Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354

Contents lists available at ScienceDirect

Journal of Traditional Chinese Medical Sciences

journal homepage: www.elsevier.com/locate/jtcms

Key elements that determine the efficacy of cupping therapy: A

bibliometric analysis and review of clinical studies
Jiayin Tao a, Pei Zhao a, Tingting Mo a, Ruiming Zhao b, Nan Yang a, Myeong Soo Lee c, d,
Jianping Liu e, Huijuan Cao e, *
a
Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
b
Department of Respiration, China-Japan Friendship Hospital, Beijing, 100029, China
c
Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, 34054, South Korea
d
Korean Convergence Medicine, University of Science & Technology, Daejeon, 34113, South Korea
e
Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this review was to identify the possible mechanisms behind cupping therapy by
Received 13 March 2020 employing an evidence-based approach, and to explore its possible regional and systemic effects in the
Received in revised form human body.
3 November 2020
Methods: We searched six electronic databases and four online trial registries for articles published up to
Accepted 3 November 2020
January 1, 2020. Clinical studies on the mechanisms of retained cupping, flashing cupping, moving
Available online 9 November 2020
cupping, and vacuum cupping were considered for this review. The methodological qualities of
controlled studies were assessed using the National Institute for Clinical Excellence methodology
Keywords:
Cupping therapy
checklist, the Newcastle-Ottawa Scale, and the Cochrane risk of bias tool. Characteristic statistical
Negative pressure description and qualitative summary of results were used for data analysis.
Immunomodulation Results: Thirty-eight studies (37 full texts and one abstract) were included in this study. Due to the
Temperature clinical heterogeneity among the studies, we could not conduct a meta-analysis. The results showed that
Hemodynamics the key factors that contribute to the efficacy of cupping therapy are negative pressure and temperature.
Bibliometrics Cupping therapy mainly causes local and systemic changes in hemodynamics, immune regulation,
metabolism, and pain relief.
Conclusion: We identified negative pressure as the key element behind cupping therapy. Cupping
therapy may cause redistribution of oxygen at the cupping site and in neighboring tissues, thereby
inducing a therapeutic effect by increasing regional blood flow. It may also induce metabolic change,
immunomodulation, and neuromodulation. However, additional rigorous clinical research needs to be
conducted to further clarify the mechanism behind cupping therapy.
© 2020 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction periarthritis, facial paralysis, lumbar intervertebral disc herniation,

Cupping therapy is a traditional therapeutic technique that is
used as a complementary and alternative treatment worldwide.
The categories of cupping therapy are becoming more diverse;
however, it can generally be classified into wet cupping, retained
cupping, flashing cupping, moving cupping, medicinal cupping, and
needling cupping.1 According to the results of our previous studies,
cupping therapy may have a significant benefit in the treatment of
pain-related conditions, herpes zoster, scapulohumeral
dyspnea, and cervical spondylosis.2
It is widely believed that it is the temperature and the contin-
uous vacuum generated during cupping therapy that make an
impact on local skin. This continuous vacuum may stretch the skin
and underlying tissue, induce vascular recruitment, and cause the
capillaries to dilate and break. Regional stimulation causes a
microenvironmental change in vivo and leads to secretion of
chemical signals. Furthermore, these regional chemical signals
interact with each other, eventually resulting in a systemic effect.3

* Corresponding author.
E-mail address: huijuancao@bucm.edu.cn (H. Cao).
Peer review under responsibility of Beijing University of Chinese Medicine.

https://doi.org/10.1016/j.jtcms.2020.11.001
2095-7548/© 2020 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
J. Tao, P. Zhao, T. Mo et al.
Dr. Lowe indicated in his review that cupping therapy may have
antioxidant, anti-inflammatory, metabolic regulative, and immu-
nomodulatory effects in animal and human systems.4
Investigating the mechanism and impact of cupping therapy
may help elucidate its local and systemic effects. However, high-
quality clinical evidence that can explain the key elements and
mechanism of cupping therapy is still lacking. Prof. Lee assessed
five systematic reviews and came to a conclusion that reduction of
pain may be the only therapeutic effect of cupping.5 However, this
indication is not well proven as well. Given the variation in the
findings of previous studies, it is necessary to critically evaluate and
summarize the existing clinical evidence for obtaining a clearer
picture of the mechanism and therapeutic effect of cupping ther-
apy. In this review, the key elements that determine the efficacy of
cupping therapy were summarized and evaluated based on evi-
dence in the currently available literature. The results of this review
would provide practitioners with a clearer direction regarding the
use of cupping therapy in clinical practice. The aim of this review
was to identify the possible mechanisms behind cupping therapy
by utilizing an evidence-based approach, and to explore its possible
regional and systemic effects in the human body.
Methods
Search strategy
Literature concerning the mechanism of cupping therapy was
retrieved with no restriction on publication status. Due to language
barriers, we only included articles that were published in English
and Chinese. We searched the Cochrane Central Register of
Controlled Trials, PubMed, EMBASE, China National Knowledge
Infrastructure, Chinese Scientific Journals Database (Chongqing
VIP), and the Wanfang Data. Online trial registries, including the
Chinese Clinical Registry, International Clinical Trials Registry
Platform, ClinicalTrials.gov, and the Australian New Zealand Clinical
Trials Registry were searched as well. The reference lists of the
identified studies were also searched to identify other potentially
relevant studies.
The search terms we used included “cup,” “cupping,” or
“baguan” combined with “suction,” “negative pressure,” “temper-
ature,” “blood flow,” “nerve system,” “neurohormone,” “circula-
tory,” “blood,” “serum,” “plasma,” “immune systems,” or
“mechanism”. We adjusted the retrieval strategy for the different
databases.
Inclusion criteria
All kinds of clinical studies such as randomized controlled trials
(RCTs), cohort studies, case-controlled studies, cross-sectional
studies, case series, and case reports were included. Animal
studies were not included because our objective was to investigate
the impact of cupping therapy on the human body. There were no
restrictions regarding the sex, age, race, nationality, or the educa-
tion level of participants as long as they received cupping therapy
for the management of any diseases or conditions. Retained
cupping, flashing cupping, moving cupping, and vacuum cupping
were considered as interventions for this review. The controls were
cupping therapy performed at different temperatures and pres-
sures to find out the key elements that determine the efficacy of
cupping. Placebo or sham cupping were also included if they were
compared with vacuum cupping. If the control group received
placebo treatment or other treatment, such as western medicine or
complementary and alternative medicine, the study outcome was
considered mechanism-related. Studies that involved a combina-
tion of cupping therapy and other treatments (such as oral
346
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
administration of drugs, medicinal injection, wet cupping, medic-
inal cupping, and needling cupping) as intervention were not
included in this review because of the complexity of the mecha-
nisms of the different treatments administered.
Regarding the key elements of cupping therapy (e.g. vacuum
and temperature), the primary outcomes of this review were
changes in the indicators that reflect therapeutic effects in the
human body; the indicators were defined based on the involved
disease/condition. Regarding the possible mechanism of cupping in
the human body, the primary outcomes were any changes in
physiological or biochemical indicators, such as hemodynamics,
inflammatory mediators, neuroendocrine regulation, and
immunomodulation.
Data extraction and quality assessment
Five authors (JYT, PZ, TTM, RMZ, and NY) independently
extracted data on participant characteristics, details of cupping
therapy and control, outcomes, and quality-related information.
Microsoft Office Access 2016 (Office 365 MSO 18.2005.1191.0,
Microsoft, Redmond, Washington D.C.) was used for data
extraction.
Two authors (JYT and PZ) independently evaluated the meth-
odological quality of the included controlled clinical studies. The
Newcastle-Ottawa Scale was used to assess the methodological
quality of the included analytical studies (cohort studies and case-
control studies).6 Eight elements, including “comparability” be-
tween groups, “representative” selection samples, and “integrity”
and “validity” records, were assessed. The methodological qualities
of RCTs and non-randomized controlled clinical studies were
assessed using the risk of bias tools reported in the Cochrane
Handbook for Systematic Reviews of Interventions.7 The seven el-
ements of the risk of bias tool are: random sequence generation,
blindness of participants included, allocation concealment, blind-
ness of outcome assessors, selective reporting, incomplete outcome
data, and other biases. The methodological qualities of case series
were assessed according to the standards formulated by the Na-
tional Institute for Clinical Excellence.8 Scores were assigned to
multi-center studies based on whether they had “clearly described”
hypothesis/aim/objective, “clearly reported” inclusion and exclu-
sion criteria, “clearly defined” outcomes, prospectively collected
data, “consecutively recruited” patients, “clearly described” find-
ings, and “stratified” outcomes.
Data analysis
Microsoft Excel 2016 (Microsoft) was used to calculate fre-
quency. For binary outcomes, we used relative risk (RR) with 95%
confidence intervals (CI) to summarize the outcome data; for
continuous outcomes, mean difference (MD) and 95% CI were re-
ported (Table 1). Review Manager 5.3 software was used for data
calculation. However, we did not conduct a meta-analysis because
of the obvious clinical heterogeneity among the studies; only sta-
tistical description and qualitative summary of the results were
used for data analysis.
Results
Search results
We searched relevant databases and trial registries up to
January 1, 2020. Out of 7539 citations retrieved after the search,
7432 were screened out after their titles and abstracts were eval-
uated. We assessed the full texts of the remaining 107 citations; 94
articles remained after duplicates were removed. Subsequently, we
J. Tao, P. Zhao, T. Mo et al.
screened out 56 citations for a variety of reasons (Fig. 1). Thirty-
eight studies9‒46 including 37 full texts and one abstract (a total
of 1569 participants) were eligible for review.
Basic characteristics of the included studies
The number of articles published over time is shown in Fig. 2.
Thirty-one of the included studies were conducted in China; 26
were publications in Chinese Journals, and five were published in
English. For the remaining seven studies, which were published in
English, one was conducted in Korea,42 one in Iran,9 one in
Singapore,29 two in Ukraine,31,32 and two in Germany.10,45
Ten of the 38 studies were RCTs,9,10,13,27,28,34‒38 one was a non-
RCT,39 one was a cohort study,33 and the remaining were case se-
ries. Among the 10 included RCTs, two were three-arm trials,10,33
whereas eight trials had a parallel two-arm design.
The basic characteristics of the included studies are shown in
Table 1.
Assessment of risks of bias in the included trials
Eleven trials, including 10 RCTs9,10,13,27,28,34‒38 and one non-
RCT,39 were assessed using the risk of bias tool. The methods of
random sequence generation were reported in five trials;9‒11,28,36;
the random number table was used to generate the allocation in all
of them. The methods of allocation concealment were reported in
only three trials.10,27,28 In these trials, the random number was kept
in a sealed opaque envelope. Due to the manipulation and the
particularity associated with cupping therapy, it is difficult to
perform a double-blind study that involves cupping therapy. Only
reports of two trials9,10 had sufficient information that permitted
the determination of the presence of a low risk of performance bias.
In one trial,9 blinding was likely broken since the patients in the
sham cupping group may not have had any feeling of negative
pressure during the treatment. In another trial10 blinding was
highly likely to be broken based on the information from the post-
test investigation. Since all of the studies except two9,10 were not
registered, it was difficult to determine whether they were pre-
designed, and whether the methods used for sample size calcula-
tion were reasonable; therefore, we considered them as having an
unclear risk of selective reporting and other bias (Fig. 3).
Twenty-six case series were assessed using the National Insti-
tute for Clinical Excellence guideline. The average score from that
evaluation was 4.5 (range 3e6). The major defect was that all 26
researches were single-center trials, and their outcomes were not
stratified by disease stage, abnormal test results, or patient char-
acteristics. In addition, most reports did not include explicit state-
ments on whether patients were recruited consecutively or not
(Fig. 4).
The only cohort study33 was assessed using the Newcastle-
Ottawa Scale. Owing to the limitations on representativeness of
samples and comparability between groups, only four stars were
given, which indicated that the methodological quality of this study
was not very good.
Key contributing factors behind the mechanism of cupping
Negative pressure
In two trials,9,10 vacuum cupping was compared with sham
cupping; the presence of negative pressure was the only difference
between the study groups. One trial9 demonstrated that individuals
treated with vacuum cupping had significantly less severe post-
operative nausea and vomiting after surgery than those treated
with sham cupping (206 participants, P < .001). The results showed
that patients in the vacuum cupping group were less likely to have
347
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
nausea (MD ¼ 1.87; 95% CI, 2.49 to 1.25; P < .0001) or vomiting
(MD ¼ 1.01; 95% CI, 1.29 to 0.73; P < .0001) 2 h after treatment
than those in the sham cupping group. However, the results of the
other trial10 showed that there was no difference between the two
groups regarding the reduction of pain intensity (141 participants;
MD ¼ 3.0 mm; 95% CI, 9.9 to 3.9; P ¼ .396).
In the trial by Li,11 three groups that underwent treatment with
different degrees of negative pressure were compared, and the
results indicated that there were differences in the relief of urticaria
symptoms among the groups (90 participants; RR ¼ 1.27; 95% CI,
1.01 to 1.61; P ¼ .045). However, although the researchers utilized
cups of different calibers to ensure that varied degrees of pressure
were applied, they did not measure the specific values of the
pressure applied.
Temperature
In two trials,12,13 vacuum cupping was compared with retained
cupping to explore the potential effect of temperature during
treatment. In one of the trials,12 adjustments were made to ensure
the pressure in two types of cups were equal; results showed that
compared with fire cupping, the elevation of local blood perfusion
with dry cupping was significant 21 min after removing the cups (13
participants; MD ¼ 0.31 PU; 95% CI, 0.14 to 0.48, P ¼ .0015). However,
the instant efficacy of the elevation of local blood perfusion with dry
cupping was nearly the same as that of fire cupping (MD ¼ 0.00 PU;
95% CI, 0.28 to 0.28; P > .05). The other trial13 showed that there
was no significant difference between two groups in terms of
reduction of limb pain and improvement of limb activity (40 par-
ticipants; RR ¼ 1.23; 95% CI, 0.83 to 1.82; P > .05). However, in this
trial, the researchers did not take steps to ensure that the negative
pressure of cupping in the two groups was the same.
Mechanism of cupping therapy in the human body
Hemodynamic changes
Six case series,14‒19 which included a total of 75 participants,
reported blood flow data during cupping treatment. Significant
differences could be found with regard to increase of regional blood
flow in moving cupping (instant change; 20 participants;
MD ¼ 58.66 PU; 95% CI, 46.53 to 70.79; P < .001), retained cupping
(5 min after cupping; 15 participants; MD ¼ 37.97 PU; 95% CI, 28.75
to 47.18; P < .001), and vacuum cupping (0.04 MPa cupping for
5 min; 10 participants; MD ¼ 0.59 PU; 95% CI, 0.31 to 0.86;
P ¼ .0006 and instant change; 30 participants; MD ¼ 78.54 PU; 95%
CI, 66.26 to 90.82; P < .001).
Another case series20 reported that peak systolic velocity (PSV)
and end-diastolic velocity (EDV) levels increased significantly (32
spots on 22 lumbago patients; PSV: MD ¼ 8.30 cm/s; 95% CI, 7.60 to
9.00; P < .001 and EDV: MD ¼ 3.60 cm/s; 95% CI, 3.34 to 3.86;
P < .001), whereas resistance index decreased (32 spots on 22
lumbago patients; MD ¼ 0.07 cm/s; 95% CI, 0.10 to 0.04;
P < .001) after cupping treatment. The results of one trial21 indi-
cated that whole blood viscosity at a sheer rate of 200 s1 and
plasma viscosity decreased significantly (12 sub-healthy adults;
MD ¼ 0.22 mpa. s; 95% CI not clear; P < .05 and MD ¼ 0.09 mpa.
s; 95% CI, not clear; P < .05), whereas no significant difference was
found in whole blood viscosity at a sheer rate of 1 s1, 2 s1, and 3
s1. In one study,22 the yuan-acupoint was tested on the same
meridian as that of the cupping site. The bias ratio of blood
perfusion significantly decreased and was approaching normal
values as a result of cupping therapy (44 spots on 31 healthy adults;
MD ¼ 20.95%; 95% CI, not clear; P < .01); this indicates a hemo-
dynamic change caused by cupping treatment.
Hemodynamic changes may also cause changes in skin tem-
perature. Six trials,23‒28 which involved a total of 240 participants,
J. Tao, P. Zhao, T. Mo et al. Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354

Table 1
Basic characteristics of including studies.

Study ID Intervention/Comparisons Cupping site Test site Sample Conditions Main findings OR/MD (95%CI)
size (M/
F)

Negative pressure
Farhadi K. Vacuum vs. sham cupping P6 on the dominant None T: 0/ PONV Nausea: MD -1.87 (2.49, 1.25);
20169 hand 107 Vomiting: MD -1.01 (1.29, 0.73)
C: 0/99
Lauche R. Vacuum vs. sham cupping for 10 No limit on the upper None T:1/46 Fibromyalgia VAS: MD -3.0 (9.9, 3.9) mm
201610 e15 min and lower back C:1/47 syndrome
Li C. 201811 Retained cupping for 15 min with RN8, DU14, BL13, BL20, None T: 30 Urticaria Symptoms of urticaria: RR 1.27 (1.01, 1.61)
3 cm vs. 5 cm diameter cups BL23 C: 30
Temperature
Huang T Vacuum vs. retained cupping Two central points in T 7 Cupping site T: 3/10 None Blood flow: MD 0.31 (0.14, 0.48) PU
201012 e8 to L 2-3 C: 3/10
Hu YP Vacuum vs. retained cupping No limit None T: 20 Arthralgia Reducing limb pain and improving limb activity:
201813 C: 20 RR 1.23 (0.83, 1.82)
Hemodynamic change
Tian YY Retained cupping Inside of the forearm Cupping site 5/5 None Blood flow: MD 0.55 (0.31, 0.78) PU
200714
Tian YY Moving cupping Bilateral bladder Cupping site 5/9 None Blood flow: MD 0.28 (0.20, 0.36) PU
201215 meridians
Zhao YJ Moving cupping with different Governor vessel GV14 10/10 Sub-healthy Blood flow: MD 58.66 (46.53, 70.79) PU
201316 parameters (negative pressure 0.01 GV12 Blood flow: MD 58.20 (47.09, 69.31) PU
e0.02 MPa, 0.02e0.03 MPa, with the midpoint Blood flow: MD 52.27 (41.12, 63.42) PU
moving cup for 5 min or 3 min) between GV14 and
GV12
Liu W Vacuum cupping for 10 min with a GV14，GV12，GV11 GV14 15/15 None Blood flow: MD 78.54 (66.26, 90.82) PU
201317 constant negative pressure at and bilateral BL13 and GV12 Blood flow: MD 3.71 (7.85, 0.43) PU
0.04 MPa BL15 GV11 Blood flow: MD 0.36 (3.41, 4.13) PU
Left BL13 Blood flow: MD 11.87 (6.72, 17.02) PU
Right BL13 Blood flow: MD 15.17 (8.62, 21.72) PU
Left BL15 Blood flow: MD 1.53 (1.86, 4.92) PU
Right BL15 Blood flow: MD 1.65 (2.08, 5.38) PU
Jin L 201018 Retained cupping for 10 min Right BL18 Right BL18 6/9 None Blood flow: MD 37.97 (28.75, 47.18) PU
Li CQ Vacuum cupping for 5 min GV14 Left BL13 5/5 Sub-healthy Blood flow: MD -0.81 (7.98, 6.35) PU
201219 GV12 Blood flow: MD -0.41 (7.06, 6.24) PU
Tang X Retained cupping for 10 min Ashi acupoint in lower Cupping site 14/18 Lumbago PSV: MD 8.30 (7.60, 9.00) cm/s; EDV: MD 3.60
201220 back (3.34, 3.86) cm/s; RI: MD -0.07 (0.10, 0.04)
cm/s
Zhao YJ Moving cupping Bilateral bladder Venous blood 3/9 Sub-healthy Venous blood viscosity at a sheer rate of 200 s1:
201521 meridians and the MD -0.22 (CI not cleara) mpa.s; plasma viscosity:
Governor vessel MD -0.09 (CI not cleara) mpa.s
Zhao PN Vacuum cupping for 10 min Bilateral he-Sea acupoint Bilateral yuan- 14/17 None BRBP: MD -20.95 (CI not cleara) %
201822 of Jueyin and Shaoyang acupoint of Jueyin
meridians and Shaoyang
meridians
Skin surface temperature ( C)
Xin Y Vacuum cupping for 10 min Bilateral BL23, BL25, Cupping site 55 Lower back MD 1.01 (0.37, 1.65)
199423 BL31, BL40, KI1 pain
Li CQ Vacuum cupping GV14 Left BL13 20/0 None MD 0.74 (0.20, 1.68)
201124 Right BL13 MD 0.83 (0.05, 1.61)
Left BL18 MD 0.79 (0.00, 1.58)
Right BL18 MD 0.79 (0.12, 1.46)
Left BL23 MD 0.33 (0.46, 1.12)
Right BL23 MD 0.65 (0.08, 1.38)
Li CQ Vacuum cupping Governor vessel DU3 20/0 None MD 0.39 (0.17, 0.95)
201025 DU9 MD 0.64 (0.15, 1.13)
DU13 MD 0.37 (0.04, 0.78)
Zhang L Retained cupping for 15 min BL20 BL20 9/12 None MD 0.29
201126
Xu PC Vacuum cupping for 10 min BL15, BL23 Cupping site as 29/14 Low back MD 0.10 (0.37, 0.57)
201427 well as the other pain
side of cupping site
as control site
Chi LM Retained cupping vs. no treatment for SI15, GB21, LI15 SI 15 T: 3/27 Chronic neck MD 0.61 (0.35, 0.87)
201628 20 min GB21 C: 2/28 and shoulder MD 0.52 (0.24, 0.80)
LI15 pain MD 0.22 (0.01, 0.43)
Tang YH Retained cupping vs. no treatment for Bilateral bladder Upper abdomen T: 16/ Sub-healthy MD 1.08 (0.83, 1.34)
201429 10 min meridians back 15 MD 0.87 (0.15, 1.59)
C: 15/
18
Immunomodulation
Zhong L Moving cupping Bilateral bladder Venous blood 34/23 None C3b R: MD 5.83 (4.29, 7.37)  109/L (27b); MD
199930 meridians 4.15 (2.45, 5.84)  109/L (30b); immune complex

348
J. Tao, P. Zhao, T. Mo et al. Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354

Table 1 (continued )

Study ID Intervention/Comparisons Cupping site Test site Sample Conditions Main findings OR/MD (95%CI)
size (M/
F)

rosette: MD 2.51 (1.47, 3.56)  109/L (27); MD

1.96 (0.85, 3.07)  109/L (30)
Boris V. Retained cupping No limit Venous blood 0/23 None NKc: MD -3.30 (5.56, 1.04) %
201631
Boris V. Retained cupping No limit Venous blood 0/22 None HLA-DR: RR 11.00 (0.68, 177.72)
201832
Liu ZD Retained cupping for 10min DU14, LI15, SJ14, BL11, Blisters 35 Shoulder and Compared with the scald group (control group),
201833 BL12, BL13 and Ashi back pain a total of seven proteins in the cupping group
points were increased, one protein was decreased
Gong L Retained cupping for 10 min vs. oral CV8 Venous blood T: 15/ Atopic EOS: MD -0.14 (0.21, 0.08)  109/L; IgE: MD
201634 cetirizine tablets 10 dermatitis -488.62 (694.97, 282.27) U/mL
C: 12/
13
Wang D Retained cupping for 10 min vs. oral BL12, BL13, BL20 Venous blood T: 21/ Repeated IgA: MD ¼ 0.38 (0.10, 0.66) g/L; C3: MD 0.07
201835 Yupingfeng 19 common cold (0.01, 0.13) g/L; IL-2: MD 0.47 (0.15, 0.79) U/mL
C: 18/ in deficiency
22 body
Chen C Retained cupping for 8min vs. BL13, EX-B1, GV9 Venous blood T: 24/ Children IgG: MD 3.98 (3.21, 4.75) g/L; IgA: MD 0.60 (0.47,
201736 ambroxol hydrochloride oral solution 26 cough after 0.73) g/L; SIL-2R: MD -111.14 (194.29, 27.99)
C: 27/ infection U/mL
23
Luo YH Retained cupping for 35 min vs. oral Multiple meridians Venous blood T: 22/ Ulcerative IgA: MD -0.05 (0.29, 0.19) g/L; IgG: MD -2.51
200937 Changyanning tablets 18 colitis (3.15, 1.87) g/L; IgM: MD -0.97 (1.22, 0.72)
C: 20/ g/L
16
Ye LH Retained cupping for 15 min vs. blank Bilateral CV8, CV4, ST36 Venous blood T: 27/ No limit Cupping treatment may regulate IgA, IgG, IgM,
201638 control and bilateral BL13, BL20, 28 C3, C4 level in two directions
BL23 by turns C: 25/
18
Oxygen change
Li T 201739 Vacuum cupping with a constant Infraspinatus muscle Peripheral area of 11/2 None RHb: MD -19.43 (23.26, 15.6) mmol/L; OHb:
negative pressure at cupping site MD 7.73 (5.17, 10.29) mmol/L
0.075 ± 0.005 MPa for 5 min
Gao CY Vacuum cupping with a constant Acupoint of kidney Acupoint of kidney 7/5 None RHb: MD 7.69 (5.80, 9.58) mmol/L; OHb: MD
201940 negative pressure at -4.19 (5.75, 2.63) mmol/L
0.075 ± 0.005 MPa for 8 min
Zhang L Retained cupping with negative BL20 BL20 10/11 None RHb: MD 0.3124 mmol/L; OHb: MD 1.6667 mmol/
200141 pressure 0.045 ± 0.005 MPa for L
15 min
Kim S Vacuum cupping with a constant Thoracolumbar fascia Cupping site and 10/0 None The result shows a dramatic increase of the OHb
42
2019 negative pressure at 0.045 MPa for surrounding tissue and RHb concentrations at the treatment site
5 min while the OHb and RHb levels were decreased at
the surrounding tissue
Meng XW Vacuum cupping with a constant GV14 Left BL13 10/10 None TcpO2: MD -0.80 (3.47, 1.87) kPa
201243 negative pressure at 0.075 MPa Adjacent non- TcpO2: MD -0.80 (2.95, 1.35) kPa
acupoint
Zhao YJ Moving cupping with different Governor vessel GV4 5/5 Sub-healthy TcpO2: MD 0.77 mmHg; tcpCO2: MD
201544 parameters (negative pressure 0.01 -2.77 mmHg
e0.02 MPa, 0.02e0.03 MPa, with
moving cup for 5 min or 3 min)
Exchange of substance
M. Vacuum cupping for 15 min Above the side with the Venous blood 4/8 Neck pain Cupping significantly and long-lasting increased
Emerich predominant pain, or lactate level in the subcutaneous tissue. The
45
2014 above the trapezius increasing lactate/pyruvate ratio also proved
muscle that the lactate resulted from hypoxia, indicating
an anaerobe metabolism in the surrounding
tissue.
Pain reduction
Huang J Moving cupping and retained Moving cupping on Venous blood 13/12 Non-specific b-EP: MD 125.7 (79.8, 171.60) ng/mL
201246 cupping for 15e20 min bilateral bladder low back pain
meridians and retained
cupping on bilateral
BL23

Notes: M: male; F: female; CI: confidence interval; OR: odds ratio; RR: risk ratio; MD: mean difference; T: treatment group; C: control group; PONV: postoperative nausea and
vomiting; VAS: visual analogue scale; PSV: peak systolic velocity; EDV: end-diastolic velocity; RI: resistance index; BRBP: bias ratio of blood perfusion; C3b R: Complement 3b
receptor rosette; NKc: natural killer lymphocyte cell; HLA-DR: human leukocyte antigen DR; EOS: eosinophilic granulocyte; IgE: immunoglobulin E; IgA: immunoglobulin A;
C3: complement 3; IL-2: interleukin-2; IgG: immunoglobulin G; SIL-2R: soluble interleukin-2 receptor; IgM: immunoglobulin M; C4: Complement 4; RHb: reduced hemo-
globin; OHb: oxyhemoglobin; TcpO2: transcutaneous arterial oxygen tension; tcpCO2: transcutaneous arterial carbon dioxide tension; b-EP: b-endorphin.
a
The CI was not clear because of insufficient raw data.
b
The trial was conducted twice, 27 participants for the first time and 30 participants for the second.

349
J. Tao, P. Zhao, T. Mo et al.
showed that cupping therapy can significantly increase skin surface
temperature (SST) at the cupping site and even at other acupoints.
In another trial,29 SST fell and then rose during cupping, whereas
the SST of the control area fell more obviously (43 lower back pain
patients). Therefore, all the seven trials mentioned above indicated
that cupping therapy can cause a regional increase in SST.
Immunomodulation
One trial30 proved that cupping therapy could improve the
immune function of red blood cells by increasing the number of
C3b receptors (27 participants; MD ¼ 5.83  109/L; 95% CI, 4.29 to
7.37; P < .001 and 30 participants; MD ¼ 4.15  109/L; 95% CI, 2.45
to 5.84; P < .001; the trial was conducted twice) and immune
complexes (27 participants; MD ¼ 2.51  109/L; 95% CI, 1.47 to 3.56;
P < .001 and 30 participants; MD ¼ 1.96  109/L; 95% CI, 0.85 to
3.07; P < .001; the trial was conducted twice). In two trials31,32 that
included a total of 55 healthy females, the results showed a sig-
nificant decrease in the number of natural killer lymphocyte cells
(23 participants; MD ¼ 3.30%; 95% CI, 5.56 to 1.04; P ¼ .03),
which has been linked with reproductive problems in women. The
results of one trial33 showed that levels of immune-related proteins
(e.g. Ig lambda-2 chain C regions and Ig gamma-1 chain C region)
increased more among participants who had cupping blisters than
among those in the burning group. A three-arm trial11 indicated
that cupping therapy may decrease the number of CD8þ cells in
venous blood (retained cupping; diameter, 3 cm: 30 participants;
MD ¼ 5.52; 95% CI, 9.27 to 1.77; P ¼ .0055, diameter, 4 cm: 30
participants; MD ¼ 6.02; 95% CI, 9.81 to 2.23; P ¼ .0029, and
diameter, 5 cm: 30 participants; MD ¼ 5.68; 95% CI, 9.52
to 1.84; P ¼ .0053). The results of another trial34 indicated a sig-
nificant decrease in the eosinophilic granulocytes (25 participants;
MD ¼ 0.14  109/L; 95% CI, 0.21 to 0.08; P ¼ .0001) and
immunoglobulin (Ig) E levels (25 participants; MD ¼ 488.62 U/
ml; 95% CI, 694.97 to 282.27; P < .001) of participants after
cupping therapy compared with those of 50 atopic dermatitis pa-
tients treated with oral cetirizine tablets.
The report of another trial35 indicated a significant increase in
IgA (40 participants; MD ¼ 0.38 g/L; 95% CI, 0.10 to 0.66; P ¼ .0091),
C3 (40 participants; MD ¼ 0.07 g/L; 95% CI, 0.01 to 0.13; P ¼ .0163),
and IL-2 levels (40 participants; MD ¼ 0.47 U/ml; 95% CI, 0.15 to
0.79; P ¼ .0046). Another trial36 reported a significant increase in
IgG (50 participants; MD ¼ 3.98 g/L; 95% CI, 3.21 to 4.75; P＜.001)
and IgA (50 participants; MD ¼ 0.60 g/L; 95% CI, 0.47 to 0.73; P
＜.001) levels, and a drop in interleukin-2 receptor (SIL-2R) levels
(50 participants; MD ¼ 111.14 U/ml; 95% CI, 194.29 to 27.99;
P ¼ .0102). Similar upward trends in the levels of IgG and IgM were
also reported in another study.37 Dr. Ye reported that cupping
therapy may affect the immune system bidirectionally.38 However,
the results of one trial showed that there was no significant dif-
ference in IgG, IgM, and IgA levels after cupping treatment.20
Metabolic regulation
Oxygen in blood and tissue. Reduced hemoglobin (RHb) and
oxyhemoglobin (OHb) changes at the cupping site were reported in
four trials. The results of two of the trials39,40 showed that RHb
significantly decreased (MD ¼ 19.43 mmol/L; 95% CI, 23.26
to 15.6; P < .001), whereas OHb increased (MD ¼ 7.73 mmol/L; 95%
CI, 5.17 to 10.29; P < .001) around the cupping site. Around the
cupping area, there was an obvious drop in OHb (MD ¼ 4.19 mmol/
L; 95% CI, 5.75 to 2.63; P < .001) and a dramatic elevation in RHb
(MD ¼ 7.69 mmol/L; 95% CI, 5.80 to 9.58; P < .001). The results of the
other two trials41,42 indicated that both OHb and RHb significantly
increased from the baseline levels at the treatment site in 31
healthy participants. There were no significant changes in the levels
of OHb and RHb at the peripheral area of the treatment site.
350
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
Two case series investigated the partial pressure of oxygen
(tcpO2) and the partial pressure of carbon-dioxide (tcpCO2) on the
skin surface. However, the results of both reports were in contrast.
One43 reported a significant decrease in tcpO2 after cupping
treatment (in 20 healthy participants), whereas the other44 re-
ported that after moving cupping in 10 sub-healthy adults, tcpO2
increased at first and then decreased over time; at the same time,
tcpCO2 levels decreased.
Changes in metabolites and protein levels. In the trial by Emerich
et al45 that included 12 participants investigated the effects of
cupping on subcutaneous metabolic parameters. The results
showed that cupping significantly and persistently increased the
level of lactic acid in the subcutaneous tissue. The increase in the
lactic acid/pyruvate ratio also proved that the increased lactic acid
level was caused by hypoxia, indicating anaerobic metabolism in
the surrounding tissues.
Besides, another trial33 demonstrated that compared with the
scalded group (35 patients), the cupping group had significantly
increased levels of metabolism-related proteins (hemoglobin sub-
unit beta, succinyl-CoA ligase) and antioxidant stress-related pro-
teins (hemopexin, prdx2). However, changes in the superficial
blister fluid are only circumstantial evidence of the effectiveness of
cupping therapy.
Pain reduction
The results of a case series46 that included 25 patients who had
non-specific low back pain showed that the b-endorphin (b-EP)
levels of the participants were increased (MD ¼ 125.7 ng/mL; 95%
CI, 79.8 to 171.60; P < .001), indicating that moving cupping therapy
can increase the concentration of b-EP in plasma, thereby produc-
ing the effect of pain relief.
The results of one trial33 suggested that local pain-sensing
substances may be eliminated by blistering cupping therapy. In
that trial, levels of pain-related proteins (calmodulin) in blisters
were elevated through cupping treatment.
Discussion
In this review, we aimed to identify the possible mechanisms
behind cupping therapy and explore its possible regional and sys-
temic effects. This review included 38 studies; however, because of
the obvious clinical heterogeneity among the studies, we did not
conduct a meta-analysis.
We divided the included studies into two categories; some trials
explored the elements that may contribute to the efficacy of
cupping, whereas others showed what physical changes would
occur after treatment. According to the results of the studies in the
first category, negative pressure during cupping treatment may
play a more critical role than temperature in the curative effect of
cupping therapy. However, it must be noted for negative pressure,
the concept of “the higher, the better” is not true. Some researchers
believe that an appropriate amount of negative pressure could
induce hyperemia or stasis on local skin.47 If the negative pressure
is higher than 0.05 MPa, it would cause harm to local tissue,14
manifesting mainly as obstruction of venous reflux. This causes
stasis of microcirculation in the blood stream, conversely leading to
lower blood flow volume and velocity.16 The studies in second
category showed that changes in hemodynamics and metabolism
were obvious after cupping therapy. Several trials suggested that
cupping therapy could significantly increase regional blood flow.
Regarding blood oxygen, we believe that the disparity in the reports
of regional OHb and RHb changes is caused by the different cupping
sites utilized in the studies and the different practitioners and in-
dividuals involved in the studies. One opinion on the effect of
J. Tao, P. Zhao, T. Mo et al. Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354

Fig. 1. Flow diagram of the review.

Fig. 2. Line chart of the number of articles published over time.

cupping therapy on blood oxygen is that cupping can induce a state
of high supply and low consumption of oxygen.41 However, another
opinion indicates that cupping may enhance oxygen uptake39 and
cause increased consumption of oxygen and accelerated energy
metabolism.43 Both opinions imply that cupping could affect
metabolism by recruiting blood volume and redistributing oxygen
level at the cupping site and in neighboring tissues. According to
the findings of some trials, the levels of markers related to meta-
bolism, immunomodulation, and pain regulation also changed after
cupping therapy; however, the variation of the study characteristics
and outcomes prevented us from reaching a clear conclusion in that
regard.
Discussions on cupping mechanisms have gradually increased in
recent years and several theories have been proposed. One of these
theories4 suggests that negative pressure on the skin is the trigger
for increased blood flow, capillary rupture, and eventually ecchy-
mosis (known as cupping spot in cupping treatment). Ecchymosis
attracts macrophages to phagocytize the red blood cells,

351
J. Tao, P. Zhao, T. Mo et al.
Fig. 3. Summary of the risks of bias in the included randomized controlled trials and non-randomized controlled trials.
Fig. 4. Quality assessment for the included case series.
stimulating them to produce heme oxygenase-1 (HO-1), which can
break down heme into biliverdin/bilirubin, CO, and iron. The whole
HO-1 system directly and indirectly has significant antioxidant,
anti-inflammatory, antiproliferative, and neuroregulatory activ-
ities. Another theory suggests that cupping has a similar mecha-
nism with acupuncture because both procedures involve body
surface stimulation.3 During cupping therapy, changes in the
microenvironment caused by external stimulation lead to activa-
tion of immunomodulation. The signal is then transmitted to the
central nervous system, thereby initiating the neuroendocrine-
immunomodulatory network and generating an overall regulato-
ry function. Some other theories47 like the “Pain-Gate Theory,”
“Diffuse Noxious Inhibitory Controls,” and “Blood detoxification
theory” have also been proposed.
Despite the diversity of these theories, it seems to be generally
believed that negative pressure and the resulting capillary rupture
lead to a series of subsequent reactions that produce a therapeutic
352
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
effect4,49; a finding which is partly consistent with our conclusions.
Some researchers9,11 concluded that negative pressure plays the
key role in cupping therapy whereas some did not.10
Another aspect of these studies is the determination of the
pathways through which cupping therapy produces its effect;
immunomodulation3,50 and neuromodulation3,48 are the two most
commonly mentioned pathways. Some relevant clinical trials were
included in our review;30‒38,46 however, the data in these studies
were not sufficient to prove these theories.
The entire pathway of action in proposed theories,3,4,48 such as
the HO-1 theory,4 are mapped at the molecular and signal trans-
mission levels, showing a dynamic process from the beginning of
treatment to its effects. In contrast, our research was based on the
evidence provided by clinical trials, which focus more on systemic
changes, such as hemodynamic and metabolic changes, caused by
cupping treatment at a certain moment or for a certain period of
time. Therefore, this review is a static analysis of result data and
J. Tao, P. Zhao, T. Mo et al.
cannot depict the complete outline of the mechanism of action.
Many of the theories are based on logical derivations of a
combination of empirical cognition and laboratory research. They
are logically self-consistent, but whether these processes occur and
produce an effect still needs to be verified. Our research aimed to
reveal the mechanism of cupping therapy through assessment of
clinical data, which can also partially support these theories.
This review systematically summarized the evidence in existing
clinical research to identify the possible mechanism behind
cupping therapy. To the best of our knowledge, this is the first re-
view of its kind. The results of this review provide an objective and
critical evaluation of the evidence in existing studies.
However, although our search strategy was thorough, we only
included articles published in English and Chinese. Information in
relevant research reports published in other languages may be
missing because of language barriers. Out of the 38 included
studies, only 10 were RCTs. The lack of high-quality studies reduces
the strength of the evidence collated in this review.
As previously mentioned, although negative pressure is gener-
ally believed to be the key element that determines the efficacy of
cupping therapy, the available evidence on this is not sufficient.
More RCTs need to be carried out to validate this theory; comparing
different degrees of negative pressure could be a good research
direction. Although the temperature of the cups used in cupping
therapy do not exactly seem to be the key elements that produce a
therapeutic effect, the role of temperature in cupping therapy
needs to be further confirmed with high-quality evidence.
It is difficult to paint a complete picture of the mechanism
behind cupping therapy based on clinical trial data alone. This is
because the outcomes of the trials are usually static presentations
of data at a certain time, thereby making it difficult to demonstrate
dynamic processes. However, understanding the regional and sys-
tematic mechanisms behind cupping therapy and summarizing the
existing clinical evidence provides a solid basis for future research.
Adding more test indices in future clinical trials may complete the
reactive chain of the cupping theory. Moreover, studies that involve
the evaluation of the therapeutic effect on different populations are
also needed to screen out the advantaged groups, who react well
for this therapy.
Conclusion
In this review, we identified that compared to temperature,
negative pressure plays a more important role in cupping treat-
ment. In the human body, vacuum and heat induce a redistribution
of oxygen at the cupping site and in neighboring tissues, thus
producing a therapeutic effect through increased regional blood
flow velocity and volume. Physical signals may induce microenvi-
ronmental metabolic changes, immunomodulation, and neuro-
modulation. However, further rigorous clinical research needs to be
conducted to further clarify the understanding of cupping therapy.
Funding
This review is supported by the National Natural Science
Foundation of China (81804000) and the National Natural Science
Foundation of China: Major Program (81830115).
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
353
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
CRediT authorship contribution statement
Jiayin Tao: Data curation, formal analysis, project administra-
tion, visualization, and writing e original draft. Huijuan Cao:
Conceptualization, methodology, supervision, and writing e review
& editing. Pei Zhao: Formal analysis, methodology, and writing e
original draft. Tingting Mo: Resources, software, data curation, and
validation. Ruiming Zhao: Resources, software, data curation, and
validation. Nan Yang: Resources, software, and data curation.
Myeong Soo Lee: Writing e review & editing. Jianping Liu:
Funding acquisition and writing e review & editing.
References
1. Al-Bedah AM, Aboushanab TS, Alqaed MS, et al. Classification of cupping
therapy: a tool for modernization and standardization. J Alternative Compl Med.
2016;1(1):1e10.
2. Cao HJ, Li X, Liu JP. An updated review of the efficacy of cupping therapy. PloS
One. 2017;7(2), 31793.
3. Guo Y, Chen B, Wang DQ, et al. Cupping regulates local immunomodulation to
activate neural endocrine-immune worknet. Compl Ther Clin Pract. 2017;28:
1e3.
4. Lowe DT. Cupping therapy: an analysis of the effects of suction on skin and the
possible influence on human health. Compl Ther Clin Pract. 2017;29:162e168.
5. Lee MS, Kim JI, Ernst E. Is Cupping an effective treatment? An overview of
systematic reviews. J Acupunct Meridian Stud. 2011;4(1):1e4.
6. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for
assessing the quality if nonrandomized studies in meta-analysis. http://www.
ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed August 1, 2020.
Accessed:.
7. Cochrane. In: Higgins JPT, Thomas J, Chandler J, et al., eds. Cochrane Handbook
for Systematic Reviews of Interventions; 2020. version 5.0.2. http://www.
training.cochrane.org/handbook. Accessed August 1, 2020. Accessed:.
8. Yu H, Yang H, Liu JP. Methods for case and empiric reports– Design and quality
assessment of case series. J Tradit Chin Med. 2008;49(5):407e410 [Chinese].
9. Farhadi K, Choubsaz M, Setayeshi K, et al. The effectiveness of dry-cupping in
preventing post-operative nausea and vomiting by P6 acupoint stimulation: a
randomized controlled trial. Medicine (Baltim). 2016;95(38), e4770.
10. Lauche R, Spitzer J, Schwahn B, et al. Efficacy of cupping therapy in patients
with the fibromyalgia syndrome-a randomized placebo-controlled trial. Sci
Rep. 2016;6, 37316.
11. Li C. Effect of different cupping negative pressure on urticaria and its influence
on T lymphocytes and subgroups. Chin J Mod Drug Appl. 2018;12(9):76e77
[Chinese].
12. Huang T, Zhang WB, Huang X, et al. Comparing the efficacy of traditional fire-
cupping and high-tech vacuum-cupping using laser Doppler imaging at an
acupuncture clinic in Beijing. Med Acupunct. 2011;23(1):13e18.
13. Hu YP, Wang JP. Clinical effect of cupping therapy by glass jar and vacuum-
pumping jar in treatment of arthralgia syndrome. Nurs Integr Tradit Chin
West Med. 2018;4(9):65e66 [Chinese].
14. Tian YY, Qin LN, Zhang WB. Effect of different cupping pressure on skin blood
flow. Acupunct Res. 2007;32(3):184e185 [Chinese].
15. Tian YY, Wang GJ, Huang T, Jia SY, Zhang YQ, Zhang WB. Impacts on skin blood
flow under moving cupping along meridians in different directions. Chin
Acupunct Moxibustion. 2013;33(3):247e251 [Chinese].
16. Zhao YJ, Liu PD, Chen ZL, Liu YY, Zhou D, Guo Y. Preliminary observation on
local skin blood flow of back with sub-healthy human for different parameters
cupping on Du meridian. J Tianjin Univ Tradit Chin Med. 2015;34(1):18e22
[Chinese].
17. Liu W, Piao SA, Meng XW, Wei LH. Effects of cupping on blood flow under skin
of back in healthy human. World J Acupuncture-Moxibustion. 2013;23(3):
50e52.
18. Jin L, Liu YY, Meng XW, Li GL, Guo Y. A primary study of blood flow under the
effect of cupping on back. J Clin Acupunct Moxibustion. 2010;26(11):4e5
[Chinese].
19. Li CQ, Meng XW, Guo Y. Effect of cupping at Dazhui (GV14) on blood flow in the
back. Int J Tradit Chin Med. 2012;34(1):74e75 [Chinese].
20. Tang X, Xiao XH, Zhang GQ. Effect of cupping on hemodynamic levels in the
regional sucked tissues in patients with lumbago. Acupunct Res. 2012;37(5):
390e393 [Chinese].
21. Zhao YJ, Chen ZL, Diao DJ, Xing JB, Liu D, Guo Y. Study of the clinical effect of
movable cupping on sub-health body. Shanghai J Acupunct Moxibustion.
2015;34(3):223e224 [Chinese].
22. Zhao PN, Wang YP, Gu FF, et al. Comparison of the effects of the intervention
with electric thermal bian stone and air suction cup on blood perfusion at
meridian points. Chin Acupunct Moxibustion. 2018;38(2):159e163 [Chinese].
23. Xin Y, Wang SP, Fang XF, Wang XZ. Experimental observation on analgesia and
skin temperature before and after single treatment of auto-barometric
cupping. Chin J Rehabil. 1994;9(2):82 [Chinese].
24. Li CQ, Meng XW, Guo Y, Chai CX. Scarf skin in temperature changes of urinary
J. Tao, P. Zhao, T. Mo et al.
bladder meridian before and after cupping Dazhui (GV14) for healthy adults.
J Clin Acupunct Moxibustion. 2011;27(5):18e20 [Chinese].
25. Li CQ, Meng XW, Guo Y, Chai CX. Research on the scarfskin temperature
changes before and after cupping the Dazhui (GV14) on the governor meridian
of the health. In: Proceedings from the Ninth National Symposium on Acupunc-
ture and Massage for Young and Middle-Aged People of Chinese Association of
Acupuncture and Moxibustion. November 18, 2010. Shanghai, China [Chinese].
26. Zhang L. Observation on the change of skin temperature after cupping at Pishu.
Beijing, China. In: Proceedings of the Annual Meeting of Chinese Association of
Acupuncture and Moxibustion. August 19, 2011 [Chinese].
27. Chi LM, Lin LM, Chen CL, Wang SF, Lai HL, Peng TC. The effectiveness of cupping
therapy on relieving chronic neck and shoulder pain: a randomized controlled
trial. Evid Based Complement Alternat Med. 2016;2016:7358918.
28. Tang YH. The Research of Cupping Effect in Phlegm Constitution Subhealth Crowd
and the Influence of Infrared Image [master’s Thesis]. Chengdu, China: Chengdu
University of TCM; 2014 [Chinese].
29. Xu PC, Cui SL, Wee DAC, Xu S, Leang LT. Preliminary observation on effect of
cupping on the skin surface temperature of patients with back pain. World J
Acupuncture-Moxibustion. 2014;24(4):59e61.
30. Zhong L, Li L, Li J, Liao YL, Huang S. Effect of moving cupping on immune
function of erythrocyte. Chin Acupunct Moxibustion. 1999;(6):48e49 [Chinese].
31. Dons’koi BV, Chernyshov VP, Osypchuk DV, Baksheev SM. Repeated cupping
manipulation temporary decreases natural killer lymphocyte frequency, ac-
tivity and cytotoxicity. J Integ Med. 2016;14(3):197e202.
32. Dons’koi BV, Chernyshov VP, Osypchuk DV, Baksheev SM. Effectiveness of
reduction natural killer lymphocyte cytotoxicity by repeated cupping manip-
ulation depends on NK phenotype. In: American-Sino Joint Meeting of Repro-
ductive Immunology (ASRI-CSI 2018). Shanghai, China: The American Society for
Reproductive Immunology. 2018. Abstract 57.
33. Liu ZD, Chen CL, Li XY, et al. Is cupping blister harmful? e a proteomical
analysis of blister fluid induced by cupping therapy and scald. Compl Ther Med.
2018;36:25e29.
34. Gong L. Clinical observation of 25 cases of atopic dermatitis treated with
cupping therapy. Med Forum. 2016;20(8):1094e1095 [Chinese].
35. Wang D. Clinical Observation Of the Effect Of Cupping Therapy On Immune
Function Of Patients With Body Deficiency And Easy Feeling In Ceramic Moxi-
bustion Pot [master’s Thesis]. Shijiazhuang, China: Hebei Medical University;
2018 [Chinese].
36. Chen C, Xue WH, Li M, et al. Clinical observation of cupping in back specific
acupoints on children cough after infection and its effects on the immune
function, 1871 Hebei J Tradit Chin Med. 2017;39(12):1862e1866 [Chinese].
354
Journal of Traditional Chinese Medical Sciences 7 (2020) 345e354
37. Luo YH. Balanced cupping for 40 patients with ulcerative colitis. Jiangxi J Tradit
Chin Med. 2009;40(314):63e64 [Chinese].
38. Ye LH. Effects of health cupping on human immune function. Mod Rehabil J.
1998;2(10):1109 [Chinese].
39. Li T, Li YX, Li L, Li K. Significant and sustaining elevation of blood oxygen
induced by Chinese cupping therapy as assessed by near-infrared spectros-
copy. Biomed Optic Express. 2016;8(1):223e229.
40. Gao CY, Wang M, He L, He YN, Li T. Alternations of hemodynamic parameters
during Chinese cupping therapy assessed by an embedded near-infrared
spectroscopy monitor. Biomed Optic Express. 2018;10(1):196e203.
41. Zhang L, Tang LT, Tong XL, Jia H, Zhang ZY, Jiu GX. Effect of cupping therapy on
local hemoglobin in human body. Chin Acuponct Moxibustion. 2001;21(10):
619e621 [Chinese].
42. Kim S, Kim E, Jung G, Lee S, Kim JG. The hemodynamic changes during cupping
therapy monitored by using an optical sensor embedded cup. J Biophot.
2019;12(5), e201800286.
43. Meng XW, Li CQ, Guo Y. Effect of cupping at Dazhui (GV14) on the partial
pressure of oxygen of left Feishu (BL13) and its adjacent non-acupoint in
healthy adults. Shanghai J Acupunct Moxibustion. 2012;31(4):274e276
[Chinese].
44. Zhao YJ, Chen ZL, Zhou D, Guo Y. Effect of sliding-cup along governor vessel on
tcpO2 and tapCO2 in Mìngme n (GV 4) point of sub-healthy humans: observa-
tion on different cupping pressure. World J Acupuncture-Moxibustion.
2015;25(3):11e16.
45. Emerich M, Braeunig M, Clement HW, Lüdtke R, Huber R. Mode of action of
cuppingdlocal metabolism and pain thresholds in neck pain patients and
healthy subjects. Compl Ther Med. 2014;22(1):148e158.
46. Huang J, Wu JX. Effect of moving cupping therapy on b-endorphin in the
nonspecific low back pain. J Cervicodynia Lumbodynia,. 2012;33(5):349e351
[Chinese].
47. Zhao XX, Tong BY, Wang XX, Sun GL. Effect of time and pressure factors on the
cupping mark color. Chin Acupunct Moxibustion. 2009;29(5):385e388
[Chinese].
48. Al-Bedah AMN, Elisubai IS, Qureshi NA, et al. The medical perspective of
cupping therapy: effects and mechanisms of action. J Tradit Complement Med.
2018;9(2):90e97.
49. Tham LM, Lee HP, Lu C. Cupping: from a biomechanical perspective. J Biomech.
2006;39(12):2183e2193.
50. Samadi M, Kave M, Mirghanizadeh SA. Study of cupping and its role on the
immune system. Religion Health. 2013;1(1):57e63.