Effectiveness of cupping therapy for musculoskeletal pain: an umbrella review
ElMeligie et al. · Human Movement · 2024
OBJECTIVE
To synthesize evidence on the efficacy of cupping therapy for musculoskeletal pain in athletes and the general population
WHO
27,960 participants with musculoskeletal pain across 301 studies
DURATION
Analysis of studies published through May 2023
POINTS
General cupping application; specific acupoints not specified
🔬 Study Design
Cupping therapy
n=13980
Dry or wet cupping
Controls
n=13980
Usual care, medications, or no treatment
📊 Results in numbers
Pain reduction vs. no treatment
Low methodological quality
Insufficient evidence in athletes
Mild to moderate adverse events
Percentage highlights
📊 Outcome Comparison
Efficacy for pain reduction
This large review analyzed 21 studies on cupping therapy for musculoskeletal pain. The results show that cupping may be more effective than no treatment at all, but the evidence is of low quality and there is no clear recommendation for its use.
Article summary
Plain-language narrative summary
This study represents a comprehensive umbrella review that analyzed 21 systematic reviews on cupping therapy for musculoskeletal pain, encompassing 301 primary studies and 27,960 participants. Cupping therapy, a traditional technique that uses cups to create negative pressure on the skin, has been used for more than four thousand years for various medical conditions. The aim of this research was to synthesize the available evidence on the efficacy of cupping therapy in athletes and in the general population with musculoskeletal pain. The investigators conducted a systematic search of eight major databases through May 2023, including PubMed, Web of Science, Scopus, and Cochrane Central.
The methodological quality of the reviews was assessed using the AMSTAR2 tool, which examines 16 critical domains to determine the reliability of the results. The findings revealed concerning patterns in the quality of available evidence. The majority of systematic reviews (86%) had low or critically low methodological quality, with significant deficiencies in crucial aspects such as failure to present lists of excluded studies, inadequate consideration of risk of bias, and inappropriate methods for meta-analysis. When compared with passive interventions such as thermotherapy, usual care, conventional medications, or no treatment, cupping therapy demonstrated some superiority.
However, when compared with acupuncture, the effects were similar, suggesting that both techniques may share comparable mechanisms of action. For specific conditions such as nonspecific low back pain, neck pain, and knee osteoarthritis, some studies indicated modest benefits, but the significant heterogeneity among studies and high risk of bias limited the reliability of these conclusions. A particularly relevant finding was the insufficiency of evidence to recommend cupping therapy in athletes. Despite growing interest from the sports community in this modality, only two studies focused specifically on this population, and the results were not conclusive enough to recommend its use for reducing perceived pain, disability, or post-training exertion.
Reported adverse events were generally mild to moderate, including bruising, pain at the application site, transient pain exacerbation, tingling, and dizziness. Although no serious adverse events were reported, the actual frequency of these effects may be underestimated due to the limited quality of the included studies. The GRADE analysis revealed that the certainty of evidence ranged from very low to moderate for most outcomes assessed, with factors such as risk of bias, inconsistency among studies, and imprecision of results contributing to this low confidence. Identified limitations include the lack of standardized protocols for cupping therapy application, significant variability in study populations, and the absence of appropriate control groups in many studies.
The authors emphasize that, considering current evidence-based medicine standards, this review demonstrated that most systematic reviews on cupping therapy for musculoskeletal pain are of low methodological quality. Consequently, the current evidence is insufficient to make definitive recommendations regarding the efficacy of cupping therapy, especially considering that the use of unproven therapies that, at best, offer a placebo effect raises important ethical questions. The investigators recommend that future studies be rigorously planned and adequately powered to provide more definitive answers regarding the efficacy and safety of cupping therapy for musculoskeletal pain in both athletes and the general population.
Strengths
- 1Large number of participants analyzed (27,960)
- 2Rigorous umbrella review methodology
- 3Systematic assessment of methodological quality
- 4Comprehensive analysis of multiple musculoskeletal conditions
Limitations
- 1Low methodological quality of most included studies
- 2High heterogeneity among studies
- 3Insufficient evidence for specific populations such as athletes
- 4Lack of standardization in cupping therapy protocols
Expert Commentary
Prof. Dr. Hong Jin Pai
PhD in Sciences, University of São Paulo
▸ Clinical Relevance
Cupping therapy occupies a growing space within the integrative armamentarium of pain services, and this umbrella review — pooling 21 systematic reviews, 301 primary studies, and nearly 28,000 participants — offers the most comprehensive panorama available to date. For the clinician managing nonspecific low back pain, neck pain, and knee osteoarthritis, the data confirm that the technique outperforms no treatment, with a mean reduction of 1.59 points on the pain scale compared with no intervention. Compared with acupuncture, effects were similar, which is not surprising given the likely shared neuroimmune and connective-tissue modulation mechanisms. The safety profile — mild adverse events such as bruising and transient discomfort, with no serious reports — favors its consideration as an adjunct in patients with contraindications to or intolerance of anti-inflammatory drugs. The most prudent indication remains within a multimodal context, never as monotherapy.
▸ Notable Findings
The finding that deserves special attention is the equivalence of effects between cupping therapy and acupuncture for musculoskeletal conditions. This parity suggests shared mechanisms — negative pressure, mechanical stimulation of subcutaneous tissue, activation of A-delta and C fibers, and local release of mediators such as nitric oxide — that go beyond the simple placebo effect frequently attributed to both techniques. Another striking finding is the categorical absence of evidence for use in athletes: only two studies covered this population, with no applicable conclusions. In a context where cupping gained enormous visibility after the 2016 Olympic Games, having an umbrella review flag this evidentiary gap is clinically valuable. The 86% of reviews with low or critically low quality on AMSTAR2 does not invalidate the positive findings, but appropriately calibrates the degree of confidence that should be placed in the effect estimates.
▸ From My Experience
In my practice at the Pain Center, I incorporate cupping therapy predominantly as an adjunct to systemic acupuncture in cases of lumbar and cervical myofascial pain, especially when there is diffuse fascial tension that responds less well to isolated acupuncture points. I typically observe perceptible improvement between the second and third session, particularly in subjective perception of stiffness and range of motion. For an initial cycle, I work with six to eight weekly sessions, evaluating the response at the end of each block before recommending monthly maintenance. The patient profile that responds best, in my experience, is the sedentary adult with chronic low back pain of predominantly myofascial origin, without overt radiculopathy. I do not usually indicate cupping alone in patients with coagulopathies, those on oral anticoagulants, or those with very fragile skin — extensive bruising becomes a clinical problem and an adherence issue. The equivalence with acupuncture documented in this review reflects what we have informally observed over the years: combining the two techniques in the same session produces practical synergy, and patients report additive benefit that justifies the additional procedure time.
Full original article
Read the full scientific study
Human Movement · 2024
DOI: https://doi.org/10.5114/hm/194774
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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