pain
This systematic review and meta-analysis investigated the effectiveness and safety of manual therapy (MT) interventions compared to oral or topical pain medications in the management of neck pain.
The investigators searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to oral or topical medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. Trials with usual care arms were also included if they prescribed medication as part of the usual care and they did not include a manual therapy component. The authors used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.
Nine trials with a total of 779 participants were included in the meta-analysis.
- low certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants),
- moderate certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: −0.36; 95% CI −0.55 to −0.17; 6 trials, 567 participants),
- low certainty evidence that the risk of adverse events may be lower for patients who received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).
The authors conluded that MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.
Let’s have a look at the primary studies. Here they are with their conclusions (and, where appropriate, my comments in capital letters):
- For participants with acute and subacute neck pain, spinal manipulative therapy (SMT) was more effective than medication in both the short and long term. However, a few instructional sessions of home exercise with (HEA) resulted in similar outcomes at most time points. EXERCISE WAS AS EFFECTIVE AS SMT
- Oral ibuprofen (OI) pharmacologic treatment may reduce pain intensity and disability with respect to neural mobilization (MNNM and CLG) in patients with CP during six weeks. Nevertheless, the non-existence of between-groups ROM differences and possible OI adverse effects should be considered. MEDICATION WAS BETTER THAN MT
- It appears that both treatment strategies (usual care + MT vs usual care) can have equivalent positive influences on headache complaints. Additional studies with larger study populations are needed to draw firm conclusions. Recommendations to increase patient inflow in primary care trials, such as the use of an extended network of participating physicians and of clinical alert software applications, are discussed. MT DOES NOT IMPROVE OUTCOMES
- The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine. THIS IS A PILOT STUDY, A TRIAL TESTING FEASIBILITY, NOT EFFECTIVENESS
- The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.
- In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
- Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up. MT IS NOT SUPERIOR [SAME TRIAL AS No 6]
- In this randomized clinical trial, for patients with chronic neck pain, Chuna manual therapy was more effective than usual care in terms of pain and functional recovery at 5 weeks and 1 year after randomization. These results support the need to consider recommending manual therapies as primary care treatments for chronic neck pain.
- In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit. SAME TRIAL AS No 5
- An impairment-based manual physical therapy and exercise (MTE) program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound. THIS STUDY DID NOT TEST MT ALONE AND SHOULD NOT HAVE BEEN INCLUDED
I cannot bring myself to characterising this as an overall positive result for MT; anyone who can is guilty of wishful thinking, in my view. The small differences in favor of MT that (some of) the trials report have little to do with the effectiveness of MT itself. They are almost certainly due to the fact that none of these studies were placebo-controlled and double blind (even though this would clearly be possible). In contrast to popping a pill, MT involves extra attention, physical touch, empathy, etc. These factors easily suffice to bring about the small differences that some studies report.
It follows that the main conclusion of the authors of the review should be modified:
There is no compelling evidence to show that MT is more effective for people with neck pain in both short and long-term when compared to patients receiving oral pain medications.
Cervical spondylosis is a chronic degenerative process of the cervical spine characterized by pain in neck, degenerative changes in intervertebral disc and osteophyte formation. The present study was aimed at evaluating the effect of wet cupping (Ḥijāma Bish Sharṭ) in the pain management of cervical spondylosis.
This Open, randomized, clinical study was conducted on 44 patients.
- Subjects in the test group (n = 22) received a series of three-staged wet cupping treatment, performed on 0, 7th and 14th day.
- Subjects in the control group (n = 22) received 12 sittings of Transcutaneous Electrical Nerve Stimulation (TENS): 6 sittings per week for two weeks.
The outcomes were assessed with the help of VAS, Neck Disability Index (NDI) and Cervical range of motion.
Intra group comparison in test group from baseline to 21st day were found highly significant (p < 0.001) in terms of VAS, NDI, Flexion, Extension and Left rotation score. While in Right rotation, Left rotation and Left lateral flexion score were found moderately significant (p < 0.01). Statistically significant difference was observed between two groups at 21st day in VAS scale, NDI, and Cervical range of motion score (p < 0.001).
The authors concluded that Ḥijāma Bish Sharṭ was found better in the management of pain due to cervical spondylosis than TENS. It can be concluded that Ḥijāma Bish Sharṭ may a better option for the pain management of cervical spondylosis.
Wet cupping is the use of a vacuum cup applied to the skin which has previously been lacerated. It draws blood and can thus be seen as a form of blood letting. It has been used in various cultures for the treatment of joint pain and many other conditions since antiquity.
The authors point out that, in Unani medicine, it is believed to reduce pain and other symptoms by diverting and evacuating the causative pathological humours (akhlāṭ-e-fasida). Galen (Jalinoos) mentioned wet cupping as a very useful modality in evacuating the thick humours (akhlāṭ-e-Ghaleez) (Nafeesi, 1954; Qamri, 2008). Wet cupping works on the principle of diversion and evacuation of morbid matter (imala wa tanqiya-i-mawād-i-fasida). It opens the pores of the skin, enhances the blood circulation, nourishes the affected area with fresh blood, improves the eliminative function and facilitates the evacuation of morbid matter from the body.
There are several studies of wet cupping, most of which are as flawed as the one above. This new trial has several limitations, e.g.:
- It makes no attempt to control for placebo effects which could well be more prominent for wet cupping than for TENS.
- It did not inhibit the influence of verbal or non-verbal communications between therapists and patients which are likely to influence the results.
- The sample size is far too small, particularly as the study was designed as an equivalence study.
But some might say that my arguments a petty and argue that, regardless of a flimsy study, wet cupping is still worth a try. I would disagree – not because of the flaws of this study, nor the implausibility of the long-obsolete assumptions that underpin the therapy, but because wet cupping is associaated with infections of the skin lacerations which occasionally can be serious.
Dry needling is a therapy that is akin to acupuncture and trigger point therapy. It is claimed to be safe – but is this true?
Researchers from Ghent presented a series of 4 women aged 28 to 35 who were seen at the emergency department (ED) with post-dry needling pneumothorax between September 2022 and December 2023. None of the patients had any relevant medical history. All had been treated for a painful left shoulder, trapezius muscle or neck region in outpatient physiotherapist practices. At least three different physiotherapists were involved.
One patient presented to the ER on the same day as the dry needling procedure, the others presented the day after. All mentioned thoracic pain and dyspnoea. Clinical examination in all of these patients was unremarkable, as were their vital signs. Diagnosis was confirmed with ultrasound (US) and chest X-ray (CXR) in all patients. The latter exam showed left-sided apical pleural detachment with a median of 3.65 cm in expiration.
Two patients were managed conservatively. One patient (initial pneumothorax 2.5 cm) was discharged. The US two days later displayed a normally expanded lung. One patient with an initial apical size of 2.8 cm was admitted with 2 litres of oxygen through a nasal canula and discharged from the hospital the next day after US had shown no increase in size. Her control CXR 4 days later showed only minimal pleural detachment measuring 6 mm. The two other patients were treated with US guided needle aspiration. One patient with detachment initially being 4.5 cm showed decreased size of the pneumothorax immediately after aspiration. She was admitted to the respiratory medicine ward and discharged the next day. Control US and CXR after 1 week showed no more signs of pneumothorax. In the other patient, with detachment initially being 5.5 cm, needle aspiration resulted in complete deployment on US immediately after the procedure, but control CXR showed a totally collapsed lung 3 hours later. A small bore chest drain was placed but persistent air leakage was seen. Several trials of clamping the drain resulted in recurrent collapsing of the lung. After CT-scan had shown no structural deformities of the lung, suction was gradually reduced and the drain was successfully removed on the sixth day after placement. The patient was then discharged home. Control CXR 3 weeks later was normal.
The authors concluded that post-dry needling pneumothorax is, contrary to numbers cited in literature, not extremely rare. With rising popularity of the technique we expect complications to occur more often. Patients and referring doctors should be aware of this. In their informed consent practitioners should mention pneumothorax as a considerable risk of dry needling procedures in the neck, shoulder or chest region.
The crucial question, in my view, is this: do the risks of dry-needling out weigh the risks of this form of therapy? Let’s have a look at some of the recent evidence that we discussed on this blog:
- Spinal Manipulation and Electrical Dry Needling for Subacromial Pain Syndrome: A Nonsensical Trial
- Dry needling is useless for rehabilitation after shoulder surgery
- High velocity, low amplitude techniques are not superior to no treatment in the management of tension-type headache
- Which treatments are best for acute and subacute mechanical non-specific low back pain? A systematic review with network meta-analysis
- Acupuncture for chronic pain: the new NICE guideline
- Acupuncture for the Relief of Chronic Pain? A new, thorough synthesis fails to produce strong evidence that acupuncture works
The evidence is clearly mixed and unconvincing. I am not sure whether it is strong enough to afford a positive risk/benefit balance. In other words: dry needling is a therapy that might best be avoided.
Millions of US adults use so-called alternative medicine (SCAM). In 2012, 55 million adults spent $28.3 billion on SCAMs, comparable to 9% of total out-of-pocket health care expenditures. A recent analysis conducted by the US National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) suggests a substantial increase in the overall use of SCAM by American adults from 2002 to 2022. The paper published in the Journal of the American Medical Association, highlights a surge in the use of SCAM particularly for pain management.
Data from the 2002, 2012, and 2022 National Health Interview Surveys (NHISs) were employed to evaluate changes in the use of 7 SCAMs:
- yoga,
- meditation,
- massage therapy,
- chiropractic,
- acupuncture,
- naturopathy,
- guided imagery/progressive muscle relaxation.
The key findings include:
- The percentage of individuals who reported using at least one of the SCAMs increased from 19.2% in 2002 to 36.7% in 2022.
- The use of yoga, meditation, and massage therapy experienced the most significant growth.
- Use of yoga increased from 5% in 2002 to 16% in 2022.
- Meditation became the most popular SCAM in 2022, with an increase from 7.5% in 2002 to 17.3% in 2022.
- Acupuncture saw an increase from 1% in 2002 to 2.2% in 2022.
- The smallest rise was noted for chiropractic, from 79 to 86%
The analyses also suggested a rise in the proportion of US adults using SCAMs specifically for pain management. Among participants using any SCAM, the percentage reporting use for pain management increased from 42% in 2002 to 49% in 2022.
Limitations of the survey include:
- decreasing NHIS response rates over time,
- possible recall bias,
- cross-sectional data,
- differences in the wording of the surveys.
The NCCIH researchers like such surveys and tend to put a positive spin on them, i.e. SCAM is becoming more and more popular because it is supported by better and better evidence. Therefore, SCAM should be available to everyone who wants is.
But, of course, the spin could also turn in the opposite direction, i.e. the risk/benefit balance for most SCAMs is either negative or uncertain, and their cost-benefit remains unclear – as seen regularly on this blog. Therefore, the fact that SCAM seems to be getting more popular is of increasing concern. In particular, more consideration ought to be given to the indirect risks of SCAM (think, for instance, only of the influence SCAM practitioners have on the vaccination rates) that we often discuss here but that the NCCIH conveniently tends to ignore.
Medical Acupuncture is the name of a quarterly journal published for the ‘American Academy of Medical Acupuncture’ that publishes around 60 pro-acupuncture articles every year. Its editor is Richard C. Niemtzow, M.D., Ph.D., M.P.H. Richard is a retired US Air Force colonel who was the first full-time physician acupuncturist in the US Armed Forces. He is probably best known for his invention called ‘BATTLE FIELD ACUPUNCTURE’, a form of ear-acupuncture allegedly reducing pain in emergency situations.
Medline lists 79 papers (mostly published in 3rd class journals such as ‘Medical Acupuncture’) in Niemtzow’s name. Only one of them – 21 years ago – was a clinical trial. Here it is:
Purpose: We performed a pilot trial to assess the response of lower urinary tract symptoms and prostate specific antigen (PSA) to acupuncture in a population of patients biopsy negative for prostate cancer.
Materials and methods: A total of 30 patients were randomly assigned to 1 of 3 study groups, including observation for 3 months with 6 blood samples for PSA at set intervals, 9 sessions of acupuncture in 3 months to points of the kidney-bladder distinct meridian expected to treat the prostate with 6 blood samples for PSA at set intervals and 9 sessions of acupuncture in 3 months to points not expected to treat the prostate with 6 blood samples for PSA at set intervals. The effect of acupuncture on lower urinary tract symptoms was assessed monthly using the International Prostate Symptom Score.
Results: Trend analysis (repeated measures ANOVA) revealed no significant changes in the 3-month period in the randomized arms. Statistical analysis showed p = 0.063 for the International Prostate Symptom Score, p = 0.945 for PSA and p = 0.37 for the free-to-total PSA ratio.
Conclusions: Acupuncture to the kidney-bladder distinct meridian neither relieves lower urinary tract symptoms nor impacts PSA.
Yes, an acupuncture study with a negative result!
Niemtzow has, as far as I can see, never himself conducted a study of ‘battle field acupuncture’. In fact, there only very few trials of ‘battle field acupuncture‘. The most recent (albeit lousy) study even suggest that it is less effective than electroacupuncture (EA): EA was more effective than ‘battle field auricular acupuncture’ at reducing pain severity, but both similarly improved physical and mental health scores.
This does not stop Niemtzow to continue praising acupuncture in dozens of papers, particularly his ‘battle field’ version and especially in his ‘own’ journal. The most recent example has just been published; allow me to present an excerpt to you:
In December of 2023, I had the opportunity to visit the Van Gogh Museum in Amsterdam. The only day I had for this visit was characterized by a pouring and chilling rain. This did not stop the crowds of people visiting this famous exhibition. I reminded myself that Van Gogh was a troubled spirit. He lived a short tumultuous life characterized by cutting off his left ear lobe and he spent a sojourn in an asylum. Yet, his art emerged in all its beauty and splendor to become famous in the world. Despite all his troubles, he contributed a precious collection of magnificent art. Many individuals would not have surfaced out of personal disorders to produce such a wonderful gift to society. However, history tells us that many sensational contributions originated from people embroiled in mental health illnesses.
Medical Acupuncture published more than 13 years ago the acupuncture ‘‘diagnosis’’ of Vincent Van Gogh. The article, which is worth rereading, discussed the Five-Element pattern associated with the artist’s hallucinations, alcoholism, severe depression, insomnia, anxiety, dizziness, headaches, nightmares, etc. The author, Vera Kaikobad, LAc, stated: ‘‘It is poignant to realize that a few needles in the hands of a skilled acupuncturist may have spared this great artist such torment and perhaps saved his life.’’ Feasibly, in 2024 we should not only examine our patients for their physical complaints; we should venture into their mental health status as well. A back or neck pain is important, but so is anxiety, insomnia, etc. In promoting mental health, we may assist many patients who are perhaps capable of contributing to the well-being of the world. It is our responsibility as acupuncturists not to think of our patients as a neck or back pain, etc.; instead, we must see them as whole persons having spiritual and physical needs that must be addressed.
I feel that, overall, this remarkable effort justifies Niemtzow’s admission to my ALTERNATIVE MEDICINE HALL OF FAME.
WELCOME, RICHARD!
And let me introduce you to the rest of the 24 laureates:
- Helmut Kiene (anthroposophical medicine)
- Helge Franke (osteopathy, Germany)
- Tery Oleson (acupressure , US)
- Jorge Vas (acupuncture, Spain)
- Wane Jonas (homeopathy, US)
- Harald Walach (various SCAMs, Germany)
- Andreas Michalsen ( various SCAMs, Germany)
- Jennifer Jacobs (homeopath, US)
- Jenise Pellow (homeopath, South Africa)
- Adrian White (acupuncturist, UK)
- Michael Frass (homeopath, Austria)
- Jens Behnke (research officer, Germany)
- John Weeks (editor of JCAM, US)
- Deepak Chopra (entrepreneur, US)
- Cheryl Hawk (chiropractor, US)
- David Peters (osteopathy, homeopathy, UK)
- Nicola Robinson (TCM, UK)
- Peter Fisher (homeopathy, UK)
- Simon Mills (herbal medicine, UK)
- Gustav Dobos (various SCAMs, Germany)
- Claudia Witt (homeopathy, Germany/Switzerland)
- George Lewith (acupuncture, UK)
- John Licciardone (osteopathy, US)
This study tested whether trigger point acupuncture (TrPA) is beneficial for office workers who have reduced job performance (presenteeism) due to chronic neck and shoulder pain (katakori).
A 4-week single-center randomized clinical trial was conducted on 20 eligible female office workers with chronic neck and shoulder pain of at least 3-month duration. The control group implemented only workplace-recommended presenteeism measures, whereas the intervention group received TrPA up to 4 times per month in addition to the presenteeism measures recommended by each workplace. The major outcome measure was the relative presenteeism score on the World Health Organization Health and Work Performance (WHO-HPQ). The secondary outcome measures were pain intensity (numerical rating scale), absolute presenteeism (WHO-HPQ), anxiety and depression (Hospital Anxiety and Depression Scale; HADS), catastrophic thoughts related to pain (Pain Catastrophizing Scale; PCS), and sleep (Athens Insomnia Scale; AIS).
All 9 cases in the intervention group and 11 cases in the control group were analyzed. TrPA up to 4 times per month reduced the intensity of neck and shoulder pain by 20% (P < .01, d = 1.65) and improved labor productivity (relative presenteeism value) by 0.25 (P < .01, d = 1.33) compared with the control group over 1 month. No significant differences were observed between the 2 groups in terms of absolute presenteeism score, HADS, PCS, or AIS.
The authors concluded that these results suggest that regular intervention with TrPA may be effective in the relative presenteeism score before and after the intervention and the degree of neck and shoulder pain over 28 days compared with the control group.
Sure, TrPA may be effective.
But is it?
I thought the trial was aimed at answering that question!
But it didn’t!
Why not?
Because, as we have discussed ad nauseam on this blog, the A+B versus B study design cannot answer it. On the contrary, it will always generate a positive result without determining whether the treatment or a nonspecific (placebo) effect caused the outcome (which, of course, is the reason why this study design is so popular in SCAM research).
In view of this, I suggest to re-formulate the conclusions as follows:
The study suggests that the researchers were ill-informed when designing it. Therefore, the findings show nothing of value.
After the nationwide huha created by the BBC’s promotion of auriculotherapy and AcuSeeds, it comes as a surprise to learn that, in Kent (UK), the NHS seems to advocate and provide this form of quackery. Here is the text of the patient leaflet:
Kent Community Health, NHS Foundation Trust
Auriculotherapy
This section provides information to patients who might benefit from auriculotherapy, to complement their acupuncture treatment, as part of their chronic pain management plan.
What is auriculotherapy?
In traditional Chinese medicine, the ear is seen as a microsystem representing the entire body. Auricular acupuncture focuses on ear points that may help a wide variety of conditions including pain. Acupuncture points on the ear are stimulated with fine needles or with earseeds and massage (acupressure).
How does it work?
Recent research has shown that auriculotherapy stimulates the release of natural endorphins, the body’s own feel good chemicals, which may help some patients as part of their chronic pain management plan.
What are earseeds?
Earseeds are traditionally small seeds from the Vaccaria plant, but they can also be made from different types of metal or ceramic. Vaccaria earseeds are held in place over auricular points by a small piece of adhesive tape, or plaster. Applying these small and barely noticeable earseeds between acupuncture treatments allows for patient massage of the auricular points. Earseeds may be left in place for up to a week.
Who can use earseeds?
Earseeds are sometimes used by our Chronic Pain Service to prolong the effects of standard acupuncture treatments and may help some patients to self manage their chronic pain.
How can I get the most out my treatment with earseeds?
It is recommended that the earseeds are massaged two to three times a day or when symptoms occur by applying gentle pressure to the earseeds and massaging in small circles.
Will using earseeds cure my chronic pain?
As with any treatment, earseeds are not a cure but they can reduce pain levels for some patients as part of their chronic pain management programme.
________________________
What the authors of the leaflet forgot to tell the reader is this:
- Auriculotherapy is based on ideas that fly in the face of science.
- The evidence that auriculotherapy works is flimsy, to say the least.
- The evidence earseeds work is even worse.
- To arrive at a positive recommendation, the NHS had to heavily indulge in the pseudo-scientific art of cherry-picking.
- The positive experience that some patients report is due to a placebo response.
- For whichever condition auriculotherapy is used, there are treatments that are much more adequate.
- Advocating auriculotherapy is therefore not in the best interest of the patient.
- Arguably, it is unethical.
- Definitely, it is not what the NHS should be doing.
- an immediate osteopathic manipulative therapy (OMT) intervention group,
- a delayed OMT (waiting period) group.
The intervention consisted of three to four OMT sessions over 4–6 weeks, after which the participants switched (crossed-over) groups. The OMT techniques included a mandatory HVLA thrust technique to the lumbar spine region and any (or none) combination of the following four techniques: (i) soft tissue, (ii) muscle energy, (iii) myofascial, and (iv) articulatory. For patients who could not tolerate the HVLA treatment, a physician had to attempt this technique, minimally by attempting to place the patient in the position to perform this maneuver.
The primary clinical outcomes were average pain, current pain, Patient-Reported Outcomes Measurement Information System (PROMIS) 29 v1.0 pain interference and physical function, and modified Oswestry Disability Index (ODI). Secondary outcomes included the remaining PROMIS health domains and the Fear Avoidance Beliefs Questionnaire (FABQ). These measures were taken at baseline (T0), after one OMT session (T1), at the crossover point (T2), and at the end of the trial (T3). Due to the carryover effects of OMT intervention, only the outcomes obtained prior to T2 were evaluated utilizing mixed-effects models and after adjusting for baseline values.
- This study is far too small to allow conclusions about safety.
- The trial compared OMT with no therapy; it is likely that the observed outcomes have little to do with OMT but are due to a placebo response.
- The primary outcome measure showed no effect which essentially means that the study finding was that OMT is ineffective.
My conclusion:
a poor study conducted by wishful thinkers.
The aim of this study was to investigate whether there is a difference in outcome between participants with high compared to low pain self-efficacy (PSE) receiving manual therapy, acupuncture, and electrotherapy.
Participants were stratified into high or low baseline (i) PSE, (ii) shoulder pain and disability index (SPADI), and (iii) did or did not receive the treatment. Whether the effect of treatment differs for people with high compared to low PSE was assessed using the 95% confidence interval of the difference of difference (DoD) at a 5% significance level (p < 0.05).
Treatment was labelled using 3 categories, 2 of which were subcategories of the first
- “Any passive treatment” – any form of manual therapy and/or acupuncture and/or electrotherapy.
- “Any manual therapy” – shoulder or spine joint mobilisations, deep transverse frictions, capsular stretches, trigger point therapy, muscle facilitation, or other techniques listed by the treating physiotherapist.
- “Spinal/shoulder joint mobilisation” – for example, Maitland, Kaltenborn or Mulligan techniques.
To be categorised, treatment must have been delivered by the physiotherapist at least once and may have been delivered in conjunction with other treatments.
Six-month SPADI scores were consistently lower (less pain and disability) for those who did not receive passive treatments compared to those who did (statistically significant less pain and disability in 7 of 24 models). However, DoD was statistically insignificant.
The authors concluded that PSE did not moderate the relationship between treatment and outcome. However, participants who received passive treatment experienced equal or more pain and disability at 6 months compared to those who did not. Results are subject to confounding by indication but do indicate the need for further appropriately designed research.
This analysis suggests that manual therapy, electrotherapy, or acupuncture in addition to advice and exercise offered no improvement in pain or disability at six months, irrespective of PSE. Some patients who receive these treatments experienced more pain and disability at six months compared to those who do not.
I am not aware of compelling evidence that either of these treatments, all of which are often recommended, are effective for shoulder pain, and the results of this new study certainly do not suggest they are. However, as the design of the study was not primarily for this research question, these findings are, of course, merely tentative and need to be investigated further.
This systematic review aimed to investigate the effectiveness of cupping therapy on low back pain (LBP). Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).
Eleven trials involving 921 participants were included. Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. The findings reveal:
- High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p=0.004).
- There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p=0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p=0.11).
- Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p=0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p=0.008) at the endpoint intervention.
- There was no evidence indicating the association between pain reduction and different types of cupping (p=0.2).
- Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p=0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p=0.78) at the endpoint intervention.
- Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p<0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p=0.29).
- A potential association between pain reduction and different cupping locations (p=0.05) was found.
- Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n=8; d=1.8 [95% CI: 1.22 – 2.39], p<0.001) and usual care (n=5; d=1.07 [95% CI: 0.21- 1.93], p=0.01).
- Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 hours, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p<0.001).
- Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p=0.03).
- There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p=0.39).
- A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).
The authors concluded that high- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The real therapeutic effects of cupping could be confirmed using a sham device or objective outcome measurements. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.
Confused?
No need, it’s really quite simple: cupping can, according to this review, be shown to have some short-lasting effect, provided the study is flawed and does not control for placebo effects.
Surprised?
No need! There is hardly a form of so-called alternative medicine (SCAM) that does not have a similarly small effect of back pain, if tested in equally dodgy studies. This is particularly true for those treatments that can act as a theatrical placebo, e.g. acupuncture or chiropractic.
So, should a back pain sufferer try cupping?
If he/she insists, why not? But please don’t use wet cupping (which can do quite a bit of harm). Dry cupping (without injuring the skin) is arguably better (less risk, less expense, possibility of home treatment by your partner) than chiropractic, osteopathy, acupuncture, or many other SCAMs.
My conclusions – as mentioned many times previously – are as follows:
- Most SCAMs help a little with back pain (and similar conditions) because they can have a powerful placebo effect.
- Conventional medicine is also not convincingly effective for back pain.
- If you insist on SCAM, it is best to use one that is relatively harmless and inexpensive.
