Complementary Therapies in Clinical Practice 23 (2016) 30e33

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

The effect of traditional wet cupping on shoulder pain and neck pain:
A pilot study
Müzeyyen Arslan a, *, Nurcan Go
€ kgo
€ z a, Şenol Dane b
a
Turgut Ozal University, School of Nursing, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey
b €
Turgut Ozal University, Medical Faculty, Department of Physiology, Yunus Emre Mahallesi, Takdir Caddesi No:5 Yenimahalle, Etlik, Ankara, Turkey

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

Article history: Objectives: Wet cupping therapy (WCT) is a traditional complementary method recommended to
Received 17 December 2015 decrease the symptoms of a lot of diseases and used in the treatment of pain syndromes. In this pilot
Received in revised form study, the possible effects of wet cupping therapy on nonspecific neck and upper shoulder pain were
14 February 2016
investigated.
Accepted 24 February 2016
Methods: Sixty one eligible volunteer participants with nonspecific neck and upper shoulder pain for at
least 3 months were allocated. The Numeric Rating Scale (NRS) was used to assess pain scores. Pain
Keywords:
scores were recorded before and after wet cupping therapy.
Cupping
Neck
Results: The mean scores of neck pain in study group were 7.02 (SD ¼ 1.8) before and 3.70 (SD ¼ 2.2)
Shoulder after cupping therapy. The decrease of pain scores between pre- and post-test was statistically significant
Pain (p < 0.05).
Discussion: It can be stated that WCT has potential therapeutic effect in nonspecific neck and upper
shoulder pain. Future full-scale randomized controlled trials will be needed to provide firm evidence of
the effectiveness of this intervention.
© 2016 Elsevier Ltd. All rights reserved.

1. Background treatment applications [7e9].

In modern world, neck and upper shoulder pain is a very com-
mon health problem. The incidence of neck and shoulder muscle
pain is increased in recent years. The rate of shoulder pain in
general population may be 6%e11% under the age of 50 years and
16%e25% in elderly people [1]. The neck and shoulder pain may be
due to different factors. Excessive physical strain may cause micro
traumas in connective tissues, and psychosocial stress may lead to
increased muscular tension [2].
There are different treatment alternatives such as nonsteroidal
anti-inflammatory drugs, physical therapy or exercise, but these
have only limited evidence for the neck and shoulder pain treat-
ment [3e5]. In the literature and treatment guidelines, drug,
manual or massage therapies cannot be recommended [3,4,6].
Different therapeutic exercises have moderate effects in neck and
shoulder pain relief in the long term [6]. Therefore, physicians and
patients look for traditional, alternative or complementary
* Corresponding author.
E-mail addresses: muzeyyen24@hotmail.com (M. Arslan), nurcan.hilalay55@
€kgo
gmail.com (N. Go €z), sdane@turgutozal.edu.tr (Dane).
Cupping therapy is mostly used in Asian and Middle Eastern
countries and has been suggested to reduce pain as well as many
other symptoms [10]. Cupping therapy are already used for
shoulder and neck pain as a complementary medicine [11]. ]. There
are two types of cupping. Dry cupping pulls the skin into a cup
without drawing blood. In wet cupping, the skin is lacerated so that
blood is drawn into a cup. Traditional dry or wet cupping has been
utilized to treat many complaints for thousands of years [12e14]. A
glass or plastic cup is used to generate suction on the painful area or
point before lacerations are made on the skin. This process gets the
body rid of the congested blood and therefore blood and lymphatic
circulation increases which relieves painful muscle tension
[12,15,16].
The main purpose of this therapy is to precipitate the circulation
of blood and qi and to remove blood-stasis and waste from the body
[17].
Recently, there is growing evidence that cupping might be
effective in various painful conditions [11,18e21]. Recent system-
atic reviews and findings suggested that wet cupping is effective for
musculoskeletal problems [17,22].
The aim of this pilot study was to retest the efficacy of a

http://dx.doi.org/10.1016/j.ctcp.2016.02.003
1744-3881/© 2016 Elsevier Ltd. All rights reserved.
 M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33 31

traditional wet cupping treatment in patients with non-specific 10e15 min, and the skin was disinfected and a plaster was applied.
neck and shoulder pain. However, since bleeding generally stopped during the treatment,
this was only a precaution. Patients were asked not to take a bath or
2. Methods go swimming within the next 24 h to prevent delays in wound
healing. After some minutes of rest patients were free to leave. No
2.1. Participants adverse events were reported throughout the study.

A one-group, pre-test and post-test quasi experimental design 2.5. Statistical analysis
was utilized to measure the change in neck and shoulder pain
scores before and after wet cupping therapy intervention. We The data were analyzed using the Statistical Package for Social
recruited participants through advertisements on notice board of a Sciences 16.0 (SPSS). Paired samples T-test was used for analysis.
university hospital in Ankara. After a telephone interview, potential
participants were invited to be assessed on whether they were
3. Results
eligible for the study. Participants visited the Turgut Ozal University
Medical School. The physicians conducting the study informed
Our study population consisted of 61 volunteers with nonspe-
them about the study details. Their eligibility was determined by a
cific neck and upper shoulder pain, 43 females (70.5%) and 18 males
physician through physical exams, and relevant questionnaires.
(29.5%); aged 20e60 years (mean age 45.59 ± 10.9 years). The mean
Men and women aged 20e60 years were eligible to participate.
body mass index (BMI) of the subjects was 29 (SD ¼ 5.5). The mean
Patients with traumatic neck pain, inflammatory or malignant
scores of neck and upper shoulder pain in study group were 7.02
diseases, congenital malformation of the spine, radicular symptoms
(SD ¼ 1.8) before and 3.70 (SD ¼ 2.2) after cupping therapy (see
such as radiating pain, paresis, prickling, or tingling, invasive
Fig. 1). The decrease of pain scores between pre- and post-test was
treatments within the last 4 weeks, who had surgery to the spine
statistically significant (p < 0.05).
within the last year, and who were on corticosteroid, opioid or any
There were no serious adverse events in study group. A regular
other similar treatments were excluded. Further exclusion criteria
minor adverse effect was a hematoma on the site of application of a
were pregnancy, serious acute or chronic organic diseases such as
cupping glass. All scarified wounds healed without any
diabetes or cancer, mental disorders, and hemorrhagic tendency or
complications.
anticoagulation treatment.

2.2. Ethical consideration 4. Discussion

The study protocol was approved by the Turgut Ozal University
ethics committee. Signed informed consent was obtained from
every participant before beginning the study.
2.3. Data collection
The data were collected using a questionnaire, The Numeric
Rating Scale (NRS) [23]. NRS is a simple and frequently used
method for the assessment of variations in the subjective intensity
of pain. In clinical practice, as a measure of the efficacy of the
treatment, NRS segmented numeric version is often used in which
respondents select a whole number (integers 0e10) that best re-
flects the intensity of their pain [24]. The NRS is used to assess pain
in general in the previous week on a scale ranging from 0 to 10,
where 0 represents ‘‘no pain’’ and 10 represents ‘‘extreme pain’’.
Participants stated their pain level on the scale. This ensured that
statistical evaluation of the effects of the wet cupping treatment
was not influenced by alterations in medications or physiotherapy
during the study.
In the present study, the decrease in pain scores secondary to
wet cupping therapy was walloping and the mean scores of neck
pain decreased from 7.02 to 3.70. It can be stated that wet cupping
must be accepted as a complementary therapy in clinical practice
for patients with chronic and tenacious neck and upper shoulder
pain.
Pain in the upper neck and shoulder is highly prevalent in many
countries [26,27]. Since conservative options for treatment are
limited, new therapeutic approaches need to be noted. It has lately
been proposed that cupping, a traditional method of treatment,
may be beneficial in neck and shoulder pain when applied to the
referred shoulder-neck region. A recent randomized study and
systematic review suggested that cupping alleviates lower back
pain [28,29].
The mechanism of action of wet cupping is still not clear; the-
ories and many studies have been sectional. Different modes of
actions might explain the effect of traditional cupping on chronic
neck pain. They involve hematological [30], neural [31], antioxidant

2.4. Intervention

Cupping was performed by the study physician and two certi-

fied nurses. For the cupping therapy, sterile disposable cups of 5 cm
in diameter were used. Treatment points were selected to be five
points of the posterior neck, bilateral perispinal areas of the neck
and scapula according to the WHO Guideline for Acupuncture [25].
Same points were applied to all participants.
The cupping procedure involved the following steps: Applica-
tion areas were cleaned with antiseptic solution. Disposable cups
were placed onto these points and negative pressure was applied
by the cupping pump. After two to 3 min, cups were removed. The
skin was disinfected; superficial incisions were made with a
disposable micro lancet on the areas of pain; the cups were placed
on the same incision points. The glasses were removed after Fig. 1. The mean pain scores before and after cupping therapy.
32 M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33
[32], and psychological effects [11]. By taking pressure off the tis-
sues of the affected area, traditional cupping therapy evacuates the
neck and shoulder from the toxic congestions and inflammatory
agents which also increase blood and lymph flows. This could help
clarify the local effects on pressure pain thresholds [11].
The result of this study supports the use of wet cupping in
reducing neck and upper shoulder pain for at least one week after
the wet cupping. In a recent review, both dry and wet cupping
therapies were suggested for various musculoskeletal pain condi-
tions [28]. In a recent study, it has been reported that dry cupping
therapy can be confidently used to reduce the upper shoulder and
neck pain in office workers as a therapeutic application and
possibly as a preventative method [21]. Lauche and et al. [11] re-
ported that the effects of traditional cupping are already present on
the day after cupping treatment. This conforms to clinical obser-
vations, in which traditional cupping often showed immediate ef-
fects on pain and other complaints. Michalsen et al. presented [18]
the results of a randomized trial on the clinical effects of traditional
cupping therapy in patients with carpal tunnel syndrome. Cupping
of segmentally related shoulder zones appears to alleviate the
symptoms of carpal tunnel syndrome.
Cupping (both dry and wet) therapy has been asserted to drain
accumulated fluids, toxins and other chemical compounds such as
lipids from interstitial fluid to blood and lymphatic capillaries
[33,34].
The possible curative effects of wet cupping therapy in reducing
non-specific neck and shoulder pain can be due to two its three
mechanisms: (1) by stimulating the peripheral nervous system [14]
and (2) removing oxidants and decreasing oxidative stress [32] and
(3) by excreting toxic heavy metals [35]. Wet cupping therapy
decreased the psychological stress conditions by restoring the
sympathovagal imbalances and by decreasing static electric [14]. It
can be accepted that the decrease in stress is important in relieving
of pain. Oxidants or oxidative stress causes pain via lipid peroxi-
dation injury in cell membranes. Therefore, the wet cupping ther-
apy can be suggested as an antioxidant application in clinical
practice [32]. Also, it is well known that the accumulation of heavy
metals is the most toxic and hazardous factors for all body tissues.
The excretion of heavy metals via wet cupping [35] from the body
can be effective in the relieving of neck and upper shoulder pain.
Also, in a recent study, all sleep quality parameters were posi-
tively affected after wet cupping therapy in healthy subjects. They
concluded that the increase in sleep quality may be secondary to
decrease in different pains and stresses and also the removal of
some macromolecules and heavy metals accounts for the improved
sleep quality [36].
The studies in future must be focused the effectiveness of wet
cupping therapy on other pains such as headache, back pain and
cancer pain. Also, wet cupping therapy can be compared to the
other medical and physical therapies in future studies.
In addition to the evaluation of effectiveness, safety issues are
very important in wet cupping practice and must be paid attention.
In conventional wet-cupping, non-sterile, reusable cups and lan-
cets are used without any consideration of the possibility of an
infection.
5. Conclusion
The result of this study supports the use of wet cupping in
reducing non-specific neck and shoulder pain. But, these results
must be supported by randomized and placebo controlled trials. A
single application of traditional wet cupping might be effective in
the treatment of chronic non-specific neck pain. It should be
considered for other musculoskeletal pain conditions, as a com-
plement to medical treatment.
Conflict of interests
All authors disclose any commercial association that might
create a conflict of interest in connection with the paper. There is no
competing financial interest for any of the authors.
References
[1] D.A. van der Windt, E. Thomas, D.P. Pope, A.F. de Winter, G.J. Macfarlane,
L.M. Bouter, A.J. Silman, Occupational risk factors for shoulder pain: a sys-
tematic review, Occup. Environ. Med. 57 (2000) 433e442.
[2] J. Ylinen, E.-P. Takala, M. Nyk€anen, A. H€ akkinen, E. M€ €, T. Pohjolainen, S.-
alkia
L. Karppi, H. Kautiainen, O. Airaksinen, Active neck muscle training in the
treatment of chronic neck pain in women: a randomized controlled trial,
JAMA 289 (2003) 2509e2516.
[3] P.M.J. Peloso, A. Gross, T. Haines, K. Trinh, C.H. Goldsmith, S.J. Burnie, Me-
dicinal and Injection Therapies for Mechanical Neck Disorders, The Cochrane
Library, 2007.
[4] J. Ezzo, B.G. Haraldsson, A.R. Gross, C.D. Myers, A. Morien, C.H. Goldsmith,
G. Bronfort, P.M. Peloso, C.O. Group, Massage for mechanical neck disorders: a
systematic review, Spine 32 (2007) 353e362.
[5] A. Gross, T.M. Kay, J.P. Paquin, S. Blanchette, P. Lalonde, T. Christie, G. Dupont,
N. Graham, S.J. Burnie, G. Gelley, Exercises for Mechanical Neck Disorders, The
Cochrane Library, 2015.
[6] J. Albright, R. Allman, R.P. Bonfiglio, A. Conill, B. Dobkin, A.A. Guccione,
S.M. Hasson, R. Russo, P. Shekelle, J.L. Susman, Philadelphia Panel evidence-
based clinical practice guidelines on selected rehabilitation interventions for
neck pain, Phys. Ther. 81 (2001) 1701e1717.
[7] S.K. Ndao-Brumblay, C.R. Green, Predictors of complementary and alternative
medicine use in chronic pain patients, Pain Med. 11 (2010) 16e24.
[8] K.J. Sherman, A.J. Cook, R.D. Wellman, R.J. Hawkes, J.R. Kahn, R.A. Deyo,
D.C. Cherkin, Five-week outcomes from a dosing trial of therapeutic massage
for chronic neck pain, Ann. Fam. Med. 12 (2014) 112e120.
[9] R. Lauche, M. Schuth, M. Schwickert, R. Lüdtke, F. Musial, A. Michalsen,
G. Dobos, K.E. Choi, Efficacy of the Alexander Technique in treating chronic
non-specific neck pain: A randomized controlled trial, Clin. Rehabil. (2015),
0269215515578699.
[10] S.S. Yoo, F. Tausk, Cupping: east meets west, Int. J. Dermatol. 43 (2004)
664e665.
[11] R. Lauche, H. Cramer, C. Hohmann, E. Choi, T. Rampp, F.J. Saha, F. Musial,
J. Langhorst, G. Dobos, The effect of traditional cupping on pain and me-
chanical thresholds in patients with chronic nonspecific neck pain: a rando-
mised controlled pilot study, Evid. Based Complementary Altern. Med. 2011
(2012).
[12] H. Cao, X. Li, J. Liu, An updated review of the efficacy of cupping therapy, PLoS
One 7 (2012) e31793.
[13] M. Arslan, N. Kutlu, M. Tepe, N.S. Yilmaz, L. Ozdemir, S. Dane, Dry cupping
therapy decreases cellulite in women: A pilot study, Indian J. Tradit. Knowl. 14
(2015) 359e364.
[14] M. Arslan, N. Yesilçam, D. Aydin, R. Yüksel, S. Dane, Wet cupping therapy
restores sympathovagal imbalances in cardiac rhythm, J. Altern. Comple-
mentary Med. 20 (2014) 318e321.
[15] C. Iz, Cupping Therapy, Elservier, Philadelphia, PA, 2007.
[16] H. Cao, M. Han, X. Li, S. Dong, Y. Shang, Q. Wang, S. Xu, J. Liu, Clinical research
evidence of cupping therapy in China: a systematic literature review, BMC
Complementary Altern. Med. 10 (2010) 70.
[17] J.-I. Kim, M.S. Lee, D.-H. Lee, K. Boddy, E. Ernst, Cupping for treating pain: a
systematic review, Evid. Based Complementary Altern. Med. 2011 (2011).
[18] A. Michalsen, S. Bock, R. Lüdtke, T. Rampp, M. Baecker, J. Bachmann,
J. Langhorst, F. Musial, G.J. Dobos, Effects of traditional cupping therapy in
patients with carpal tunnel syndrome: a randomized controlled trial, J. pain
10 (2009) 601e608.
[19] K. Jong-In, K. Tae-Hun, L.M. Soo, K.J. Won, K.K. Hyung, C. Jun-Yong, K. Kyung-
Won, K. Ae-Ran, S. Mi-Suk, J. So-Young, Evaluation of wet-cupping therapy for
persistent non-specific low back pain: a randomised, waiting-list controlled,
open-label, parallel-group pilot trial, Trials 12 (2011) 146.
[20] H.-J. Cao, J.-P. Liu, H. Hu, N.S. Wang, Using a partially randomized patient
preference study design to evaluate the therapeutic effect of acupuncture and
cupping therapy for fibromyalgia: study protocol for a partially randomized
controlled trial, Trials 15 (2014) 280.
[21] M. Arslan, G. Yaman, E. Ilhan, M. Alemdag, A. Bahar, S. Dane, Moving dry
cupping therapy reduces upper shoulder and neck pain in office workers, Clin.
Investig. Med. 38 (2015) 217e220.
[22] Y.D. Kwon, H.J. Cho, Systematic review of cupping including bloodletting
therapy for musculoskeletal diseases in Korea, Korean J. Orient. Physiol.
Pathol. 2l (2007) 789e793.
[23] C.T. Hartrick, J.P. Kovan, S. Shapiro, The numeric rating scale for clinical pain
measurement: a ratio measure? Pain Pract. 3 (2003) 310e316.
[24] J.T. Farrar, J.P. Young, L. LaMoreaux, J.L. Werth, R.M. Poole, Clinical importance
of changes in chronic pain intensity measured on an 11-point numerical pain
rating scale, Pain 2 (2001) 149e158.
[25] WHO, Guidelines on Basic Training and Safety in Acupuncture, 1999. Available
 M. Arslan et al. / Complementary Therapies in Clinical Practice 23 (2016) 30e33
at: http://apps.who.int/medicinedocs/en/d/Jwhozip56e/. Accessed June 26,
2015.
[26] Y. Lizuka, H. Iizuka, T. Mieda, T. Tajika, A. Yamamoto, T. Ohsawa, T. Sasaki,
K. Takagishi, Association between neck and shoulder pain, back pain, low back
pain and body composition parameters among the Japanese general popula-
tion, BMC Musculoskelet. Disord. 16 (2015) 333e343.
[27] L. Punnett, D.H. Wegman, Work-related musculoskeletal disorders: the
epidemiologic evidence and the debate, J. Electromyogr. Kinesiol. 14 (2004)
13e23.
[28] C.Y. Huang, M.Y. Choong, T.S. Li, Effectiveness of cupping therapy for low back
pain: a systematic review, Acupunct. Med. (2013) acupmed-2013e010385.
[29] A. AlBedah, M. Khalil, A. Elolemy, A.A. Hussein, M. AlQaed, A. Al Mudaiheem,
R.A. Abutalib, F.M. Bazaid, A.S. Bafail, A. Essa, The Use of wet cupping for
persistent nonspecific low back pain: randomized controlled clinical trial,
J. Altern. Complementary Med. 21 (2015) 504e508.
[30] M. Ernst, M.H. Lee, Sympathetic effects of manual and electrical acupuncture
of the Tsusanli knee point: comparison with the Hoku hand point sympathetic
effects, Exp. Neurol. 94 (1986) 1e10.
33
[31] A. Sato, Neural mechanisms of autonomic responses elicited by somatic
sensory stimulation, Neurosci. Behav. Physiol. 27 (1997) 610e621.
[32] S.M. Tagil, H.T. Celik, S. Ciftci, F.H. Kazanci, M. Arslan, N. Erdamar, Y. Kesik,
H. Erdamar, S. Dane, Wet-cupping removes oxidants and decreases oxidative
stress, Complementary Ther. Med. 22 (2014) 1032e1036.
[33] S.M. El Sayed, A.-S. Al-quliti, H.S. Mahmoud, H. Baghdadi, R.A. Maria,
M.M.H. Nabo, A. Hefny, Therapeutic benefits of Al-hijamah: in light of modern
medicine and prophetic medicine, Am. J. Med. Biol. Res. 2 (2014) 46e71.
[34] J.-I. Kim, T.-H. Kim, M.S. Lee, J.W. Kang, K.H. Kim, J.-Y. Choi, K.-W. Kang, A.-
R. Kim, M.-S. Shin, S.-Y. Jung, Evaluation of wet-cupping therapy for persistent
non-specific low back pain: a randomised, waiting-list controlled, open-label,
parallel-group pilot trial, Trials 12 (2011) 1e7.
[35] S. Gok, F.H. Kazanci, H. Erdamar, N. Gokgoz, S.S. Hartiningsih, S. Dane, Is it
possible to remove heavy metals from the body by wet cupping therapy,
Indian J. Tradit. Med. (2015) (in press).
[36] S. Cikar, G. Ustundag, S. Haciabdullahoglu, S. Yuksel, S. Dane, Wet cupping
(hijamah) increases sleep quality, Clin. Investig. Med. 38 (2015) 258e261.