Cupping Therapy on Relieving Chronic Neck and Shoulder Pain

The research aimed to investigate the effectiveness of cupping therapy (CT) in changes on skin surface temperature (SST) for relieving chronic neck and shoulder pain (NSP) among community residents. A single-blind experimental design constituted of sixty subjects with self-perceived NSP. The subjects were randomly allocated to two groups. The cupping group received CT at SI 15, GB 21, and LI 15 acupuncture points, and the control group received no intervention. Pain was assessed using the SST, visual analog scale (VAS), and blood pressure (BP). The main results were SST of GB 21 acupuncture point raised from 30.6°C to 32.7°C and from 30.7°C to 30.6°C in the control group. Neck pain intensity (NPI) severity scores were reduced from 9.7 to 3.6 in the cupping group and from 9.7 to 9.5 in the control group. The SST and NPI differences between the groups were statistically significant (). One treatment of CT is shown to increase SST. In conjunction with the physiological effect the subjective experience of NSP is reduced in intensity. Further studies are required to improve the understanding and potential long-term effects of CT.

1. Introduction
Chronic neck and shoulder pain (NSP) is a type of musculoskeletal pain typically occurring in middle- and older-aged people [1–3]. The prevalence of NSP is approximately 16% to 78% among the general population [2–4]. The impact of chronic pain on the family includes social activities, life changes, emotional impact, and alteration of future plans [5].

Cupping therapy (CT) is a traditional Chinese medical (TCM) treatment which has been practiced for thousands of years. The World Health Organization’s (WHO) definition of cupping is a therapeutic method (Code 5.3.2) involving the application of suction by creating a vacuum. This is typically done using fire in a cup or jar (Code 5.3.7) on the dermis of the affected part of the body [6].

In Taiwan, approximately 12.8% of the participants reported the use of cupping therapies in the past year [7]. The cupping mechanism constitutes creating a vacuum on the skin, with the ensuing negative pressure resulting in capillary rupture. This method is known as retained or dry cupping [8]. The skin of the localized area becomes flushed and may show petechiae and ecchymosis [9] or bruising, in which the duration is therapeutically beneficial [10]. Cupping has multiple therapeutic functions which include (1) warming the channels to remove cold, (2) promoting qi and blood circulation, (3) relieving swelling, (4) accelerating healing, (5) adjusting body temperature, (6) fibromyalgia [11], (7) stroke rehabilitation, hypertension, musculoskeletal pain, herpes zoster [8, 12], (8) facial paralysis, acne, and cervical spondylosis [13], and (9) alleviating pain [14], including chronic neck [15–17], shoulder pain [2], and low back pain [17, 18].

Traditional acupuncture points, jianshongshu (SI 15), jianjing (GB 21), and jianju (LI 15), have been suggested for improving NSP. The SI 15 point is positioned on the back, approximately 3 to 4 cm lateral to the lower border of the spinous process of the seventh cervical vertebra (dazhui). This point is associated with shoulder and back pain and coughing. The GB 21 is situated at the midpoint that connects the dazhui point (DU 14) and the acromion (the shoulder peak). It is primarily used to treat headaches, neck pain, stroke-induced speech impairment, and shoulder, back, and arm pain. The LI 15 point is located on the lateral side of the arm and on the deltoid muscle. It is the depressed area distal and anterior to the acromion when the arms are stretched outward or forward. This point is used to treat shoulder joint pain and hemiplegia [19].

The current literature remains sparse for studies on skin temperature differences at acupuncture points in relation to thermal effect of cupping therapy. Liu et al. showed that localized skin temperature increased [20, 21], while blood pressure decreased [22], after CT. It is suggested that these physiological responses to CT may be related to the positive therapeutic effect. Currently, due to the paucity of available research focusing on skin temperature changes due to CT, the potential effect and its relationship remains unclear. This study investigated the effectiveness of CT for relieving chronic NSP among community residents and the changes in skin surface temperature (SST).

2. Methods
2.1. Subjects
This study was a single-blind experimental design. Subjects with diagnosed and self-perceived chronic NSP were recruited in Hualien City, Taiwan, via advertising and e-mail from October 2012 to February 2013. This research was conducted in a nursing research laboratory at the Tzu Chi University of Science and Technology. The room temperature was controlled at 20 to 24°C and the humidity level was maintained at 60 to 70%. A Chinese traditional medicine nurse and traditional Chinese medical practitioner were also asked to verify the choice and location of the selected acupuncture points and the cupping treatment.

The inclusion criterion is as follows: (1) working at least 40 hours a week and (2) suffering work-related NSP continuously for at least 3 consecutive months with an intensity of at least 3 points on the visual analog scale (VAS, 0–10). Participants were excluded if the following exist: (1) infection, injury, or bleeding of the skin surrounding the area for cupping therapy, (2) neuropathy in the cervical spinal cord, (3) analgesic ingestion within 4 hrs preceding experiment, and (4) consumed coffee, tea, or any other caffeinated beverage within 4 hrs prior to the baseline measurement. Also, no tobacco products had been smoked for a minimum of 30 min before the baseline data were recorded.

2.2. Sample Size
In the pilot study () for NSP a statistically significant result between group difference of 1.18 (effect size = 0.81) using the VAS was found. Employing the Wilcoxon Mann-Whitney test (G power v 3.1.3) [23] to achieve a power of 0.8, with Cronbach’s value = 0.05 and an effect size of 0.80, the required size for each group is minimum of 27 subjects.

2.3. Randomization
Subjects were assigned “cupping group” or “control group” based on random selection from sealed envelopes which had been sequence coded prior to study commencement. Neither the researcher nor the participants were aware of which group the participants would be assigned to. Figure 1 displays the flowchart of the study.

Figure 1

Flowchart of this study.
This study was reviewed and approved by the Research Ethics Committee of the Buddhist Tzu Chi General Hospital (Registration number 101-60). Written consent was obtained from the participants prior to the start of the study. The objectives of the research were explained and the option to withdraw from the study at any time was made known.

2.4. Intervention
The cupping group received fire CT at three acupuncture points, SI 15, GB 21, and LI 15. The medium size glass cup with diameter of 4 cm and volume of 260 mL (Cosmos International Supplies Co., Ltd., Taiwan) was used. Participants were asked to sit comfortably in a chair with both feet flat on the floor and expose their neck and shoulder regions. The cupping procedure is as follows: (1) an alcohol swab is ignited, (2) the burning swab is quickly placed inside the cup and withdrawn, (3) the cups are placed over the three acupuncture points, (4) the cups were then removed after 10 min [24], and (5) the same process was repeated for the same amount of time on the subject’s left side (Figure 2(a)). The entire treatment totaled 20 minutes to treat both sides of the body.
Figure 2

The skin surface temperature (°C) at SI 15, GB 21, and LI 15 acupuncture points displayed by infrared camera by cupping (a) and after cupping therapy (b).
Participants in the control group received resting for 20 min.

2.5. Outcomes
Participant characteristics included demographic data such as age, sex, and a brief medical history including past experience of cupping.

2.5.1. Skin Surface Temperature (SST) and Blood Pressure (BP)
An infrared camera (FLIR ThermaCAM P25 HS system) was used to measure SST of the right SI 15, GB 21, and LI 15 acupuncture points (Figure 2(b)). Measurements were recorded for SST at 4 time points with a 5-minute interval between each measurement. The FLIR infrared camera is an infrared thermal detector, with 320 × 240 pixel geometric resolution of 76.800 pixels per picture. Measurements can be performed which range from 0 to 250°C ± 0.001°C. The data was transferred to a notebook computer using the ThermaCAM Researcher V.2.8 software (FLIR Systems Inc., Portland, Oregon, USA).

BP was measured using a mercury sphygmomanometer (Model S-300, standard sphygmomanometer, Taiwan) using the participants’ right arm. BP was recorded both before and after intervention.

2.5.2. Neck and Shoulder Pain Intensity
Pain was scored using VAS; a Likert scale was used for evaluating the subjective experience of pain intensity [25, 26]. The neck pain intensity test involved (1) leaning forward and backward, (2) rotating to the left and right, and (3) inclining to the left and right [27]. The shoulder pain intensity assessment involved (1) raising both arms, stretching the chest, and extending the arms backward to touch the back of the neck and (2) raising both arms upward, placing them against the ears, and placing the palms together [28]. The subjects were asked to select a point on the scale that most accurately reflected their level of pain before and then after the pain inducing movement [29].

2.6. Statistical Analysis
Data were analyzed using SPSS V.18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The univariate analysis of covariance (ANCOVA) was used to assess the level of NSP intensity. ANCOVA was used to assess the changes in the SST and BP, while adjusting the baseline for both groups. The Friedman test was conducted to evaluate the overall changes within each group. Wilcoxon test was used to compare the difference within groups. A value of <0.05 was considered statistically significant
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