The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials
Zhang et al. · Complementary Therapies in Medicine · 2024
Evidence Level
MODERATEOBJECTIVE
To investigate the effectiveness of cupping therapy on low back pain
WHO
921 adults with chronic and nonspecific low back pain
DURATION
2-8 weeks of treatment with follow-up to 6 months
POINTS
Acupuncture points (BL-23, BL-24, BL-25) and lumbar region
🔬 Study Design
Cupping Group
n=609
Dry or wet cupping at specific points
Control Group
n=592
Medication, usual care, or sham cupping
📊 Results in numbers
Pain reduction at end of treatment
Wet cupping vs dry cupping
Acupoint vs lumbar region
Disability improvement at 1-6 months
📊 Outcome Comparison
Pain Reduction (d score)
This study showed that cupping therapy is effective in reducing low back pain and improving physical function. Wet cupping and application at specific acupuncture points showed better results, being superior to conventional medications for pain relief.
Article summary
Plain-language narrative summary
This systematic review and meta-analysis investigated the effectiveness of cupping therapy in the treatment of low back pain, analyzing 11 randomized controlled trials with 921 participants. Cupping therapy, a traditional Chinese medicine technique that uses negative pressure through cups applied to the skin, has gained increasing interest as a complementary treatment for musculoskeletal conditions. The researchers searched the Medline, Embase, Scopus, and WANFANG databases through September 2023, including articles in English and Chinese that evaluated adults with low back pain treated with dry or wet cupping. The methodology rigorously followed PRISMA guidelines and Cochrane Handbook protocols, with independent quality assessment of the studies by reviewers.
Results demonstrated high-quality evidence that cupping therapy significantly improves low back pain in the 2-8 week period after treatment (d=1.09, p=0.004). However, no continued improvement was observed at 1 month (p=0.85) and 3-6 months of follow-up (p=0.11), suggesting that benefits are most pronounced in the immediate post-treatment period. Subgroup analysis revealed important differences between cupping types: wet cupping (which involves small skin incisions before application) showed a significant effect (d=1.5, p=0.008), while dry cupping did not show statistically significant improvement (p=0.14). Additionally, application of cups at specific acupuncture points was superior to application over the general lumbar region (d=1.29 vs 0.35).
Regarding low back pain classifications, treatment was more effective for nonspecific low back pain and persistent nonspecific low back pain, but did not show significant benefits for chronic low back pain and chronic nonspecific low back pain. Cupping therapy demonstrated superiority both compared to drug treatment (d=1.8, p<0.001) and to usual care (d=1.07, p=0.01). Two studies showed that cupping significantly improves sensory and emotional pain immediately, after 24 hours, and 2 weeks post-intervention. Moderate evidence suggested improvement in functional disability at 1-6 month follow-up (d=0.67, p=0.03), although without immediate effect in the 2-8 week period.
Strengths of the study include the comprehensive analysis of different cupping protocols, the inclusion of studies in multiple languages, and the rigorous methodological quality assessment. Limitations include high heterogeneity among studies (I²>50%), variability in treatment protocols, reliance on self-reported pain measures, and challenges in implementing adequate blinding due to the nature of the intervention.
Strengths
- 1First meta-analysis to systematically investigate different cupping protocols
- 2Detailed subgroup analysis by cupping type and treatment location
- 3Inclusion of studies in English and Chinese for broader evidence coverage
- 4Rigorous methodological quality assessment using Cochrane tools
- 5Robust sample size with 921 participants
Limitations
- 1High heterogeneity among studies makes definitive conclusions difficult
- 2Variability in treatment protocols and session duration
- 3Reliance on self-reported pain measures subject to subjective bias
- 4Difficulties in adequate blinding due to visible cupping marks
- 5Limited evidence on long-term efficacy beyond 6 months
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
Low back pain remains one of the most prevalent conditions in rehabilitation and pain services, and the search for adjunct interventions that reduce dependence on analgesics justifies attention to this meta-analysis. With 921 participants across 11 randomized trials, the work offers a sufficient dataset to guide short-term clinical decisions. The most robust effect occurs in the 2- to 8-week window, which makes cupping therapy a coherent option for patients with nonspecific low back pain in the acute or subacute phase who do not tolerate NSAIDs or who respond unsatisfactorily to the conventional arsenal. Patients with contraindications to NSAIDs due to renal, cardiovascular, or gastrointestinal disease represent a population in which the clinician may reasonably consider including this technique, provided there is adequate experience by the executing professional.
▸ Notable Findings
The most clinically impactful data point is the substantial difference between application at specific acupoints versus the general lumbar region — effect sizes of 1.29 versus 0.35, respectively. This magnitude suggests that careful point selection is not a protocol detail but a central determinant of outcome. The superiority of wet cupping (d=1.5) over dry cupping (without statistical significance) is equally relevant, although the former involves microincisions and requires a controlled clinical context and specific training. Another finding worth noting is the temporal dissociation between analgesia and function: improvement in disability appears only in the 1- to 6-month follow-up, while pain reduction is concentrated in the active treatment phase. This implies that the functional benefit may be mediated indirectly, perhaps via adherence to other rehabilitative interventions facilitated by initial pain reduction.
▸ From My Experience
In my practice in the musculoskeletal pain clinic, I usually see noticeable analgesic response starting from the third or fourth session of negative-pressure techniques associated with dry needling in nonspecific low back pain. The patient profile that responds best is one with a predominantly myofascial component, frequently identified by the presence of trigger points in the paravertebral musculature and quadratus lumborum, without significant neuropathic radiation. I typically structure cycles of 6 to 10 sessions and counsel that functional benefits emerge with some delay relative to pain relief — which aligns with what this meta-analysis demonstrates. I do not indicate the technique in patients on anticoagulants, with active dermatologic conditions, or with significant skin fragility. I routinely combine it with kinesiotherapy and, when there is an inflammatory component, with NSAIDs for a short period. The observed superiority of acupoint-based application confirms what I have observed empirically: well-localized technique surpasses indiscriminate regional application, and this should guide the training of clinicians who incorporate cupping therapy into their repertoire.
Full original article
Read the full scientific study
Complementary Therapies in Medicine · 2024
DOI: 10.1016/j.ctim.2024.103013
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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