The Use of Wet Cupping for Persistent Nonspecific Low Back Pain: Randomized Controlled Clinical Trial

This randomized controlled clinical trial conducted in Saudi Arabia investigated the efficacy of wet cupping therapy (hijama) in the treatment of persistent nonspecific low back pain, a condition that affects millions of people worldwide and represents one of the leading causes of disability and work absenteeism. Persistent nonspecific low back pain is defined as pain that persists for at least 12 weeks without an identifiable specific cause, accounting for approximately 80% of all low back pain cases. The study was motivated by the need to find effective therapeutic alternatives for this condition, which is often resistant to conventional treatments. The research was carried out in three secondary hospitals in different cities in Saudi Arabia between April and September 2014.

The investigators recruited 80 adult participants (18-60 years) with nonspecific low back pain for at least 3 months, excluding those with medical conditions contraindicating cupping therapy, anticoagulant use, or other chronic illnesses. Participants were equally randomized into two groups: intervention (wet cupping) and control (no treatment). The treatment protocol consisted of six wet cupping sessions distributed over two weeks, with three sessions per week. In each session, two acupuncture points were selected from BL-23, BL-24, and BL-25 on the bladder meridian.

The technique used followed a modified protocol that differed from the traditional Middle Eastern practice by using puncture followed by application of the cups, instead of the traditional cup-puncture-cup sequence. Both groups were allowed to use up to three 500 mg acetaminophen tablets per day as rescue medication, and other medications, alternative therapies, and physical therapy were prohibited during the four weeks of the study. Outcome assessment was performed using three validated instruments: the Numeric Rating Scale (NRS), the McGill Present Pain Intensity Questionnaire (PPI), and the Oswestry Disability Questionnaire (ODQ). Measurements were taken at baseline, after two weeks (end of intervention), and after four weeks (two weeks post-treatment).

The primary outcome was the difference in NRS score between groups at the end of the two-week treatment period. The results demonstrated statistically significant differences favoring the wet cupping group on all three outcome measures. The mean NRS score in the cupping group was 29.2 points compared with 57.9 points in the control group (p < 0.0001). On the ODQ, the cupping group had a score of 19.6% versus 35.4% in the control group.

Strikingly, 77.5% of patients in the cupping group demonstrated clinically meaningful improvement (reduction ≥ 15 points on the NRS) after two weeks, compared with only one patient in the control group. In addition, the benefits were maintained during the two-week post-treatment follow-up period, with some measures showing additional improvement. Acetaminophen use was lower in the cupping group, although this difference did not reach statistical significance. No adverse events were reported during the entire study.

The clinical implications of these findings are substantial, suggesting that wet cupping therapy may represent a safe and effective therapeutic option for patients with chronic low back pain. The study also had an impact on the Saudi health care system, establishing for the first time cupping therapy clinics in secondary government hospitals and creating an integrative medicine model involving multidisciplinary professionals. The investigators conducted patient satisfaction surveys and workshops with health insurance companies to discuss extending coverage for integrated complementary therapies.