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Cupping Therapy

Technical Report · December 2012

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 CUPPING THERAPY

HEALTH TECHNOLOGY ASSESSMENT SECTION

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
010/2012
i
DISCLAIMER
Technology review is a brief report, prepared on an urgent basis, which draws on
restricted reviews from analysis of pertinent literature, on expert opinion and / or
regulatory status where appropriate. It has not been subjected to an external
review process. While effort has been made to do so, this document may not
fully reflect all scientific research available. Additionally, other relevant scientific
findings may have been reported since completion of this review.

Please contact: htamalaysia@moh.gov.my, if you would like further information.

Health Technology Assessment Section (MaHTAS),

Medical Development Division
Ministry of Health Malaysia
Level 4, Block E1, Precinct 1
Government Office Complex
62590 Putrajaya

Tel : 603 88831246

Fax : 603 8883 1230

Available at the following website: http://www.moh.gov.my

ii
Prepared by:
Dr. Hanin Farhana Kamaruzaman
Assistant Director
Health Technology Assessment Section (MaHTAS)
Ministry of Health Malaysia

Reviewed by:
Datin Dr Rugayah Bakri
Deputy Director
Health Technology Assessment Section (MaHTAS)
Ministry of Health Malaysia

DISCLOSURE

The author of this report has no competing interest in this subject and the
preparation of this report is totally funded by the Ministry of Health, Malaysia.

iii
EXECUTIVE SUMMARY

Introduction
Cupping therapy is a physical treatment which refers to a technique that uses
small glass cups or bamboo jars as suction devices that are placed on the skin.
This method is mostly used in Asian and Middle Eastern countries. Cupping is
believed to have potential benefit in treating myriad types of disease and
conditions. The most common conditions were pain related such as chronic
muscle pain, low back pain, neuralgia pain, fibromyalgia and headache.

This technology review was requested by the Director of Traditional and

Complementary Medicine (TCM), Ministry of Health Malaysia to evaluate the
therapeutic effect of cupping therapy on certain diseases or conditions.

Objective/aim
To assess the efficacy, effectiveness and safety of cupping therapy in treating
diseases or medical conditions such as herpes zoster, facial paralysis, back pain,
spondylosis, cerebrovascular accident, hypertension, fibromyalgia, bronchitis,
asthma and headache.

Results and conclusions

Three full text articles (one systematic review and two systematic reviews with
meta-analysis) were included in this technology review discussing the efficacy
and effectiveness of cupping therapy, with or without comparative treatments. As
for safety issues, 2 articles discussed on the adverse effects of cupping therapy.

This review showed that there is insufficient high quality evidence to support the
effectiveness of cupping therapy in treating diseases or medical conditions such
as herpes zoster, facial paralysis, back pain, spondylosis, cerebrovascular
accident, hypertension, fibromyalgia, bronchitis, asthma and headache.

Although cupping therapy is considered relatively safe and no major adverse

effects were reported directly on the therapy itself, it is very important to ensure
that the practitioners are properly trained and aware of the dangers involved in
the cupping therapy.

Methods
Electronic databases were searched through the MEDLINE(R) In-process and
other Non-Indexed Citations and Ovid MEDLINE(R) 1948 to present, EBM
Reviews - Cochrane Central Register of Controlled Trials and EBM Reviews -
Health Technology Assessment. Other database was PubMed, Cochrane
Library, Australia & New Zealand Horizon Scanning Network (ANZHSN) and US
Food & Drugs Administration (US FDA).

iv
1. INTRODUCTION

Cupping therapy is a physical treatment which refers to a technique that

uses small glass cups or bamboo jars as suction devices that are placed on
the skin.1 It has been used for thousands of years, said to be as early as
3000 BC. However, the earliest recorded evidence of cupping is in Ebers
Papyrus, one of the oldest medical textbooks in the world which described
that in 1550 BC, Egyptians used cupping as one of the treatment method. In
ancient Greece, Hippocrates used cupping for internal disease and
structural problems. This method is mostly used in Asian and Middle
Eastern countries and has been claimed to reduce pain and other
symptoms.2

Originally, practitioners would use hollowed-out animal horns for cups and
place them over particular points or meridians on the body, especially the
back part of the torso.2 Today, most therapists use cups made of thick glass
or plastic, although bamboo, iron and pottery cups are still being used in
some countries. Glass cups are the preferred method of therapy because
they do not break as easily as pottery or deteriorate like bamboo, and they
allow the therapists to see the skin and evaluate the effects of treatment. 1

In general, there are two types of cupping therapy, dry cupping and wet
cupping. Dry cupping is the process using vacuum on different areas of the
body in order to accumulate blood in that area without any incisions made.
Olive oil may be applied to the cupping area to allow easy movements of
the cups and create a massaging effect. In wet cupping, small incisions or
puncture are made on the skin using small razor or needle before treatment.
When the cup is applied and the skin is drawn up using vacuum, a small
amount of blood may flow from the puncture sites, which are believed to
help removing harmful substances and toxins from the body.1

Cupping is believed to have potential benefit in treating myriad types of

disease and conditions. The most common conditions were pain related,
including chronic muscle pain, low back pain, neuralgia pain, fibromyalgia,
headache and migraine.3 Other common diseases that were also treated
with cupping therapy are cough, common cold, facial paralysis, herpes
zoster, stroke rehabilitation, hypertension, sinusitis, acne and others. 3 In
oriental countries such as China and Korea, cupping therapy has been
applied as a formal modality in hospitals and act as a complementary
therapy to the current modern medicine.4

This technology review was requested by the Director of Traditional and

Complementary Medicine (TCM), Ministry of Health Malaysia to evaluate
the therapeutic effect of cupping therapy on certain diseases or conditions.

1
2. OBJECTIVE/AIM

To assess the efficacy, effectiveness and safety of cupping therapy in

treating diseases or medical conditions such as herpes zoster, facial
paralysis, back pain, spondylosis, cerebrovascular accident, hypertension,
fibromyalgia, bronchitis, asthma and headache.

3. TECHNICAL FEATURES

There are several ways used by acupuncturists or other traditional

complementary therapists to create the suction in the cups. Conventionally,
therapists swab alcohol onto the bottom of the cup, or using a cotton ball
soaked in alcohol, then lighting it and applied the cup immediately against
the skin.1 This method utilized the flaming heating power to achieve suction
through negative pressure inside the cups and apply them on the desired
part of the body. This type of vacuum method is still in use today, although
most current modern therapists who use vacuum technology therapeutically
rely on machines that pull the air out of the cupped part of the patient’s skin.
Vacuum machine can be set so that the pressure inside the chamber is at a
specific strength. Depending on the conditions being treated, the cups will
be left in place for 5 to 30 minutes. Several cups may be placed on a
patient’s body at the same time. . Some practitioners will also apply small
amounts of medicated oils or herbal oils to the skin just before the cupping
procedure, which allow them to move the cups.

Apart from dry cupping and wet cupping, there are some other methods of
cupping being practiced worldwide such as:

a) Moving / massage cupping

Prior to applying the cups, oil is administered to the skin to facilitate
smooth movements of the cups, giving a massage effect.

b) Needle/ acupuncture cupping

Acupuncture and cupping are done in the same place, by applying
acupuncture needle first then cupping over the needle.

c) Flash cupping
Cupping are performed several times in quick succession along the area
being treated to promote blood circulation.

d) Water cupping
This technique involves filling a glass or bamboo cup one-third full with
warm water and pursuing the cupping process quickly without spilling
the water.

2
 e) Medicinal / herbal cupping
Bamboo cups and herbs prescribed by traditional medicine practitioner
were immersed in water, boiled and simmered for 30 minutes before
applying. The steam from boiled herbs will provide vacuum as well as
therapeutic effect.

3.1 Mechanisms of Action

The mechanisms of action of cupping therapy and its curative process are
not yet discovered by modern science like in the case of acupuncture. The
postulated modes of actions include the interruption of blood circulation and
congestion as well as stopping the inflammatory extravasations from the
tissues.5 Others have postulated that cupping could affect the autonomic
nervous system and help to reduce pain .5 However, none of these theories
are proven and established in scientific view.

Figure 1 : Three types of cups – glass, bamboo and pottery

Figure 2 : Method in creating vacuum by flaming the alcohol-swabbed cup

and apply it to the skin

3
Figure 3 : Modern cupping set. Image available at :
http://img06.taobaocdn.com/imgextra/i6/120484/T2t6haXjRaXXXXXXXX_!!120484.jpg

Figure 4 : Wet / Bleeding cupping. Image available at:

http://www.thejakartapost.com/files/images/p19-b-1_17.jpg

4
4. METHODS

4.1. Searching

Electronic databases were searched through the MEDLINE(R) In-process

and other Non-Indexed Citations and Ovid MEDLINE(R) 1948 to present,
EBM Reviews - Cochrane Central Register of Controlled Trials and EBM
Reviews - Health Technology Assessment. Other database was PubMed,
Cochrane Library, Australia & New Zealand Horizon Scanning Network
(ANZHSN) and US Food & Drugs Administration (US FDA). The search
terms used can be referred in Appendix 1.

4.2. Selection

A reviewer screened the titles and abstracts against the inclusion and
exclusion criteria and then evaluated the selected full-text articles for final
article selection. The inclusion and exclusion criteria were:

Inclusion criteria
Population Herpes zoster, facial paralysis, Bell’s palsy, back pain,
spondylosis, stroke, cerebrovascular accident, cerebral
stroke, brain vascular accident, hypertension,
fibromyalgia, bronchitis, asthma, headache
Interventions Cupping therapy alone or cupping therapy combined with
other therapies (other traditional complementary therapy
such as acupuncture, or conventional therapy)
Comparators Conventional therapy, medicines, placebo
Outcomes Efficacy/effectiveness and safety of cupping therapy
Study design Randomized control trials, systematic reviews, meta-
analysis, case control, cohort and descriptive studies
Type of English
publication

Exclusion criteria
Study design Abstract, animal study
Type of Other language than English
publication

Relevant articles were critically appraised using Critical Appraisal Skills

Programme (CASP) and evidence graded according to the US / Canadian
Preventive Services Task Force (Appendix 2).

5
5. RESULTS AND DISCUSSION

Three full text articles were included in this technology review discussing
the efficacy and effectiveness of cupping therapy, with or without
comparative treatments. As for safety issues, 2 articles discussed on the
adverse effects of cupping therapy.

5.1 EFFICACY / EFFECTIVENESS OF CUPPING THERAPY

The three studies included in this technology review were one systematic
review and two systematic reviews with meta-analysis.

Cao et al conducted a systematic review and meta-analysis to evaluate the

therapeutic effect of cupping therapy for specific disease or conditions. The
eligible studies were randomized controlled trials (RCT) that examined the
effectiveness of cupping therapy, including one or more types of cupping
methods, compared with no treatment, placebo, or conventional medication.
Cupping combined with other interventions and compared with other
interventions alone were also included. However, studies that assessing the
effectiveness of cupping therapy combined with other traditional
complementary (TCM) therapies, such as acupuncture, compared with non-
TCM therapies were excluded. As the result, 135 studies were included in
the review and different types of cupping methods were used in the trials
that were selected. The six most common diseases or conditions for which
cupping was applied were herpes zoster, facial paralysis (Bell’s plasy), ,
acne, cervical spondylosis, lumbar disc herniation and also cough and
dyspnea. Meta-analyses were conducted on the first four of the above listed
conditions and due to the heterogeneity of the RCTs of the remaining two
diseases- lumbar disc herniation and cough and dyspnea- meta-analyses
could not be completed. 4, level I Among the limitations in this study were the
inconsistency of the outcome measures that has been used by each and
every single RCTs that were included in this systematic review. The
included trials used composite non-standardized outcome measures, which
categorized treatment efficacy into four grades: “cure”, “markedly effective”,
“effective” and “ineffective”. This classification was not internationally
recognized and the exact meaning is open to various interpretations.

Fifteen RCTs were included to evaluate the efficacy of wet cupping therapy
in treating herpes zoster. Wet cupping therapy was found to be superior to
pharmaceutical medications, such as antiviral, in providing cure (RR 2.07,
CI 1.77 to 2.43, p<0.0001, 5 trials, random model) and in lowering the
incidence rate of post-herpetic neuralgia (RR 0.12, CI 0.06 to 0.28,
p<0.0001, 4 trials, fixed model). But no difference was identified in the
number of patients with improved symptoms (RR 1.11, CI 1.00 to 1.23, p =
0.06, 5 trials, random model). Wet cupping in combination with
pharmaceutical medications was significantly better than medications alone

6
in effecting a cure (RR 1.93, CI 1.23 to 3.04, p= 0.005, 5 trials, random
model), but no difference in symptom improvement was observed (RR 1.00,
CI 0.97 to 1.03, p= 0.99, 4 trials, random model). Wet cupping combined
with acupuncture was superior to acupuncture alone both in providing cure
(RR 1.65, CI 1.08 to 2.53, p= 0.02, 3 trials, random model) and in improving
symptoms (RR 1.13, CI 1.02 to 1.25, p= 0.02, 3 trials, random model). 4

In the same review, the authors included 17 RCTs that assessed the
therapeutic effect of cupping therapy for facial paralysis. However, two of
the trials were excluded from meta-analysis due to the incomparability
between treatment and control groups. Meta-analysis showed that flash
cupping combined with acupuncture (RR 1.51, CI 1.29 to 1.76, p< 0.00001,
5 trials, fixed model) and wet cupping combined with acupuncture (RR 1.60,
CI 1.33 to 1.93, p< 0.00001, 6 trials, fixed model) were markedly better than
acupuncture alone in providing cure. In addition, cupping in combination
with medications, such as neurotrophic drugs, was superior to medications
alone in reducing average cure time (MD -6.05, CI -9.83 to -2.27, p= 0.002,
2 trials, random model).4

The review also included 6 trials in evaluating the efficacy of cupping

therapy for acne. In improving the cure rate, wet cupping therapy was
significantly better than medications, such as tanshinone, tetracycline and
ketoconazole (RR 2.14, CI 1.42 to 3.22, p= 0.0003, 3 trials, fixed model).
Furthermore, cupping therapy combined with other interventions was
superior to other interventions alone (RR 1.93, CI 1.40 to 2.65, p< 0.0001, 3
trials, fixed model).4

For cervical spondylosis, 6 trials evaluated the efficacy of cupping therapy

on the condition were included in the review. Cupping therapy especially
wet cupping, combined with other treatment, including acupuncture and
traction, was better than other treatments alone in effecting a cure (RR 1.52,
CI 1.20 to 1.92, p= 0.0005, 5 trials, fixed model) and in relieving symptoms
(RR 1.52, CI 1.20 to 1.92, p< 0.00001, 6 trials, fixed model). One trial
compared wet cupping with flunarizine for symptom improvement, and
found no difference between the two groups (RR 1.18, CI 0.60 to 2.32,
p=0.63, 1 trial).4

The authors concluded that despite the large number of studies on cupping
therapy, there was still lack of well-designed investigations. Of the 135
RCTs included in this review, 84.44% were categorized as having high risk
of bias based on criteria from the Cochrane Handbook for Systematic
Reviews of Interventions. The meta-analysis also revealed that cupping
therapy combined with other treatments, be it acupuncture or medications,
showed significant benefit over other treatments alone in effecting a cure for
herpes zoster, facial paralysis, acne and cervical spondylosis. This appears
to support the common practice in the authors’ country, China, of combining

7
TCM therapeutic modalities, either TCM with TCM, or TCM with routine
modern medicine and practice, to enhance efficacy. However, due to the
limitations especially high risk of bias of the studies that were included in
this review, the authors suggested that it is necessary to conduct further
RCTs that are of high quality and larger sample sizes in order to draw a
definitive conclusion.4

From another oriental country, Republic of Korea, Kim et al conducted a

systematic review to summarize and evaluate the effectiveness of cupping
therapy as a singular treatment of pain. The authors included 7 RCTs that
met the inclusion criteria of their review. All of the included trials adopted a
two-armed parallel group design. The treated pain-related conditions were
low back pain, cancer pain, trigerminal neuralgia, brachialgia paraesthetica
nocturna (BPN) and herpes zoster. One RCT compared the effects of dry
cupping on cancer pain with conventional drug therapy and reported
favourable effects for cupping after 3-day intervention (response rate: 67%
versus 43%, p<0.05). Another RCT compared dry cupping with non-
steroidal anti-inflammatory drugs in non-specific low back pain and
suggested a significant difference in pain relief on Visual Analogue Scale
(VAS) after treatment duration (MD 22.8 of 100mm VAS, CI 11.4 to 34.2, p<
0.001). The third RCT suggested that wet cupping reduced pain compared
with analgesics in acute trigerminal neuralgia after the intervention period
(response rate 93% versus 47%, p< 0.01). The fourth RCT tested wet
cupping plus usual care for pain reduction compared with usual care in non-
specific low back pain and suggested significant differences in pain relief
using McGill Pain Questionnaire at 3 months after 3 treatment sessions
(MD 2.2 of 6 points present pain intensity; CI 1.7 to 2.6, p< 0.01). The fifth
RCT reported that one session of wet cupping plus usual care significantly
reduced pain during a week compared with usual care alone in patients with
BPN (MD 1.6 of 10 points score, CI 0.13 to 3.07, p= 0.03). The sixth RCT
showed favourable effects of one session of wet cupping on pain reduction
compared with a heat pad in patients with BPN at 7 days after treatment
(MD 22.9 of 100mm VAS, CI 10.5 to 35.3, p< 0.001). A further RCT of wet
cupping plus conventional drugs on pain reduction compared with
conventional drugs alone in patients with herpes zoster failed to show
significant effects of wet cupping after interventions (response rate 100%
versus 88%, p= 0.065). In conclusion, the results of this systematic review
provide some suggestive evidence for the effectiveness of cupping in the
management of pain conditions. However, the total number of RCTs
included in the analysis and the methodological quality were too low to draw
firm conclusions. Furthermore, the studies with negative outcomes or
effects of cupping therapy remained unpublished thus may obscure the
overall picture. 5, level 1

8
 Cao et al conducted a systematic review and meta-analysis to evaluate the
therapeutic effect and safety of traditional Chinese medicine, including
Chinese herbal medicine for treatment of fibromyalgia which is
characterised by chronic widespread pain multiple tender points over the
body. A total of 25 RCTs were included in this review. The effects of
traditional Chinese therapies in providing pain relief and restoring
functionality as well as improving quality of life of the patients were studied.
Three of the RCTs compared acupuncture plus cupping therapy with
medications alone. However, only 2 trials were chosen for meta-analysis
because of low risk of bias. The analysis on the 2 RCTs showed that a
combination of acupuncture and cupping therapy plus medications was
significantly better than conventional medications alone in reducing pain
(pain reduction assessed using 10mm Visual Analogue Scale, MD -1.66, CI
2.14 to -1.19, p< 0.00001, I2= 0%) and reducing depression symptoms
(assessment of depression symptoms using Hamilton Depression Scale
(HAMD) scores, MD -4.92, CI -6.49 to -3.34, p< 0.0001, I2= 32%). The
authors concluded that patients with fibromyalgia might benefit from
traditional Chinese therapies however, more rigorously designed trials with
larger number of patients were warranted in demonstrating the
effectiveness and long term effects of these therapies.6, level 1

5.2 SAFETY OF CUPPING THERAPY

Cupping therapy is considered relatively safe with no major side effects.

However, it can cause some swelling and bruising on the skin. These
bruises are usually painless and disappear within a few days post-
treatment.1 There are several instances where cupping should not be
performed. Patients with inflamed skin and those who bleed easily are not
suitable candidates for cupping. Pregnant women or menstruating women
and patients with bone fracture or muscle spasms are also believed to be
contra-indicated.2 Cupping therapy also cannot be applied to a site of Deep
Vein Thrombosis (DVT), where there are ulcers, arteries or places where
pulses can be felt.2

The adverse effects of cupping therapy was briefly described in a

systematic review done by Cao et al as the secondary outcomes of the
review. One of the trials included in the review reported that a patient had
mild scalding on the skin after having cupping therapy. However, the
authors did not discussed in detail regarding that incident.6

A case study reported by Iblher et al described a significant thermal injury

following cupping therapy that warranted plastic surgery assessment and
management. A 59 year old Greek woman arrived at the Emergency
Department of Freiburg University Hospital, Germany by ambulance and
was found to have extensive truncal and upper extremity burns. The patient

9
 reported receiving cupping treatment from her husband due to chronic back
pain. Six to eight cups were heated by a burning cloth which had been
soaked in petrol before ignition. The heated cups were then applied to the
skin of her back. During the treatment, the petrol container fell, spilling the
contents over the patient and she was subsequently caught on fire. The
accident had resulted in superficial to deep partial-thickness burns to the
back, abdomen, chest and right arm, involving a total body surface area of
15%. There were also rounded hematomas caused by cupping therapy
itself. The patient needed debridement and silicon-collagen foil burn
dressing, which required 10-day of hospital stay. No specific details whether
her husband is a recognized cupping therapist. 7, level III Eventhough the
incident was rare and more of the caution during the treatment process, it is
important to create awareness among the public and the therapists on the
risk of the injuries related to cupping therapy.

5.3 LIMITATIONS

This technology review has several limitations. The selection of studies was
done by one reviewer. Although there was no restriction in language during
the search but only English full text articles were included in this report. Any
abstracts without a full text articles were also excluded.

6. CONCLUSION

6.1 EFFICACY/EFFECTIVENESS

This review suggested that there is insufficient high quality evidence to

support the use of cupping therapy in treating diseases or medical
conditions such as herpes zoster, facial paralysis, back pain, spondylosis,
cerebrovascular accident, hypertension, fibromyalgia, bronchitis, asthma
and headache. There was fair level of evidence to show the effectiveness of
cupping therapy in treatment of certain disease or medical conditions,
especially pain-related conditions. However, most of the trials combined
cupping therapy with other traditional complementary (TCM) treatment or
with conventional medications and standard therapeutic modalities that are
available in the hospitals. No retrievable evidence to prove that cupping
therapy as a single treatment is effective in treating any medical conditions.
Another drawback that has been identified is most of the articles that
reported positive effects of cupping therapy are from Chinese literature and
there are hardly any studies reported in Western literature, thus, the
possibility of publication bias is undeniable. The long term effect of cupping
therapy is not known.

10
6.2 SAFETY

Although cupping therapy is considered relatively safe and no major

adverse effects reported directly on the therapy itself, it is very important to
ensure that the practitioners are properly trained and aware of the dangers
involved in the cupping therapy. The burns are preventable, and therefore
the first step is to increase the awareness of the public and healthcare
professionals on the risk of these injuries. The long term complications and
adverse events related to cupping therapy is not known.

7. REFERENCES

1. The Many Benefits of Chinese Cupping. Available at :

http://www.itmonline.org/arts/cupping (retrieved on 14/5/2012)

2. Evaluation of the effects of traditional cupping on the biochemical,

hematological and immunological factors of human venous blood. Available
at: cdn.intechweb.org/pdfs/26488.pdf.

3. Cao H, Han M, Li X, et al. Clinical research evidence of cupping therapy in

China: a systematic literature review. BMC Complement Altern Med. 2010
Nov 16;10:70.

4. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy.

PLoSOne. 2012;7(2):e31793.

5. Kim JI, Lee MS, Lee DH et al. Cupping for treating pain: a systematic
review. Evid Based Complement Alternat Med. 2011;2011:467014.

6. Cao H, Liu J, Lewith GT. Traditional Chinese Medicine for treatment of

fibromyalgia: a systematic review of randomized controlled trials. J Altern
Complement Med. 2010 Apr;16(4):397-409.

7. Iblher N, Stark B. Cupping treatment and associated burn risk: a plastic

surgeon's perspective. J Burn Care Res. 2007 Mar-Apr;28(2):355-8.

11
8. APPENDIX

8.1. Appendix 1: LITERATURE SEARCH STRATEGY

Ovid MEDLINE® In-process & other Non-Indexed citations and OvidMEDLINE® 1948 to
present

1. exp herpes zoster/

2. herpes zoster.tw.
3. exp facial/ adj1 paralysis/
4. facial paralysis.tw.
5. Bell’s palsy.tw.
6. exp back pain/
7. back pain.tw.
8. exp spondylosis/
9. spondylosis.tw.
10. exp stroke/
11. stroke.tw.
12. cerebrovascular accident$.tw.
13. brain vascular accident$.tw.
14. cerebral stroke.tw.
15. exp hypertension/
16. hypertension.tw.
17. exp fibromyalgia/
18. fibromyalgia.tw.
19. exp bronchitis/
20. bronchitis.tw.
21. exp asthma/
22. asthma.tw.
23. exp headache/
24. headache.tw.
25. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or
18 or 19 or 20 or 21 or 22 or 23 or 24
26. Bloodletting/ or cupping therapy.mp.
27. cupping.tw.
28. cupping therap$.tw.
29. (cupping adj1 therap$).tw.
30. 26 or 27 or 28 or 29
31. 25 AND 30

12
OTHER DATABASES
EBM Reviews - Cochrane Same MeSH, keywords, limits used as per MEDLINE search
Central Register of Controlled
Trials
EBM Reviews - Database of
Abstracts of Review of Effects
EBM Reviews - Cochrane
database of systematic reviews

EBM Reviews - Health

Technology Assessment
PubMed

NHS economic evaluation

database
INAHTA
FDA

13
 8.2. Appendix 2

HIERARCHY OF EVIDENCE FOR EFFECTIVENESS STUDIES

DESIGNATION OF LEVELS OF EVIDENCE

I Evidence obtained from at least one properly designed randomized controlled

trial.

II-I Evidence obtained from well-designed controlled trials without

randomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies,

preferably from more than one centre or research group.

II-3 Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments (such as the results of the
introduction of penicillin treatment in the 1940s) could also be regarded as this
type of evidence.

III Opinions or respected authorities, based on clinical experience; descriptive

studies and case reports; or reports of expert committees.

SOURCE: US/CANADIAN PREVENTIVE SERVICES TASK FORCE (Harris 2001)

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