: A randomized controlled trial, Clin. Rehabil. (2015), 0269215515578699. [10] S.S. Yoo, F. Tausk, Cupping: east meets west, Int. J. Dermatol. 43 (2004) 664e665. [11] R. Lauche, H. Cramer, C. Hohmann, E. Choi, T. Rampp, F.J. Saha, F. Musial, J. Langhorst, G. Dobos, The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study, Evid. Based Complementary Altern. Med. 2011 (2012). [12] H. Cao, X. Li, J. Liu, An updated review of the efficacy of cupping therapy, PLoS One 7 (2012) e31793. [13] M. Arslan, N. Kutlu, M. Tepe, N.S. Yilmaz, L. Ozdemir, S. Dane, Dry cupping therapy decreases cellulite in women: A pilot study, Indian J. Tradit. Knowl. 14 (2015) 359e364. [14] M. Arslan, N. Yesilçam, D. Aydin, R. Yüksel, S. Dane, Wet cupping therapy restores sympathovagal imbalances in cardiac rhythm, J. Altern. Complementary Med. 20 (2014) 318e321. [15] C. Iz, Cupping Therapy, Elservier, Philadelphia, PA, 2007. [16] H. Cao, M. Han, X. Li, S. Dong, Y. Shang, Q. Wang, S. Xu, J. Liu, Clinical research evidence of cupping therapy in China: a systematic literature review, BMC Complementary Altern. Med. 10 (2010) 70. [17] J.-I. Kim, M.S. Lee, D.-H. Lee, K. Boddy, E. Ernst, Cupping for treating pain: a systematic review, Evid. Based Complementary Altern. Med. 2011 (2011). [18] A. Michalsen, S. Bock, R. Lüdtke, T. Rampp, M. Baecker, J. Bachmann, J. Langhorst, F. Musial, G.J. Dobos, Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized controlled trial, J. pain 10 (2009) 601e608. [19] K. Jong-In, K. Tae-Hun, L.M. Soo, K.J. Won, K.K. Hyung, C. Jun-Yong, K. KyungWon, K. Ae-Ran, S. Mi-Suk, J. So-Young, Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot trial, Trials 12 (2011) 146. [20] H.-J. Cao, J.-P. Liu, H. Hu, N.S. Wang, Using a partially randomized patient preference study design to evaluate the therapeutic effect of acupuncture and cupping therapy for fibromyalgia: study protocol for a partially randomized controlled trial, Trials 15 (2014) 280. [21] M. Arslan, G. Yaman, E. Ilhan, M. Alemdag, A. Bahar, S. Dane, Moving dry cupping therapy reduces upper shoulder and neck pain in office workers, Clin. Investig. Med. 38 (2015) 217e220. [22] Y.D. Kwon, H.J. Cho, Systematic review of cupping including bloodletting therapy for musculoskeletal diseases in Korea, Korean J. Orient. Physiol. Pathol. 2l (2007) 789e793. [23] C.T. Hartrick, J.P. Kovan, S. Shapiro, The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract. 3 (2003) 310e316. [24] J.T. Farrar, J.P. Young, L. LaMoreaux, J.L. Werth, R.M. Poole, Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale, Pain 2 (2001) 149e158. [25] WHO, Guidelines on Basic Training and Safety in Acupuncture, 1999. Available
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[26]
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[28] [29]
[30]
at: http://apps.who.int/medicinedocs/en/d/Jwhozip56e/. Accessed June 26, 2015. Y. Lizuka, H. Iizuka, T. Mieda, T. Tajika, A. Yamamoto, T. Ohsawa, T. Sasaki, K. Takagishi, Association between neck and shoulder pain, back pain, low back pain and body composition parameters among the Japanese general population, BMC Musculoskelet. Disord. 16 (2015) 333e343. L. Punnett, D.H. Wegman, Work-related musculoskeletal disorders: the epidemiologic evidence and the debate, J. Electromyogr. Kinesiol. 14 (2004) 13e23. C.Y. Huang, M.Y. Choong, T.S. Li, Effectiveness of cupping therapy for low back pain: a systematic review, Acupunct. Med. (2013) acupmed-2013e010385. A. AlBedah, M. Khalil, A. Elolemy, A.A. Hussein, M. AlQaed, A. Al Mudaiheem, R.A. Abutalib, F.M. Bazaid, A.S. Bafail, A. Essa, The Use of wet cupping for persistent nonspecific low back pain: randomized controlled clinical trial, J. Altern. Complementary Med. 21 (2015) 504e508. M. Ernst, M.H. Lee, Sympathetic effects of manual and electrical acupuncture of the Tsusanli knee point: comparison with the Hoku hand point sympathetic effects, Exp. Neurol. 94 (1986) 1e10.
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[31] A. Sato, Neural mechanisms of autonomic responses elicited by somatic sensory stimulation, Neurosci. Behav. Physiol. 27 (1997) 610e621. [32] S.M. Tagil, H.T. Celik, S. Ciftci, F.H. Kazanci, M. Arslan, N. Erdamar, Y. Kesik, H. Erdamar, S. Dane, Wet-cupping removes oxidants and decreases oxidative stress, Complementary Ther. Med. 22 (2014) 1032e1036. [33] S.M. El Sayed, A.-S. Al-quliti, H.S. Mahmoud, H. Baghdadi, R.A. Maria, M.M.H. Nabo, A. Hefny, Therapeutic benefits of Al-hijamah: in light of modern medicine and prophetic medicine, Am. J. Med. Biol. Res. 2 (2014) 46e71. [34] J.-I. Kim, T.-H. Kim, M.S. Lee, J.W. Kang, K.H. Kim, J.-Y. Choi, K.-W. Kang, A.R. Kim, M.-S. Shin, S.-Y. Jung, Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot trial, Trials 12 (2011) 1e7. [35] S. Gok, F.H. Kazanci, H. Erdamar, N. Gokgoz, S.S. Hartiningsih, S. Dane, Is it possible to remove heavy metals from the body by wet cupping therapy, Indian J. Tradit. Med. (2015) (in press). [36] S. Cikar, G. Ustundag, S. Haciabdullahoglu, S. Yuksel, S. Dane, Wet cupping (hijamah) increases sleep quality, Clin. Investig. Med. 38 (2015) 258e261.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
The effect of traditional wet cupping on shoulder pain and neck pain: A pilot study € kgo € z a, S¸enol Dane b Müzeyyen Arslan a, *, Nurcan Go a b
Turgut Ozal University, School of Nursing, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey € Turgut Ozal University, Medical Faculty, Department of Physiology, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 December 2015 Received in revised form 14 February 2016 Accepted 24 February 2016
Objectives: Wet cupping therapy (WCT) is a traditional complementary method recommended to decrease the symptoms of a lot of diseases and used in the treatment of pain syndromes. In this pilot study, the possible effects of wet cupping therapy on nonspecific neck and upper shoulder pain were investigated. Methods: Sixty one eligible volunteer participants with nonspecific neck and upper shoulder pain for at least 3 months were allocated. The Numeric Rating Scale (NRS) was used to assess pain scores. Pain scores were recorded before and after wet cupping therapy. Results: The mean scores of neck pain in study group were 7.02 (SD ¼ 1.8) before and 3.70 (SD ¼ 2.2) after cupping therapy. The decrease of pain scores between pre- and post-test was statistically significant (p < 0.05). Discussion: It can be stated that WCT has potential therapeutic effect in nonspecific neck and upper shoulder pain. Future full-scale randomized controlled trials will be needed to provide firm evidence of the effectiveness of this intervention. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Cupping Neck Shoulder Pain
1. Background In modern world, neck and upper shoulder pain is a very common health problem. The incidence of neck and shoulder muscle pain is increased in recent years. The rate of shoulder pain in general population may be 6%e11% under the age of 50 years and 16%e25% in elderly people [1]. The neck and shoulder pain may be due to different factors. Excessive physical strain may cause micro traumas in connective tissues, and psychosocial stress may lead to increased muscular tension [2]. There are different treatment alternatives such as nonsteroidal anti-inflammatory drugs, physical therapy or exercise, but these have only limited evidence for the neck and shoulder pain treatment [3e5]. In the literature and treatment guidelines, drug, manual or massage therapies cannot be recommended [3,4,6]. Different therapeutic exercises have moderate effects in neck and shoulder pain relief in the long term [6]. Therefore, physicians and patients look for traditional, alternative or complementary
* Corresponding author. E-mail addresses: [email protected] (M. Arslan), nurcan.hilalay55@ €kgo €z), [email protected] (Dane). gmail.com (N. Go http://dx.doi.org/10.1016/j.ctcp.2016.02.003 1744-3881/© 2016 Elsevier Ltd. All rights reserved.
treatment applications [7e9]. Cupping therapy is mostly used in Asian and Middle Eastern countries and has been suggested to reduce pain as well as many other symptoms [10]. Cupping therapy are already used for shoulder and neck pain as a complementary medicine [11]. ]. There are two types of cupping. Dry cupping pulls the skin into a cup without drawing blood. In wet cupping, the skin is lacerated so that blood is drawn into a cup. Traditional dry or wet cupping has been utilized to treat many complaints for thousands of years [12e14]. A glass or plastic cup is used to generate suction on the painful area or point before lacerations are made on the skin. This process gets the body rid of the congested blood and therefore blood and lymphatic circulation increases which relieves painful muscle tension [12,15,16]. The main purpose of this therapy is to precipitate the circulation of blood and qi and to remove blood-stasis and waste from the body [17]. Recently, there is growing evidence that cupping might be effective in various painful conditions [11,18e21]. Recent systematic reviews and findings suggested that wet cupping is effective for musculoskeletal problems [17,22]. The aim of this pilot study was to retest the efficacy of a
M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33
traditional wet cupping treatment in patients with non-specific neck and shoulder pain. 2. Methods 2.1. Participants A one-group, pre-test and post-test quasi experimental design was utilized to measure the change in neck and shoulder pain scores before and after wet cupping therapy intervention. We recruited participants through advertisements on notice board of a university hospital in Ankara. After a telephone interview, potential participants were invited to be assessed on whether they were eligible for the study. Participants visited the Turgut Ozal University Medical School. The physicians conducting the study informed them about the study details. Their eligibility was determined by a physician through physical exams, and relevant questionnaires. Men and women aged 20e60 years were eligible to participate. Patients with traumatic neck pain, inflammatory or malignant diseases, congenital malformation of the spine, radicular symptoms such as radiating pain, paresis, prickling, or tingling, invasive treatments within the last 4 weeks, who had surgery to the spine within the last year, and who were on corticosteroid, opioid or any other similar treatments were excluded. Further exclusion criteria were pregnancy, serious acute or chronic organic diseases such as diabetes or cancer, mental disorders, and hemorrhagic tendency or anticoagulation treatment.
31
10e15 min, and the skin was disinfected and a plaster was applied. However, since bleeding generally stopped during the treatment, this was only a precaution. Patients were asked not to take a bath or go swimming within the next 24 h to prevent delays in wound healing. After some minutes of rest patients were free to leave. No adverse events were reported throughout the study. 2.5. Statistical analysis The data were analyzed using the Statistical Package for Social Sciences 16.0 (SPSS). Paired samples T-test was used for analysis. 3. Results Our study population consisted of 61 volunteers with nonspecific neck and upper shoulder pain, 43 females (70.5%) and 18 males (29.5%); aged 20e60 years (mean age 45.59 ± 10.9 years). The mean body mass index (BMI) of the subjects was 29 (SD ¼ 5.5). The mean scores of neck and upper shoulder pain in study group were 7.02 (SD ¼ 1.8) before and 3.70 (SD ¼ 2.2) after cupping therapy (see Fig. 1). The decrease of pain scores between pre- and post-test was statistically significant (p < 0.05). There were no serious adverse events in study group. A regular minor adverse effect was a hematoma on the site of application of a cupping glass. All scarified wounds healed without any complications.
2.2. Ethical consideration
4. Discussion
The study protocol was approved by the Turgut Ozal University ethics committee. Signed informed consent was obtained from every participant before beginning the study.
In the present study, the decrease in pain scores secondary to wet cupping therapy was walloping and the mean scores of neck pain decreased from 7.02 to 3.70. It can be stated that wet cupping must be accepted as a complementary therapy in clinical practice for patients with chronic and tenacious neck and upper shoulder pain. Pain in the upper neck and shoulder is highly prevalent in many countries [26,27]. Since conservative options for treatment are limited, new therapeutic approaches need to be noted. It has lately been proposed that cupping, a traditional method of treatment, may be beneficial in neck and shoulder pain when applied to the referred shoulder-neck region. A recent randomized study and systematic review suggested that cupping alleviates lower back pain [28,29]. The mechanism of action of wet cupping is still not clear; theories and many studies have been sectional. Different modes of actions might explain the effect of traditional cupping on chronic neck pain. They involve hematological [30], neural [31], antioxidant
2.3. Data collection The data were collected using a questionnaire, The Numeric Rating Scale (NRS) [23]. NRS is a simple and frequently used method for the assessment of variations in the subjective intensity of pain. In clinical practice, as a measure of the efficacy of the treatment, NRS segmented numeric version is often used in which respondents select a whole number (integers 0e10) that best reflects the intensity of their pain [24]. The NRS is used to assess pain in general in the previous week on a scale ranging from 0 to 10, where 0 represents ‘‘no pain’’ and 10 represents ‘‘extreme pain’’. Participants stated their pain level on the scale. This ensured that statistical evaluation of the effects of the wet cupping treatment was not influenced by alterations in medications or physiotherapy during the study. 2.4. Intervention Cupping was performed by the study physician and two certified nurses. For the cupping therapy, sterile disposable cups of 5 cm in diameter were used. Treatment points were selected to be five points of the posterior neck, bilateral perispinal areas of the neck and scapula according to the WHO Guideline for Acupuncture [25]. Same points were applied to all participants. The cupping procedure involved the following steps: Application areas were cleaned with antiseptic solution. Disposable cups were placed onto these points and negative pressure was applied by the cupping pump. After two to 3 min, cups were removed. The skin was disinfected; superficial incisions were made with a disposable micro lancet on the areas of pain; the cups were placed on the same incision points. The glasses were removed after
Fig. 1. The mean pain scores before and after cupping therapy.
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[32], and psychological effects [11]. By taking pressure off the tissues of the affected area, traditional cupping therapy evacuates the neck and shoulder from the toxic congestions and inflammatory agents which also increase blood and lymph flows. This could help clarify the local effects on pressure pain thresholds [11]. The result of this study supports the use of wet cupping in reducing neck and upper shoulder pain for at least one week after the wet cupping. In a recent review, both dry and wet cupping therapies were suggested for various musculoskeletal pain conditions [28]. In a recent study, it has been reported that dry cupping therapy can be confidently used to reduce the upper shoulder and neck pain in office workers as a therapeutic application and possibly as a preventative method [21]. Lauche and et al. [11] reported that the effects of traditional cupping are already present on the day after cupping treatment. This conforms to clinical observations, in which traditional cupping often showed immediate effects on pain and other complaints. Michalsen et al. presented [18] the results of a randomized trial on the clinical effects of traditional cupping therapy in patients with carpal tunnel syndrome. Cupping of segmentally related shoulder zones appears to alleviate the symptoms of carpal tunnel syndrome. Cupping (both dry and wet) therapy has been asserted to drain accumulated fluids, toxins and other chemical compounds such as lipids from interstitial fluid to blood and lymphatic capillaries [33,34]. The possible curative effects of wet cupping therapy in reducing non-specific neck and shoulder pain can be due to two its three mechanisms: (1) by stimulating the peripheral nervous system [14] and (2) removing oxidants and decreasing oxidative stress [32] and (3) by excreting toxic heavy metals [35]. Wet cupping therapy decreased the psychological stress conditions by restoring the sympathovagal imbalances and by decreasing static electric [14]. It can be accepted that the decrease in stress is important in relieving of pain. Oxidants or oxidative stress causes pain via lipid peroxidation injury in cell membranes. Therefore, the wet cupping therapy can be suggested as an antioxidant application in clinical practice [32]. Also, it is well known that the accumulation of heavy metals is the most toxic and hazardous factors for all body tissues. The excretion of heavy metals via wet cupping [35] from the body can be effective in the relieving of neck and upper shoulder pain. Also, in a recent study, all sleep quality parameters were positively affected after wet cupping therapy in healthy subjects. They concluded that the increase in sleep quality may be secondary to decrease in different pains and stresses and also the removal of some macromolecules and heavy metals accounts for the improved sleep quality [36]. The studies in future must be focused the effectiveness of wet cupping therapy on other pains such as headache, back pain and cancer pain. Also, wet cupping therapy can be compared to the other medical and physical therapies in future studies. In addition to the evaluation of effectiveness, safety issues are very important in wet cupping practice and must be paid attention. In conventional wet-cupping, non-sterile, reusable cups and lancets are used without any consideration of the possibility of an infection. 5. Conclusion The result of this study supports the use of wet cupping in reducing non-specific neck and shoulder pain. But, these results must be supported by randomized and placebo controlled trials. A single application of traditional wet cupping might be effective in the treatment of chronic non-specific neck pain. It should be considered for other musculoskeletal pain conditions, as a complement to medical treatment.
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