Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis
Kim et al. · BMJ Open · 2018
OBJECTIVE
To evaluate the efficacy of cupping therapy in the treatment of cervical pain through systematic review
WHO
Adults with neck pain (acute or chronic)
DURATION
Analysis of studies through January 2018
POINTS
Cervical region, upper shoulders, and Ashi points
🔬 Study Design
Cupping Therapy
n=534
dry or wet cupping in the cervical region
Control
n=509
no treatment, waiting list, or standard care
📊 Results in numbers
Pain reduction vs. no treatment
Pain reduction vs. active control
Cervical function improvement
Adverse events
📊 Outcome Comparison
Pain reduction (0-10 scale)
This review shows that cupping therapy may be an effective treatment to reduce neck pain and improve cervical function. Benefits were observed both when compared to no treatment and to other active treatments, with side effects generally mild and temporary.
Article summary
Plain-language narrative summary
This systematic review and meta-analysis examined the efficacy of cupping therapy in the treatment of cervical pain, analyzing 18 randomized controlled trials with a total of 1,043 participants. Cupping therapy is a millennia-old therapeutic technique that uses cups applied over the skin to create negative pressure through suction, and may be performed in dry form (without bleeding) or wet form (with scarification). Researchers conducted a comprehensive search across nine databases, including Chinese, Korean, and Japanese sources, with no language restrictions, to ensure a complete analysis of the literature available through January 2018. The studies included adults with cervical pain, both acute and chronic, excluding cases of trauma such as whiplash or sports injuries.
Cupping therapy treatments were applied mainly to the upper cervical region and shoulders, frequently at Ashi points (painful points) and other nearby points. Treatment frequency varied considerably between studies, from single sessions to more than 10 sessions, depending on the severity and chronicity of the condition. Results demonstrated that cupping therapy was significantly effective in reducing pain when compared to both no-treatment groups and active controls. Specifically, when compared to no intervention, cupping therapy showed a mean pain reduction of 2.42 points on the visual analog scale, surpassing the minimum clinically important difference threshold of 0.8 points.
In addition to pain reduction, patients also experienced significant improvements in cervical function, with a mean reduction of 4.34 points on the Neck Disability Index, again exceeding the clinically relevant threshold of 3 points. When compared to active treatments such as physical therapy, anti-inflammatory medications, or acupuncture, cupping therapy still demonstrated superiority with mean pain reduction of 0.89 points. Subgroup analysis revealed that both dry and wet cupping therapy were effective, although with variations in effect sizes. Benefits also extended to quality of life, with significant improvements observed in the mental component of the SF-36 questionnaire when compared to no treatment, and in the physical component when compared to active controls.
Regarding safety, only 8 of the 18 studies reported adverse events, which were predominantly mild and temporary. The most common side effects included pain at the application site, minor hematomas, temporary headache, and muscle tension, all resolving spontaneously within a few days. No serious adverse events directly related to cupping therapy were identified in the analyzed studies. However, it is important to note that many studies did not adequately report safety issues, representing a significant limitation.
The clinical implications of these findings are considerable, especially considering that cervical pain is the second leading cause of years lived with disability worldwide. Cupping therapy offers a non-pharmacological therapeutic option that may be particularly valuable for patients seeking alternatives to conventional medications or who experience side effects with standard treatments. The therapy may also be used as a complementary treatment, potentiating the effects of other interventions. However, several important limitations must be considered.
The overall quality of evidence was rated as low to very low due to methodological concerns, including risk of bias, imprecision, and inconsistency between studies. Many studies did not use adequate randomization or allocation concealment methods, and blinding was problematic due to the nature of the intervention. In addition, the significant heterogeneity between studies, particularly in wet cupping therapy protocols, suggests that different techniques may have variable efficacies. Exclusive reliance on patient-reported outcomes may also have introduced bias, since adequate blinding was not possible.
Another limitation was that almost all included studies focused on chronic cervical pain, leaving uncertain whether the benefits apply equally to acute pain.
Strengths
- 1Comprehensive search across multiple databases without language restriction
- 2Analysis of 18 randomized controlled trials
- 3Assessment of both dry and wet cupping therapy
- 4Safety and adverse event analysis
Limitations
- 1Low to very low quality of included evidence
- 2Inability to adequately blind participants
- 3High heterogeneity between studies
- 4Many studies did not adequately report adverse events
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
Chronic cervical pain occupies a prominent position in the daily routine of any rehabilitation service, and cupping therapy frequently arrives at the office as a patient demand even before any medical prescription. This meta-analysis of 18 randomized clinical trials with 1,043 participants provides, for the first time on a systematic scale, effect estimates that exceed the minimum clinically important differences — reduction of 2.42 points in pain versus no treatment and a drop of 4.34 points in NDI. These thresholds are objective benchmarks that allow the physiatrist to position cupping therapy with some quantitative basis within the non-pharmacological armamentarium. The patient profile that benefits most appears to be the patient with chronic cervicalgia who does not tolerate or refuses NSAIDs, who has already undergone conventional physical therapy with partial response, or who presents with a high burden of myofascial trigger points in the upper cervical musculature and trapezius — a condition in which the negative pressure of cupping operates in a mechanically complementary way to needling.
▸ Notable Findings
Two findings deserve special attention. First, the superiority of cupping therapy over active controls — physical therapy, NSAIDs, acupuncture — by 0.89 points, although modest, breaks with the narrative that the technique would work only by therapeutic context effect; it suggests a specific effect component, probably mediated by mechanical modulation of connective tissue and cutaneous nociceptive afferents. Second, the 4.34-point improvement on the NDI comfortably exceeds the clinical relevance threshold of 3 points, which is functionally expressive — corresponding to measurable gains in activities such as cervical rotation for vehicle driving and tolerance for desk work. The extension of benefits to the mental component of the SF-36 also draws attention: interventions targeted at cervical myofascial tissue appear to have repercussions on central neuromodulation, a hypothesis consistent with what is known about central sensitization in chronic cervical pain.
▸ From My Experience
In my practice at the musculoskeletal pain clinic, I introduced sliding cupping therapy over the trapezius and levator scapulae as a complement to dry needling of trigger points, and the combination usually accelerates the response — patients who, with isolated needling, took four or five sessions to report consistent relief, with cupping added tend to report improvement as early as the second or third session. I usually reserve static dry cupping for early phases in patients with high mechanical sensitivity, switching to sliding cupping when pressure hyperalgesia has already partially yielded. The profile that responds best in my experience is the middle-aged adult with chronic cervicalgia of predominantly myofascial component, low tolerance for invasive procedures, and a history of good response to massage therapy. I do not indicate cupping therapy over skin with trophic changes, full anticoagulation, or suspected acute compressive radiculopathy without adequate prior imaging investigation. For maintenance, I have used a schedule of eight to twelve initial sessions with functional reassessment by NDI — exactly the outcome this work uses — which makes it easier to communicate objective progress to the patient.
Full original article
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BMJ Open · 2018
DOI: 10.1136/bmjopen-2017-021070
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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