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Journal of the Neurological Sciences 294 (2010) 70–73

Contents lists available at ScienceDirect

Journal of the Neurological Sciences


j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j n s

Cupping for stroke rehabilitation: A systematic review


Myeong Soo Lee a,b,⁎, Tae-Young Choi a, Byung-Cheul Shin c, Chang-ho Han d, Edzard Ernst b
a
Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
b
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK
c
Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, Republic of Korea
d
Department of Oriental Medicine, Graduate School of Oriental Medicine, Dongguk University, Seoul, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Cupping is often used for stroke rehabilitation in Asian countries. Currently, no systematic review of this
Received 26 December 2009 topic is available. The aim of this systematic review is to summarize and critically evaluate the evidence for
Received in revised form 21 March 2010 and against the effectiveness of cupping for stroke rehabilitation. Thirteen databases were searched from
Accepted 24 March 2010
their inception through March of 2010 without language restrictions. Prospective clinical trials were
included if cupping was tested as the sole treatment or as an adjunct to other conventional treatments for
Keywords:
Cupping
stroke rehabilitation. We found 43 potentially relevant articles, of which 5 studies including 3 randomized
Stroke clinical trials (RCTs) and 2 uncontrolled observational studies (UOSs) met our inclusion criteria. Cupping was
Rehabilitation compared with acupuncture, electro-acupuncture and warm needling. Some superior effects of cupping
Systematic review were found in two of the RCTs when compared to acupuncture in hemiplegic shoulder pain and high upper-
limb myodynamia after stroke. The other RCT failed to show favorable effects of cupping when compared to
acupuncture and warm needling in patients with hemiplegic hand edema. The two UOSs reported favorable
effects of cupping on aphasia and intractable hiccup after stroke. There are not enough trials to provide
evidence for the effectiveness of cupping for stroke rehabilitation because most of the included trials
compared the effects with unproven evidence and were not informative. Future RCTs seem warranted but
must overcome the methodological shortcomings of the existing evidence.
© 2010 Elsevier B.V. All rights reserved.

1. Introduction drains excess fluids, loosens adhesions and lifts connective tissue,
brings blood flow to stagnant skin and muscles, and stimulates the
Stroke is one of the common causes of death worldwide [1]. Stroke peripheral nervous system. In addition, cupping is said to reduce pain
survivors often need long-term institutional care, which is a major and high blood pressure and modulate neurohormone and immune
burden for all involved. In Western medicine, no single form of systems [4,7]. Cupping is used to improve subcutaneous blood flow
complementary and alternative medicine (CAM) is in particularly circulation and to stimulate the autonomic nervous system. In clinical
common use for the management of stroke rehabilitation or recovery practice, cupping is often used for stroke rehabilitation and its
[2]. In Eastern medicine, acupuncture and Chinese herbs are widely complications [4]. Various web sources also illustrate the benefits of
used [2]. One recent survey reported that 46% of stroke patients used cupping for stroke.
some forms of CAM, such as herbal medicine, acupuncture-type Currently, no systematic review of this subject is available. It is
treatment or chiropractic treatment [3]. therefore pertinent to evaluate the effectiveness of cupping for stroke
Cupping is a physical treatment used by acupuncturists or other rehabilitation. The objective of this systematic review is to summarize
therapists that uses a plastic, bamboo, or glass cup to create suction on and critically assess the evidence of cupping for stroke rehabilitation.
the skin over an acupuncture point or painful area [4]. It has been said
to reduce pain as well as a host of other symptoms [5–7]. In dry 2. Methods
cupping, which pulls the skin into the cup without drawing blood,
negative pressure acts on the skin and irritates subcutaneous muscles. 2.1. Data sources
In wet cupping the skin is lacerated so that stagnant blood is drawn
into the cup. It has been claimed that cupping (both dry and wet) The following databases were searched from their inception
through March of 2010: Medline, EMBASE, CINAHL, PsycInfo, The
Cochrane Library 2010 (Issue 2), six Korean Medical Databases
⁎ Corresponding author. Division of Standard Research, Korea Institute of Oriental
Medicine, Daejeon, 305-811, Republic of Korea. Tel.: +82 42 868 9266; fax: +82 42 863
(Korean Studies Information, DBPIA, Korea Institute of Science and
9464. Technology Information, Research Information Service System, Kor-
E-mail addresses: drmslee@gmail.com, mslee@kiom.re.kr (M.S. Lee). eaMed and the Korean National Assembly Library), the Chinese

0022-510X/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jns.2010.03.033
M.S. Lee et al. / Journal of the Neurological Sciences 294 (2010) 70–73 71

Medical Database (CNKI) and the Japanese Medical Database (J- 3.2. Risk of bias
Stage). Twelve major Korean traditional medicine journals were also
manually searched for relevant articles. The search terms used were: Only one RCT employed an appropriate method of sequence
cupping AND (stroke OR apoplexy OR cerebrovascular attack OR generation (random number table) [9], while others did not have
cerebrovascular accident OR cerebrovascular* OR cerebral infarction information available [10,11]. Assessor blinding and allocation
OR cerebral hemorrhage OR cerebral*) in Korean, Chinese, Japanese concealment were judged to have been achieved in none of the
and English. In addition, our own files and journals (FACT — Focus on studies. None of the included RCTs incorporated patient blinding.
Alternative and Complementary Therapies, and Research in Comple-
mentary Medicine [Forschende Komplementarmedizin] up to March 3.3. Outcome
of 2010) were manually searched. Hardcopies of all articles were
obtained and read in full. Yuan [9] tested the effects of wet cupping in patients with
hemiplegic shoulder pain. Patients were randomized into two groups,
2.2. Study selection one receiving wet cupping plus exercise therapy and the other
receiving acupuncture plus exercise therapy. After treatment, the pain
Prospective clinical trials of cupping for stroke rehabilitation were intensity on the visual analogue scale (VAS) and pain frequency were
included. Trials comparing any type of cupping with any type of significantly reduced in the cupping group compared to control
control intervention were included. We included trials that employed groups. There was also a favorable effect of cupping on range of
cupping an adjunct to conventional treatment. Trials with cupping as motion.
a part of a complex (mixed but not add-on) intervention were Zhang [10] evaluated the efficacy of wet cupping on responder's
excluded. Trials were also excluded if outcome measures were not rate in patients with hemiplegic hand edema. A total of 150 patients
relevant to stroke rehabilitation. Trials published in dissertation and were randomly divided into three groups receiving wet cupping
abstract form were included. No language restrictions were imposed. (n = 34), acupuncture (n = 36) or warm needling (n = 80). The main
outcome was responder's rate. There was a favorable effect of wet
2.3. Data extraction, quality and validity assessment cupping compared to acupuncture; however, warm needling had a
more beneficial effect compared to wet cupping.
All articles were read by two independent reviewers (T.Y.C. and Ni and Shen [11] conducted an RCT to evaluate the effects of wet
B.C.S.) who extracted data from the articles according to predefined cupping in patients with high upper-limb myodynamia after stroke
criteria. Risk of bias was assessed using the Cochrane classification compared to acupuncture. Sixty-two patients were randomly divided
with four criteria: randomization, blinding, withdrawals and to receive wet cupping (n = 31) or acupuncture (n = 31). The main
allocation concealment [8]. Considering that it is difficult for blind outcome measures were responder's rate and reduction of myody-
therapists to use cupping, we assessed patient and assessor blinding namia. The differences between the wet cupping and control groups
separately. Disagreements were resolved by discussion between the were statistically significant in favor of wet cupping for response rate
two reviewers by consulting a third reviewer (M.S.L.). and reduction in myodynamia. The two UOSs included in the present
systematic review assessed the effects of cupping for stroke
2.4. Data synthesis rehabilitation [12,13]. One trial showed that wet cupping had positive
effects on aphasia after five treatments [12]. The other UOS found that
To summarize the effects of cupping on each outcome, we five to ten treatments of dry cupping improved the intractable hiccup
abstracted the risk estimates (relative risk: RR), and mean difference after stroke [13].
and 95% confidence interval (CI) were calculated using the Cochrane
Collaboration's software (Review Manager (RevMan) Version 5.0 for 3.4. Adverse events
Windows. Copenhagen: The Nordic Cochrane Centre). For studies
with insufficient information, we contacted the primary authors to None of the included studies mentioned adverse events.
acquire and verify data where possible. If appropriate, we then pooled Clinical heterogeneity among the studies (conditions of patients,
the data across studies using random effects models (if excessive etc.) prohibited us from pooling the data.
statistical heterogeneity or clinical heterogeneity did not exist). The
chi-square test, and the Higgins I2 test were used to assess 4. Discussion
heterogeneity.
Few rigorous RCTs testing the effects of cupping for stroke
3. Results rehabilitation are currently available, and the existing studies do not
provide much information for efficacy of cupping for stroke
3.1. Study description rehabilitation. To date, the effects of acupuncture for stroke
rehabilitation have not been confirmed. Furthermore, two RCTs
We identified 43 potentially relevant articles, of which 38 studies [9,11] evaluated here showed favorable effects of wet cupping for
were excluded (Supplement 1). Key data of the included three stroke rehabilitation while the other [10] failed. Future well-designed
randomized clinical trials (RCTs) and two uncontrolled observational clinical trials are needed to decipher the effectiveness of cupping for
studies (UOSs) are summarized in Table 1 [9–13]. Thirteen studies stroke rehabilitation.
were excluded because cupping was included as part of complex In three studies evaluated here, cupping was compared to
treatment or because of the use of other non-proven therapies acupuncture and warm needling [9–11]. Some superior effects of
(Supplement 2). A total of 292 participants were included in these cupping were found when compared to acupuncture treatment for
studies. All trials originated from China. One RCT assessed the effects hemiplegic shoulder pain [9] and high upper-limb myodynamia after
of cupping on hemiplegic shoulder pain [9], one tested hemiplegic stroke [11]. The other RCT [10] failed to show favorable effects of
hand edema [10] and the other RCT assessed the effects of cupping on cupping when compared to acupuncture and warm needling in
high upper-limb myodynamia after stroke [11]. The two UOSs tested patients with hemiplegic hand edema. These trials, however,
aphasia [12] and intractable hiccup after stroke [13]. Wet cupping was compared the effects with unproven techniques and were not
used in four trials [9–12] and dry cupping was employed in one trial informative. One problem with clinical trials employing cupping is
[13]. All RCTs tested cupping vs. several types of acupuncture. finding a suitable sham or placebo control [14]. Considering that the
72
Table 1
Summary of clinical studies on cupping for stroke rehabilitation.

First author Design/sample size Intervention group Control group Main outcomes Intergroup differences Risk of bias Adverse
(year) Conditions (Regime) (Regime) events
Duration of disease

M.S. Lee et al. / Journal of the Neurological Sciences 294 (2010) 70–73
Yuan (2008) RCT/58 (A) Wet cupping (10 min, once (B) AT (routine treatment) 1) Responder rate 1) P = 0.44, RR, 1.11 (0.85 to 1.45) (Y,N,N,N, n.r.
[9] Hemiplegic shoulder pain every 2 days, total 10 times, (1 session = 30 min, once 2) Pain intensity(VAS) 2) P = 0.004, MD, − 1.19 (− 1.99 to − 0.39) N)
(A) 19–115 days n = 30), plus exercise therapy daily, total 5 times, next 3) Pain frequency 3) P = 0.002, MD, − 2.00 (− 3.06 to − 0.94)
(B) 14–111 days Affected side, most pain point session after 2 days rest, 4) Range of motion 4) Flexion: P b 0.0001, MD, 6.00 (4.18, 7.82);
total 4 sessions, n = 28), posterior extension: P b 0.0001, MD,
plus exercise therapy 4.90 (3.17, 6.63); abduction: P b 0.0001, MD,
TE14, SI9, SI11, GV26, HT1,etc. 6.90 (4.90, 8.90); adduction: P b 0.00001, MD,
6.4 (4.29, 8.51)
Zhang (2002) RCT/150 (A) Wet cupping (1 session = 10 min, (B) AT (1 session = 20 min, once Responder rate A vs. B; P = 0.66, RR, 1.06 (0.82 to 1.37) (U,N,N,U, n.r.
[10] Hemiplegic hand edema once daily,for 5 days, total 6 sessions, daily for 5 days, total 6 sessions, n = 36) A vs. C; P = 0.02, RR, 0.81 (0.68 to 0.97) U)
2 days–3 months n = 34) (C) Warm needle (1 session = once daily
Local area for 5 days, 6 sessions, n = 80)
Ni (2004) RCT/62 (A) Wet cupping (10 min, 2 times (B) AT (30 min, 2–3 times per week, 1) Responder rate 1) P = 0.0007, RR, 2.36 (1.43 to 3.89) (U,N,N,U, n.r.
[11] High upper-limb per week, for 1 month, n = 31) for 1 month, n = 31) 2) Reduction of myodynamia 2) P = 0.009, MD, − 6.95 (− 12.14 to − 1.76) U)
myodynamia Biceps muscle area LI14, LI11, LI4, LU5, etc.
after stroke
(A) 7.4 months
(B) 7.2 months
Liu (2000) UCT/16 Wet cupping (once daily, 5 sessions) N/A Responder rate 15:1(94%) N/A n.r.
[12] Aphasia Ex-aphasia after stroke
2 weeks–1 year
Huang (2009) UCT/6 Dry cupping (10–30 min, 5–10 times) N/A Responder rate 6:0(100%) N/A n.r.
[13] Intractable hiccup after stroke CV8
3.5 days

RCT: randomized clinical trial; n.r.: not reported; N/A: not available; NS: not significant; RR: risk ratio; VAS: visual analogue scale; Ex: extra points; MD: mean difference.
Risk of bias: (Sequence generation, allocation concealment, incomplete outcome (attrition bias), patient blinding, assessor blinding); Yes (Y): low risk of bias; No (N): high risk of bias; Unclear (U): uncertain risk of bias.
M.S. Lee et al. / Journal of the Neurological Sciences 294 (2010) 70–73 73

possible effects of cupping may come from the draining of excess warranted but must overcome the methodological shortcomings of
fluids and toxins, loosening of adhesions, lifting of connective tissue, the existing evidence.
bringing blood flow to stagnant skin and muscles and giving tactile
neuromuscular stimulation by contact or negative pressure to Conflicts of interest
promote stroke rehabilitation [4,5], sham cupping may include
suctioning non-acupuncture points or treating with or without All of authors do not have any conflicts of interest.
negative pressure. At the present time, however, no suitable sham
cupping has been developed. Because of this, a range of methods has Acknowledgements
been used, some of which may not be adequate.
Assuming that cupping is beneficial for stroke rehabilitation, its M. S. Lee and T. Y. Choi were funded by KIOM. B.C. Shin and C. Han
mechanisms of action may be of interest. The postulated modes of were supported by a grant of the Oriental Medicine R&D Project, the
action include draining excess fluids and toxins and can be done via Ministry for Health, Welfare and Family Affairs (MIHWAF), Republic
gas exchange between the inside and outside, which also improves of Korea [No. B080053].
subcutaneous blood flow circulation. In the views of oriental
medicine, cupping expels the cold qi or restores and regulates the
Appendix A. Supplementary data
normal flow of qi and blood (or circulation) to the affected meridian. It
also nourishes the local muscles and tendons [4]. None of these
Supplementary data associated with this article can be found, in
theories, however, have been established in the literature.
the online version, at doi:10.1016/j.jns.2010.03.033.
This systematic review has several limitations. Although we
attempted to retrieve all relevant RCTs, we cannot be certain that
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