Cupping therapy for Chronic Back Pain

to evaluate the evidence from the literature regarding the effects of cupping therapy on chronic back pain in adults, the most used outcomes to evaluate this condition, the protocol used to apply the intervention and to investigate the effectiveness of cupping therapy on the intensity of chronic back pain.

systematic review and meta-analysis carried out by two independent researchers in national and international databases. Reference lists of systematic reviews were also explored. The quality of evidence was assessed according to the Jadad scale.

611 studies were identified, of which 16 were included in the qualitative analysis and 10 in the quantitative analysis. Cupping therapy has shown positive results on chronic back pain. There is no standardization in the treatment protocol. The main assessed outcomes were pain intensity, physical incapacity, quality of life and nociceptive threshold before the mechanical stimulus. There was a significant reduction in the pain intensity score through the use of cupping therapy (p = 0.001).

cupping therapy is a promising method for the treatment of chronic back pain in adults. There is the need to establish standardized application protocols for this intervention.

Descriptors: Review, Chronic Pain, Back Pain, Cupping Therapy, Meta-Analysis, Nursing
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Chronic back pain causes physical, emotional and socioeconomic changes 1 - 3 and, consequently, high use of medicines and health resources 4 . The search for demedicalization leads to an increasing use of integrative and complementary practices, such as Traditional Chinese Medicine (TCM) resources, to complement pain-related allopathic care 5 . Cupping therapy is one of the recommended TCM therapies for chronic pain reduction 6 . It involves the application of cups of different materials 7 in an acupoint or area of pain by means of heat or vacuum apparatus 8 .

The effect on pain reduction has not yet been fully elucidated 9 , but different mechanisms of action, based on several assumptions 10 , are attributed to cupping therapy, such as the metabolic, neuronal hypotheses 9 , 11 and TCM 12 . Evidence of the efficacy of this intervention is limited because of the lack of high quality, well-delineated randomized controlled trials (RCTs) 6 that result in validated and efficient protocols for the treatment of chronic back pain. Therefore, this study aims to evaluate the literature evidence regarding the effects of cupping therapy on chronic back pain in adults compared to sham, active treatment, waiting list, standard medical treatment or no treatment, outcomes most commonly used to assess this condition, the protocol used to apply the intervention and subsequently investigate the effectiveness of cupping therapy on the intensity of chronic back pain.

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A systematic review of the literature was performed, followed by meta-analysis, used to determine the intensity of back pain in adult clients. The study was based on the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA Statement) 13 .

The PICO (P - population; I - intervention; C - comparison; O - outcomes) 14 guided the elaboration of the guiding question: “What are the effects of cupping therapy on adults with chronic back pain?”

The search strategy, carried out by two independent reviewers from June 2017 to May 2018 was based on the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via the US National Library of Medicine National Institutes of Health (PUBMED), Web of Science, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), Embase, Scopus, as well as databases indexed in the Virtual Health Library (VHL), such as Latin American & Caribbean Health Sciences Literature (LILACS) and the National Information Center of Medical Sciences of Cuba (CUMED). Reference lists of systematic reviews were also explored in the search for relevant studies related to the guiding question.

The terms, controlled and free, were combined by means of the Boolean operators OR and AND as follows: (“Back Pain” OR “Low Back Pain” OR “Sciatica” OR “Chronic Pain” OR “Musculoskeletal Pain” OR Myalgia OR “Neck Pain” OR “Low Back Pains” OR “Musculoskeletal Pains” OR “Muscle Pain” OR “Neck Pains” OR “Cervical Pain” OR “Cervical Pains” OR Lumbago OR “lumbar pain”) AND (“cupping therapy” OR cupping OR cups).

The eligibility criteria for the selection of articles were: RCT with adults (18 years or older); chronic pain (for three months or more) 15 in at least one of the segments of the spine (cervical, thoracic and/or lumbar); use of cupping therapy (dry, wet, massage, flash) 7 compared to one or more of the following groups: sham, active treatment, waiting list, standard medical treatment, or no treatment. We excluded studies that did not present online abstract in full for analysis, those that were not located by any means and studies with pregnant women.

In order to collect the information from the selected studies, we used an adapted form 16 in accordance with the recommendations of the Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) 17 and the classifications of cupping therapy 7 , 18 .

The following data were extracted: article identification (title, author (s)/training area, journal, year of publication, study country/language); objectives; methodological characteristics (design, sample size and loss of follow-up; inclusion and exclusion criteria); clinical data (number of patients by sex, mean age, diagnosis, duration of symptoms); description of interventions in the follow-up groups (number of sessions, duration of treatment, type of technique applied (dry, wet, flash or massage cupping), application device, time of stay of the device, suction method (manual, fire, automatic-electric)/suction strength (light, medium, strong or pulsating) 18 ; peculiarities of the intervention; application points; training area of the professional who carried out the intervention; years of experience in the area); outcomes and methods of evaluation (number of evaluations, intervals between them, measurement tools); data analysis; main results; and study findings.

The methodological quality of eligible studies was assessed using the Jadad scale 19 , which is centered on internal validity. The questions have a yes/no answer option with a total score of five points: three times one point for the yes responses and two additional points for appropriate randomization and concealment of allocation methods. Two independent reviewers conducted the evaluation, and a third investigator was consulted to solve possible disagreements.

Data analyzes were performed using Stata SE/12.0 statistical software. The absolute difference between means with 95% confidence intervals was selected to describe the mean differences between the treated and control groups in the evaluation performed shortly after treatment. P-value <0.05 was considered as statistically significant. Potential heterogeneity among the studies was examined using Cochran Q 20 and I2( 21 statistics. Since there was statistical significance in the test for heterogeneity of the results (p <0.05) and the calculated value of I2 suggested a moderate to high heterogeneity (67.7%) 21 , the random effects model was adopted for the analysis.

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A total of 614 studies were found in electronic and manual searches. Of these, 296 were removed from the list because they were duplicates. After reviewing titles and abstracts, 265 studies were excluded and 53 remained for analysis of the full text. Of these, 11 studies were not found (online, via bibliographic switching or direct contact with authors) and 26 articles were excluded. Finally, 16 articles remained in the review for the synthesis of the qualitative analysis and 10 articles entered the quantitative analysis (Figure 1).
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