Received: 26 March 2018 Revised: 28 May 2018 Accepted: 17 December 2018

DOI: 10.1002/pri.1770

RESEARCH ARTICLE

The effects of cupping therapy as a new approach in the

physiotherapeutic management of carpal tunnel syndrome
Shirin Mohammadi1 | Mohammad Mohsen Roostayi1 | Sedigheh Sadat Naimi1 |
2
Alireza Akbarzadeh Baghban

1
Physiotherapy Research Center, School of
Rehabilitation, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
2
Department of Basic Sciences, School of
Rehabilitation, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
Correspondence
Mohammad Mohsen Roostayi, Physiotherapy
Research Center, School of Rehabilitation,
Shahid Beheshti University of Medical
Sciences, Tehran, Iran.
Email: roosta@sbmu.ac.ir
Abstract
Background and Purpose: Cupping therapy has been used widely as a safe and
common method to tackle soft tissue lesions in most Asian countries, Central Europe,
and parts of the United States. In this study, cupping therapy has been used for the
treatment of carpal tunnel syndrome (CTS), which is the most common entrapment
neuropathy. The aim of this study was to investigate the effect of cupping therapy
on the clinical findings of patients with CTS.
Methods: This is a randomized clinical trial. For this research, a total of 56 hands
with CTS were studied, aged 18–60 years, and of both genders. The participants were
divided into two groups: test and control, regardless of the severity of their CTS. In
the control group, 28 were treated with routine physiotherapy (transcutaneous elec-
trical nerve stimulation and ultrasound), and in the test group, the other 28 were
treated with routine physiotherapy with cupping therapy. The variables used to deter-
mine the effect of cupping were symptom severity scale, functional status scale, distal
sensory latency, and distal motor latency. The severity of symptoms and functional
status of patients was evaluated with the help of the Boston questionnaire, and the
distal latency was evaluated through electromyography.
Results: The results of study demonstrated a significant improvement in symptom
severity (p = 0.006) and also a significant decrease in distal sensory latency
(p = 0.007) of the test group (routine physiotherapy with cupping) as compared with
the control group (routine physiotherapy).
Conclusions: The results showed that incorporation of cupping therapy in a routine
physical therapy programme can reduce the severity of symptoms and improve the
distal sensory disturbance of the median nerve. Therefore, it is suggested that cup-
ping, as a convenient and low‐cost method, can be used as a complementary therapy
in the treatment of CTS.

KEY W ORDS

carpal tunnel syndrome, cupping therapy, TENS, ultrasound

1 | I N T RO D U CT I O N the median nerve in carpal tunnel (Ahmadi, Schwebel, & Rezaei,

2008). This syndrome consists of a constellation of symptoms, such
Carpal tunnel syndrome (CTS) is the most common peripheral nerve as numbness, burning pain in the palm and first three fingers, and
entrapment of the upper extremity and is caused by compression of reduced grip strength (Kostopoulos, 2004). The prevalence of this

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https://doi.org/10.1002/pri.1770
2 of 7
syndrome has been reported to be about 2.7–5.8% in the general
adult population (Atroshi et al., 1999). The most important aetiology
for this syndrome is the reduction in channel volume and pressure
on the median nerve as a result of the transverse carpal ligament stiff-
ness, which leads to vascular disorder, nerve oedema, and adhesions
between the nerve and the structure around it. This can ultimately
lead to sensory (pain and paraesthesia) and motor (muscle atrophy)
disorders.
To control CTS, there are both invasive and non‐invasive treat-
ments. Surgical treatment is an invasive and costly treatment, which
is effective only in 70–75% of cases and can also be associated with
post‐surgical problems (Katz, 1994). Non‐invasive treatments, such
as medication, splinting, laser, ultrasound, nerve and bone mobiliza-
tion, and tendon gliding exercises, have not had enough satisfaction
despite relative improvement of symptoms in patients. Thus, this
paper explores the possible effects of cupping therapy as a non‐
invasive, safe, and low‐cost treatment for CTS.
Cupping is the application of vacuum by heat or suction using a
cup on different parts of the body (Ahmed, Fawaz, & Hssanien,
2010; Bhikha et al., 2008). Cupping can impose a tensile stress on
the subcutaneous tissues, which results in the surface tissues and
deeper layers being drawn into the cup (Tham, Lee, & Lu, 2006). This
biomechanical effect can result in local stretching, releasing the
myofascial and scar tissue, and decreasing skin stiffness and the ulti-
mate tensile strength (Roostayi, Norouzali, Dehghan Manshadi, &
Akbarzadeh Baghban, 2016). In addition, cupping can lead to pain
reduction and improved blood flow and oxygenation (Bhikha et al.,
2008; Chirali, 1999; Li, Liting, Xiaolin, et al., 2001).
Shacklock is a researcher who has represented the neurodynamic
theory on nerve entrapment syndromes. He suggested that removal of
pressure from the nerve can improve nerve tissue viscoelastic func-
tion, intraneural blood flow, axoplasmic flow, and dispersion of nox-
ious. All of these events can help return the dynamic balance
between neural tissue and surrounding structures (Shacklock, 2005).
As per Shacklock's statements and cupping characteristics, this
hypothesis could probably reduce nerve compression of median nerve.
This compression reduction can accelerate blood supply to the median
nerve and restore the dynamic balance between different structures
of the carpal tunnel. The aim of this study was to investigate the
clinical effects of cupping used as a new approach for the treatment
of CTS.
2 | METHODS
2.1 | Subjects
In this randomized clinical trial, a total of 56 hands of patients with
CTS were studied. They belonged to the age group of 18–60 years
old and of both genders. The participants voluntarily took part in this
study and filled out the written consent form. Then, they were divided
into the test and the control group regardless of the severity of their
CTS. In this study, the distribution of patients in the two groups was
matched with respect to the confounding factors. In the control group,
28 hands were treated with routine physiotherapy (transcutaneous
MOHAMMADI ET AL.
electrical nerve stimulation and ultrasound), whereas in the test group,
the rest 28 were treated with routine physiotherapy with cupping
therapy. During the treatment, one subject in the control group was
excluded from the study due to irregular visits (27 subjects in control
group). In patients with bilateral CTS, both their hands received the
same treatment. All stages of the study were performed by two ther-
apists for both the control and experimental groups. The first therapist
studied the variables and was not aware of the type of treatment that
each group was receiving, whereas the second therapist performed
therapeutic measures (routine physiotherapy and cupping) for the
patients. This study was single blind because the therapist who exam-
ined the variables was unaware of the type of treatment. This study
was approved by the Ethics Committee of Shahid Beheshti University
of Medical Sciences.
2.2 | Inclusion criteria
Volunteers suffering from CTS with a definite diagnosis of a physician
based on clinical evidence and electrophysiological findings (distal
motor latency [DML] of median nerve more than 4.2 ms and distal
sensory latency [DSL] more than 3.7 ms), aged between 18 and
60 years, not pregnant, tested negative for nerve compression in prox-
imal regions, absence of various neuropathies, having no history of
steroid injections inside the carpal tunnel or nerve release surgery,
absence of hyperthyroidism, and immune system diseases.
2.3 | Exclusion criteria
The exclusion criteria were as follows: discontinuation of the patient's
cooperation before completing all the 10 sessions of treatment, irreg-
ularities in patient's referrals, and damage to the wrists and upper
limbs during the treatment process.
2.4 | Instrumentation for cupping
The tool used for cupping included four parts: a manual pump for neg-
ative pressure, a transparent plastic cup of 3 cm diameter, silicone
interface to allow the matching of the cup with the wrist, and a cali-
brated pressure gauge to determine the air pressure used in the sys-
tem (Figure 1).
2.5 | Measurement of symptom severity scale and
functional status scale
In this study, the Boston Carpal Tunnel Syndrome Questionnaire,
which was designed by Levine and colleagues in 1993, was used to
investigate symptoms, such as pain and numbness, and the functional
status of patients. In this questionnaire, the symptom severity scale,
which has 11 questions, was used to measure symptom severity (SS),
and the functional status scale, which has eight questions, was used
to measure functional status (FS) changes. Each question had five
options, and each option had a score from 1 to 5 (score 1 indicated
no symptoms or no functional impairment, whereas score 5 indicated
the most severe signs or the worst disorder). In order to calculate the
MOHAMMADI ET AL.
FIGURE 1 Different components of cupping apparatus: (a) cup,
(b) suction pump, (c) silicone interface, (d) pressure gauge
SS and FS, the mean scores for each section were calculated. The
higher the mean, the greater the severity of the symptoms and disabil-
ity of the patient.
2.6 | Measurement of DML and DSL
In the study of nerve conduction velocity, one of the electro‐
diagnostic outputs for CTS is the evaluation of distal latency (motor
and sensory). This variable has a specificity of 95% and a sensitivity
of 85%, with the highest standard for the definitive diagnosis of CTS
and its severity (Jablecki, Andary, So, Wilkins, & Williams, 1993). The
sensory and motor distal latency (MDL) of the median nerve was mea-
sured using a standard method—an electro‐diagnostic device (MODEL
NEMUS, Italy). All electro‐diagnostic tests were conducted with the
patient lying in the supine position, in a room with the temperature
kept at 25°C. The median motor study was performed by recording
compound muscle action potential from the abductor pollicis brevis
muscle. In order to evaluate DML, the skin of the hand was cleaned
with alcohol first. Then, with resistance to the abductor of the thumb,
the location of abductor pollicis brevis was found, and the negative
electrode was fixed on it. The nerve stimulation site is between the
flexor carpi radialis and palmaris longus, which is 5 cm proximal to
the negative electrode. A ground electrode was placed on the dorsum
of the hand. The setting was adjusted at a sweep speed of
2 ms/division, pulse duration of 0.2 ms, a stimulation frequency of
1 Hz, and filter band‐pass of 3 Hz to 10 kHz.
The sensory nerve action potential of the median nerve was
recorded using an antidromic stimulation. The active recording elec-
trodes were placed over the proximal phalanx of the index finger,
and the reference electrode was placed 3 cm distally. Subsequently,
stimulation was performed at the wrist between the palmaris longus
and flexor carpi radialis tendons (14 cm proximal to the record elec-
trodes). The placement of the ground electrode was kept same as
before. The setting was adjusted at a sweep speed of 2 ms/division,
pulse duration of 0.1 ms, a stimulation frequency of 1 Hz, and filter
band‐pass of 20 Hz to 2 kHz. The CTS was accepted as the
SDL ≥ 3.6 ms and DML ≥ 4.2 ms (Dumitru & Zwartz, 2002).
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2.7 | Experimental procedure
First, a general information questionnaire was filled out for all the
patients. Then, before the first session, the Boston questionnaire
was filled out to assess the SS and FS. Also, DML and DSL of the
median nerve were recorded by a physical medicine specialist. The
treatment interventions were first described to the patient to make
them familiar with the procedure. In each treatment session, both
the groups received transcutaneous electrical nerve stimulation with
a frequency of 80 pulses per second and a pulse duration of 60 μs
for 20 min. Pulsed ultrasound with a frequency of 1 MHz, an intensity
of 1 W/cm2, and a duty cycle of 20% were also applied for 5 min
(Oskouei, Talebi, Shakouri, & Ghabili, 2014). In the test group, cupping
was used on the wrist for 4 min at a pressure of 50 mmHg in addition
to the already mentioned treatments. This pressure was considered
according to the pilot study as a safe pressure. In order to cover all
areas of the wrist, the cup was moved mildly along the nerve pathway
during treatment. To accommodate the anatomical shape of the wrist,
changes were made to the cup openings with the help of a silicone
interface to allow proper contact between the cup and the wrist, thus
preventing skin damage during the movement of the cup. An ultra-
sound gel (no therapeutic effect) was used under the edge of the
cup to better seal and make it easier to move the cup. It should be
noted that this intervention (cupping) did not have any skin complica-
tions. The treatment was performed for 10 sessions every alternate
day, and all the variables were reassessed for both groups after these
10 sessions of intervention.
2.8 | Statistical analysis
The Kolmogorov–Smirnov test was performed to analyse the distribu-
tion of data. The Kolmogorov–Smirnov test showed that the data
were normally distributed, and hence, the researchers used parametric
data. The paired sample t‐test was used to compare the differences
between the status of each group before and after the sessions,
whereas the independent sample t‐test was used to compare the dif-
ferences between the test and control groups. The two pairs of groups
has similar demographic characteristics and severity of CTS in the
baseline. All of the data were reported as means ± standard error. All
statistical analyses were performed using the SPSS statistical software
(version 15), and the significance level was set at 0.05.
3 | RESULTS
Table 1 shows the statistical indices (mean ± standard error) of vari-
ables for each group and the mean difference between the two
groups. The paired sample t‐test revealed that SS (pain/paresthesia)
decreased and FS improved in both test and control groups. However,
comparison of the mean differences in SS and FS using the indepen-
dent sample t‐test between the two groups showed that there was
statistically significant mean difference only in SS between the test
and control groups (p = 0.006). This observation shows that, although
reduction in pain and symptoms was observed in both groups, the
improvement in the test group (routine physiotherapy along with
4 of 7 MOHAMMADI ET AL.

TABLE 1 The statistical indices (mean ± standard error) of variables for each group and the mean difference between two groups

Test group Control group Mean difference

Variables Before (n = 28) After (n = 28) Before (n = 27) After (n = 27) Test.G (n = 28) Control.G (n = 27) p value
SSS 2.46 ± 0.10 1.43 ± 0.03 2.48 ± 0.06 1.83 ± 0.08 −1.03 ± 0.09 −0.65 ± 0.83 0.006
FSS 2.44 ± 0.10 1.51 ± 0.03 2.60 ± 0.08 1.75 ± 0.08 −0.93 ± 0.85 −0.85 ± 0.08 0.49
DSL 4.93 ± 0.24 4.53 ± 0.02 5.24 ± 0.14 5.15 ± 0.13 −0.39 ± 0.08 −0.09 ± 0.06 0.007
DML 4.77 ± 0.10 4.49 ± 0.19 5.18 ± 0.14 4.91 ± 0.11 −0.27 ± 0.06 −0.27 ± 0.05 0.92

Note. DML: distal motor latency; DSL: distal sensory latency; FSS: functional status scale; SSS: symptom severity scale.

cupping) was significantly higher than the control group (routine phys-
iotherapy). There was no statistically significant mean difference in FS
between the two groups (p = 0.449; Figure 2).
Comparison of the mean differences in DSL and DML between
two groups using the independent sample t‐test showed that there
was a statistically significant mean difference only in DSL between
the test and control groups (p = 0.007). There was no statistically sig-
nificant mean difference in DML between the two groups (p = 0.449;
Figure 3).
To achieve repeatable data for DSL and DML of the median
nerve, these variables were measured twice at every alternate day
on five patients with CTS. The intraclass correlation coefficient for
both the variables was 0.890 and 0.917, respectively. From the
intraclass correlation coefficient values for DSL and DML, it could be
concluded that the measurement technique was sufficiently reliable
to extend the study to more subjects.
4 | DISCUSSION
The results of this study demonstrated a significant improvement in SS
and also a significant decrease in DSL in the test group (routine phys-
iotherapy with cupping) as compared with the control group (routine
physiotherapy). Before discussing the results of this study, it should
be noted that this is the only study that has investigated the effects
of air cupping on CTS in the wrist. Michalsen et al. (2009) also studied
the effect of cupping on patients with CTS, but they used wet cupping
on trapezius muscles. In their study, the SS and FS variables were
studied using the Levine (Boston) questionnaire, and the results
showed a significant improvement for both variables in the cupping
group as compared with those who used only heat. The results of this
study were consistent with the Michalsen study only for SS but not for
the FS variable. This is probably due to the fact that, in addition to the
difference in the type and location of cupping, there was a difference
between the aetiology of CTS in Michalsen's study and in this study.
Michelson had used patients with double crush syndrome, whereas
in this study, air cupping was performed on the wrist of patients,
which is the area of median nerve compression in the carpal tunnel.
Several studies have been conducted on the effectiveness of
ultrasound on pain and paraesthesia (SS) in CTS. Most of them have
confirmed the results obtained of this study on the significant
improvement in the severity of the symptoms (Ebenbichler et al.,
1998; Oztas, Turan, Bora, & Karakaya, 1998). Although in a review
study Page et al. reported that ultrasound therapy alone has no advan-
tage over other routine physiotherapy treatments, this study showed
that adding cupping therapy to routine physiotherapy (ultrasound)
was more effective than only ultrasound (Page, O'Connor, Pitt, &
Massy‐Westropp, 2012). It shows that cupping can have an important
role in the reduction of median nerve compression in the carpal tun-
nel, which was the reason for SS reduction. In CTS, due to the anatom-
ical placement of sensory and motor nerve fibres, the former are more
superficial (Starkey, 2004). Hence, sensory fibres' involvement (sen-
sory disturbances) appears earlier than motor disorders (Aroori &
Spence, 2008). According to this, it was expected that at the beginning
of treatment, the intensity of the sensory symptoms would be reduced
first due to the decreased compression of the sensory fibres of the
median nerve, and the results of this study confirmed the same.
One of the most important aetiologies for CTS is median nerve
compression as a result of transverse carpal ligament stiffness.
Shacklock is a researcher who represented the neurodynamic theory

FIGURE 2 The mean of symptom severity and functional status (by using Boston Questionnaire). SSS: symptom severity scale; FSS: functional
status scale; TG: test group; CG: control group; MD: mean difference
MOHAMMADI ET AL.
FIGURE 3 The mean of sensory and motor distal latency of median nerve. DSL: distal sensory latency; DML: distal motor latency; TG: test group;
CG: control group; MD: mean difference
on nerve entrapment syndromes. He stated that nerve compression
can affect physiological responses of the nerve, including intraneural
blood flow, axonal transport, mechanosensitivity, and sympathetic
evaluation (Goyal et al., 2016; Shacklock, 2005). According to Cleland
et al., nerve compression can also result in impaired microcirculation
and the onset of oedema and demyelination in the nerve (Cleland,
Childs, Palmer, & Eberhart, 2006). Therefore, it is expected that the
removal of nerve compression can help restore the nerve to normal
neurodynamic conditions. The results of this study showed that cup-
ping has been able to reduce the compression on the median nerve
by applying biomechanical effects. Also, mobilization and stretching
of the transverse ligament (biomechanical effects) can lead to its flex-
ibility. In addition, reduced nerve compression can increase blood flow
and oxygen supply to the area, the intraneural circulation, axoplasmic
flow, neural connective tissue viscoelasticity, and the absorption of
inflammatory exudates and toxins accumulated in the deep layers to
the surface and facilitate the withdrawal of these materials through
intravenous return (Roostayi et al., 2009; Shacklock, 2005). The result
of these events can lead to the return of dynamic balance between the
neural tissue and surrounding structure, improvement of the nerve tis-
sue function, and reduction in the severity of neurological symptoms.
In addition, physiological effects of cupping in pain reduction have also
been reported in most papers, including
(a) release of morphine‐like substances (enkephalin and endorphin),
serotonin or cortisol; stimulating the immune system and neuro-
transmitter release; gate control theory (Ullah, Younis, & Wali,
2006);
(b) increasing blood and lymphatic circulation (Lauche et al., 2011 &
2012);
(c) irritation of the mechanoreceptors as a result of vacuum suction
(Roostayi et al., 2009);
(d) terminating inflammatory extravasations from the tissues and its
effects on the autonomic nervous system (Kim, Lee, Lee, Boddy,
& Ernst, 2011; Yoo & Tausk, 2004).
In a systematic review, Kim et al. (2011) investigated the effects
of cupping therapy (both wet and dry cupping) on any pain syndromes.
In this study, seven randomized controlled trial papers were reviewed.
In six of these seven studies, which focused on the effects of cupping
5 of 7
on lower back pain, cancer, trigeminal neuralgia, and brachial neuralgia,
significant therapeutic results have been reported in pain relief. It
should be noted that most of these articles are not of high quality
due to the high risk of bias.
The results of this study demonstrated a significant decrease in
DSL for the test group as compared with the control group. Consider-
ing the effects of cupping on the reduction of SS, which has been
described in the beginning of the discussion section, DSL reduction
in the test group is reasonable in comparison with the control group.
According to the possible mechanisms described previously, removal
of compression from the sensory fibres of the median nerve through
cupping can facilitate re‐establishment of the nervous stream. In the
case of FS and DML, however, there were no significant differences
between the two groups. It seems that the occurrence of functional
disorders is completely affected by the duration and severity of nerve
damage. In addition, the length and number of treatment sessions and,
in particular, the intensity of cupping have an effect on the results.
This study showed that 10 treatment sessions had no significant
effect on motor fibres of the median nerve. Increasing the number
of sessions or the exclusion of patients with severe CTS could proba-
bly lead to changes in this result. Based on studies on the intensity of
cupping and its effects on the underlying tissues, it has been found
that higher vacuum levels can lead to greater displacements of the
deeper layers (Hendriks, 2005). Hence, this higher vacuum pressure
can exert higher mobilization and stretch on the underlying soft tissue
(especially the transverse ligament). Therefore, it seems that changes
in the number of sessions and intensity of cupping may also affect
the FS and DML variables. However, further studies are required to
prove this theory.
Since there were no similar studies on the effects of cupping on
electrodiagnostic findings, two studies which have investigated the
effects of non‐surgical treatment of CTS on electro‐diagnostic find-
ings, have been discussed below.
Ebenbichler et al. (1998) studied the effects of ultrasound on
patients with CTS by using results from electro‐diagnostic treatments.
At the end of 20 ultrasound therapy sessions, they reported a signifi-
cant improvement in both DSL and DML. Oztas et al. (1998) also stud-
ied the use of ultrasounds with different intensities for treating CTS
but did not consider significant effects on electrophysiological find-
ings, unlike Ebenbichler. Perhaps the reason for these different reports
about the effect of ultrasound on electro‐diagnostic findings is the
6 of 7
difference between the two studies in terms of duration of CTS
involvement and the number of treatment sessions (average duration
of the first and second study was 8 and 48 months, respectively,
and the number of sessions was 20 and 10 sessions, respectively).
Although evaluating electrophysiological changes in the median nerve
compression, factors, such as age, CTS severity, and occupational
ergonomics, may lead to the impairment of electro‐diagnostic results.
Due to this, the lack of attention towards intervening variables in
the CTS can lead to different results in the nerve conduction velocity
observations.
5 | L I M I T A T I O NS
One of the most important limitations of this study was the lack of
similar studies on the use of cupping in patients with CTS. Due to
the lack of information, intensity and duration of the vacuum were
considered to be low and completely safe based on experimental stud-
ies. The authors suggest that considering the severity of CTS, the size
of the cup, the duration of cupping in each treatment session, and var-
ious vacuum pressures can play a decisive role on the outcome of trial.
More comprehensive studies are needed to confirm the effects of
these variables on the CTS patients. Another limitation was that
follow‐up examinations were not performed.
6 | I M P LI C A T I O N S F O R P H Y S I O T H E R A P Y
PRACTICE
The results of this study showed that incorporating cupping therapy to
a routine physical therapy programme can reduce the severity of
symptoms and improve the distal sensory disturbance of the median
nerve. Therefore, it is suggested that cupping can be used as a com-
plementary therapy in the treatment of CTS as it is a convenient and
low‐cost method.
ACKNOWLEDGEMEN TS
The authors would like to thank those who made this work possible.
Special thanks to Dr. Narges Joneydi (physiatrist) and to my colleagues
at the Physiotherapy Research Centre of Shahid Beheshti University
of Medical Sciences, Tehran, Iran, for their support.
CONF LICT S OF INTE R ES T
The authors declare no conflict of interest.
AUTHOR CONTRIBUTIONS
S. M. had executive role and helped to design the manuscript. M. M. R.
designed and drafted the manuscript. S. S. N. helped to draft and
check the manuscript. A. A. B. performed the statistical analysis. All
authors have read and approved the final version of the manuscript
and agreed with the order of presentation of the authors.
ORCID
Mohammad Mohsen Roostayi https://orcid.org/0000-0002-5866-
6505
MOHAMMADI ET AL.
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How to cite this article: Mohammadi S, Roostayi MM, Naimi
SS, Baghban AA. The effects of cupping therapy as a new
approach in the physiotherapeutic management of carpal tun-
nel syndrome. Physiother Res Int. 2019;e1770. https://doi.org/
10.1002/pri.1770