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J Acupunct Res > Volume 37(1); 2020 > Article
Kim, Lee, Lee, An, Park, Choi, Lee, and Yang: Pressure Levels in Cupping Therapy: A Systemic Review

Abstract

This is a systematic review of the clinical use of cupping therapy. Four domestic databases and 2 foreign databases were searched. Studies that reported the cupping pressure used during cupping therapy were included in this study. The types of cupping, cupping site, pressure, and duration of cupping were the main parameters analyzed. A total of 27 studies, including 24 experimental studies were analyzed. There were 12 constant negative pressure (domestic) studies with a range between 60 mmHg and 600 mmHg. There were 5 maximum negative pressure (domestic) studies and the maximum negative pressure was 620 mmHg. Three studies used a maximum negative pressure of 600 mmHg. There were 4 constant negative pressure (foreign) studies with a range between 75 mmHg to 750 mmHg. There were 3 maximum negative pressure (foreign) studies with a maximum pressure of 420 mmHg. The studies differed with regards to the materials used and the amount of pressure applied. Many studies had limited information and therefore generalizability of the results in this review is limited. Further experimental studies are required to establish the correlation between cupping pressure and treatment effects so that cupping therapy can be standardised.

Introduction

Cupping therapy is a treatment to release toxins from the body by using special cups to generate suction and adsorption at the surface of the skin. Both Eastern and Western countries have used cupping therapy since ancient times, and in Korea, the practice of cupping is included in Donguibogam [1].
Cupping therapy is simple, safe, and very effective. Given the simplicity of cupping treatment it can be used in clinical practice and its wider clinical applications, and it is now used regularly in modern medicine [2].
Cupping therapy has been covered as a medical procedure by the National Health Insurance in Korea since 1987. It is used as a treatment for various diseases, and many studies have been conducted on the efficacy of cupping therapy [3]. However, research on the effectiveness of treatment according to cupping pressure is insufficient, so cupping therapy remains nonstandardised. As there are no clear criteria for pressure settings during cupping therapy, scientists are conducting research in a random manner and clinicians are using cupping in various ways in clinical practice. In this study, we aimed to review the body of evidence detailing the cupping pressure used, with a view to standardising the practice of cupping therapy.

Materials and Methods

Research method

Database search

The following domestic (Korean) academic databases were searched: Korean Information Service System (KISS), National Securities Depository Ltd. (NDSL), Regional Information Sharing Systems (RISS), and DBpia. The following foreign databases were also searched: National Center for Biotechnology Information (NCBI) PubMed, Excerpta Medica database (EMBASE).

Search words

The search words are shown in Fig. 1.

Search period and method

The search period for domestic studies was inclusive until June 30, 2019 and included both dissertations, and studies published in academic journals. The search period for foreign studies was inclusive until June 30, 2019 using the search criteria “humans, English”.
Fig. 2 shows the flow chart of study selection. One researcher conducted the search and produced the results, and another researcher reviewed them and agreed on the final studies for inclusion in this review. These studies were checked to ensure that they conformed to the study topic, and duplicate studies were excluded.

Search results

A total of 27 studies were selected out of 65 studies that were retrieved in accordance with the search criteria, with the exception of those studies that did not include the pressure used during cupping, and those studies that were duplicates.

Results

Characteristics of research studies

The characteristics of the included studies are summarized in Table 1 (domestic) and Table 2 (foreign).
In the domestic research studies, manual and plastic cupping devices were the most common types. The most common cupping site was the back. The number of studies that used silicon rubber plates increased after 2008. The thickness of silicon rubber sheets varied between 3 mm and 10 mm. Cupping pressure varied between 60 mmHg and 600 mmHg. The duration of cupping was between 1 minute and 20 minutes (Table 1).
In the foreign research studies, the most common types of cupping devices were motor-operated cups and glass cups. The most common cupping site was the lower back. The cupping pressure ranged from 60 mmHg to 750 mmHg (100 kPa). The cupping duration ranged between 6 minutes and 20 minutes (Table 2).
The biggest difference between the domestic and foreign studies was regarding the type of cupping device used.
The criteria to classify constant pressure or maximum pressure in the research articles included in this review, was according to the content of the article. If recorded measurements were up to the maximum pressure, it was classified as maximum pressure. Without any records of maximum pressure, if there were measurements taken at a specific pressure for specific time, it is classified as constant pressure (Tables 3-6).

Classification by year

Of the 27 total studies, 19 (70.4%) were domestic and 8 (29.6%) were foreign. Domestic studies that contained details of cupping pressure showed a frequency of 3 in 2008, 1 in 2009, 3 in 2010 and 2 in 2011 and the numbers of studies declined after 2013. Foreign studies showed an increase from 1 study before 2010, to 7 studies after 2010 (Fig. 3).

Categorisation by pressure

Domestic research - constant negative pressure

The constant negative pressure in the studies by Im and Moon [5], Park and Lee [7], Kweon et al [9], and Lee et al [10] was 60 mmHg. The constant negative pressure was 225 mmHg in the study by Kim et al [15], 240 mmHg in the study by Shin et al [6], and 400 mmHg in the study by Oh and Kim [8]. In comparison, the constant negative pressure in the studies by Shin [4], Ryu et al [11], Kim et al [16], Kim et al [18], and Kim et al [20] was 600 mmHg (Table 3).
In the 12 domestic studies, there were 5 studies that used 600 mmHg, 4 that used 60 mmHg, 1 that used 225 mmHg, 1 that used 240 mmHg, and 1 that used 400 mmHg. Reports that included the diameter and volume of the cups were insufficient.

Domestic research - maximum negative pressure

The maximum negative pressure in the studies by So et al [12] and Kim et al [20] was 300-400 mmHg for cup size 1. Size 1, 2, 3, 4 and 5 cups have the same diameter. The maximum negative pressure in the studies by Kim et al [13], Yi et al [14] and Yi et al [17] was 550-650 mmHg (Table 4).
In the 5 domestic studies, the maximum negative pressure was 550-650 mmHg in 3 studies, and 300-400 mmHg in 2 studies. Very few studies reported on the volume of the cups.

Foreign research - constant negative pressure

The constant negative pressure in the study by Blunt and Lee [22] was 75-150 mmHg, and 75 mmHg, 225 mmHg, and 375 mmHg in the study by Tham et al [21]. The constant negative pressure in the study by Teut et al [27] was 112.5-262.5 mmHg, and 750 mmHg in the study by Blunt and Lee [22] (Table 5).
There were 4 foreign studies using constant negative pressure. There were insufficient reports on the diameter and volume of cups in the foreign studies.

Foreign research - maximum negative pressure

The maximum negative pressure in the study by Huber et al [23] was 420 mmHg using the Alcohol Flame (AF) method. It was 236.3 mmHg in the study by Emerich et al [25] using the Healthy Volunteers (HV) method, and it was 60 mmHg in the study by Duh and Chiu [26] (Table 6).
Electronic cupping devices were used in 3 foreign studies. There were insufficient reports on the diameter of the cups in the literature.

Discussion

Cupping therapy was introduced to Korea, Japan and Southeast Asia a long time ago and it is still used today. Specially made glass cups, ceramic cups or bamboo cups are placed on the part of the human body being treated for disease [28]. Over time, various technologies to assist cupping have been developed. Recently, interest in cupping methods has resurfaced and a number of studies on cupping therapy have been undertaken [29,30]. Currently, the majority of Korean medicine doctors perform cupping for musculoskeletal problems and internal diseases. Despite this, there are no studies on post-treatment side effects such as blisters, with the exception of 1 study by Yun et al [31], and no standardised treatment procedure. In this study, a total of 27 studies related to cupping therapy were reviewed to establish the correlation between cupping pressure and treatment effects so that cupping therapy can be standardised.
It was observed that constant negative pressure used in domestic research varied widely, ranging from 60 mmHg to 600 mmHg. The diameter of the cups also varied widely, ranging between 25 mm and 50 mm, and the volume of cups was largely unreported. Therefore, further experimental studies are needed on the relative results using different diameters and volumes of cups with the same constant negative pressure.
In addition, the maximum negative pressure used in domestic research varied widely, ranging from 300–400 mmHg to 540–660 mmHg (using an electronic cupping device). Only 5 studies actually reported maximum negative pressure settings. Therefore, due to insufficient reporting, a conclusion could not be proposed.
Moreover, the reported constant negative pressure in 4 foreign studies also varied widely, ranging from 75 mmHg to 375 mmHg depending on the method of cupping used. The reported maximum constant negative pressure in the 4 foreign studies also ranged widely. Only 2 studies reported on the diameter of the cups, and this range was 40 mm to 50 mm. The number of studies was quite small and there was limited information about the volume of the cups, so conclusions could not be drawn.
Furthermore, the reported maximum negative pressure in the foreign studies varied widely (between 60 mmHg and 420 mmHg) although electronic cupping was used for all studies. Two studies reported the volume of the cup which was 168 cc. Unfortunately, the information provided on maximum negative pressure in the foreign studies was not sufficient to generalise the results.

Conclusion

In conclusion, although we investigated 27 studies, including domestic and foreign studies, there were large differences in the cupping devices used, the constant negative pressure, the maximum negative pressure, the cup size, and the cup volume. It was evident that there are no specific criteria for standardised cupping treatment, and we could not directly compare the results of these studies. Furthermore, many studies lacked detail on the methods used for cupping. Therefore, we could not make any conclusive recommendations about cupping therapy. In this context, further experimental studies are needed to establish standardised cupping therapy procedures.

Conflict of Interest

The authors have no conflicts of interest to declare.

Acknowledgements

This work was supported by the National Research Foundation of Korea grant funded by the Korea government (No:NRF-2019R1F1A1051568).

Fig. 1.
The search words used in domestic and foreign search engines.
jar-2019-00339f1.jpg
Fig. 2.
Flow chart of study selection.
jar-2019-00339f2.jpg
Fig. 3.
The published year of studies.
jar-2019-00339f3.jpg
Table 1.
Summary Characteristics of Included Studies (Domestic).
First author (y) Cupping device type Cupping position Cupping pressure (mmHg) Cupping duration (min)
Shin [4] (1979) Cupping device Shuxue points of 12 meridians Constant negative pressure: 600 1
Cups
Im [5] (1980) Electronic cupping device Back-shu point Constant negative pressure: 60 1
Glass cups
Shin [6] (1988) Cupping device Back Constant negative pressure: 240 1-3
Ceramic cups
Park [7] (1995) Electronic cupping device Back Constant negative pressure: 60 1
Cups
Oh [8] (1999) Cupping device Back, abdominal area Constant negative pressure: 400 5
Cups
Kweon [9] (2002) Cupping device Back Constant negative pressure: 60 5
Cups
Lee [10] (2002) Cupping device Chest, shoulder, upper extremity, hands Constant negative pressure: 100–200 20
Plastic cups
Ryu [11] (2006) BUDDEUMI Constant negative pressure: 600
Sho [12] (2008) Manual cupping device Silicone rubber pad Maximum negative pressure 5
Plastic cups Thickness: 10 ± 1 mm Size 1 (B: 397.28 / C: 362.36)
Area: 100 × 100 mm Size 2 (A: 342.51 / B: 444.23)
Size 3 (A: 365.56 / B: 466.50 / C: 423.10)
Size 4 (A: 391.34 / B: 481.49 / C: 450.87)
Size 5 (B: 510.28 / C: 464.83)
Kim [13] (2008) Manual cupping device Danjeon (lower part of the abdomen) area, shoulder area Maximum negative pressure: 580–620
Plastic cups
Yi [14] (2009) Electronic cupping device Silicone rubber pad Maximum negative pressure: 600 ± 10% 10
Cups Thickness: 3 ± 0.5 mm
Area: 100 × 100 mm
Kim [15] (2010) Negative pressure control device Midway between xiabai (LU4) and chize (LU5) of lung meridian (LU) Constant negative pressure: 30 kPa (225 mmHg) 5
Kim [16] (2010) Surface meridian/acupoint energy measurement system Back-shu point of bladder meridian (BL) Constant negative pressure: 80 kPa (600 mmHg) 5
Yi [17] (2010) Electronic cupping device Silicone rubber pad Maximum negative pressure 10
Cups Thickness: 3 mm Seo-ryong (600)
Area: 100 × 100 mm Noel (600)
Hansol (550)
G.O.P.O. (570)
Seoul Medical (540)
Kim [18] (2011) Measurement system for changes in meridians Back-shu point of bladder meridian (BL) Constant negative pressure: 80 kPa (600 mmHg) 1
Kim [19] (2013) Electronic cupping device Back-shu point of bladder meridian (BL) Constant negative pressure: 80 kPa (600 mmHg) 1
Cups
Kim [20] (2018) Manual cupping device Silicone rubber pad Maximum negative pressure 10
Cups Thickness: 3 mm Dongbang: Size 1 (323.2 ± 9.8)
Wet cupping Area: 100 × 100 mm DE Medical: Size 1 (318 ± 7.0)
Hansol: Size 1 (381.8 ± 13.4)
Daegun: Size 1 (322.4 ± 9.8)
Table 2.
Summary Characteristics of Included Studies (Foreign).
First author (y) Cupping device type Cupping position Cupping pressure (mmHg) Cupping duration (min)
Tham [21] (2006) Manual cupping device Soft tissue Constant negative pressure
Skin: 2 mm 100 mbar (75 mmHg)
Plastic cups Fat: 10 mm 300 mbar (225 mmHg)
Muscle: 10 mm 500 mbar (375 mmHg)
Blunt [22] (2010) Cupping device Neck Constant negative pressure: 100 kPa (750 mmHg)
Cups
Huber [23] (2011) Electronic cupping device Soft rubber pad Maximum negative pressure
LF1: 200 ± 30 hPa (150 ± 22.5 mmHg)
Glass cups LF2: 310 ± 30 hPa (232.5 ± 22.5 mmHg)
AF: 560 ± 30 hPa (420 ± 22.5 mmHg)
BA: 270 ± 16 hPa (202.5 ± 12 mmHg)
Teut [24] (2012) Electronic cupping device Lower back, knee Constant negative pressure: 100–200 mbar (75-150 mmHg) Lower back: 5
Silicone cups Knee: 10
Emerich [25] (2014) Electronic cupping device Lower back Maximum negative pressure 15
HV: 315 ± 64 hPa (236.3 ± 48 mmHg)
Glass cups NP: 283 ± 54 hPa (212.3 ± 40.5 mmHg)
WC: 299 ± 59 hPa (224.3 ± 44.3 mmHg)
Duh [26] (2015) Electronic cupping device Forearm, palm Maximum negative pressure: 60 mmHg 6
Vacuum chamber
Teut [27] (2018) Electronic cupping device Lower back Constant negative pressure: 150-350 mbar (112.5-262.5 mmHg) 8
Silicone cups
Table 3.
Constant Pressure Associated with Type, Diameter, and Volume of Cups (Domestic).
First author (y) Cupping device type Cup diameter (mm) Cup Volume (cc) Cupping pressure (mmHg)
Im [5] (1980) Electronic cupping device 50 Constant negative pressure: 60
Glass cups
Park [7] (1995) Electronic cupping device Constant negative pressure: 60
Cups
Kweon [9] (2002) Cupping device 45 73 Constant negative pressure: 60
Cups
Lee [10] (2002) Cupping device 25 Constant negative pressure: 60
Plastic cups
Kim [15] (2010) Negative pressure control device Constant negative pressure: 225
Shin [6] (1988) Cupping device Constant negative pressure: 240
Ceramic cups
Oh [8] (1999) Cupping device Constant negative pressure: 400
Cups
Shin [4] (1979) Cupping device 30 Constant negative pressure: 600
Cups
Ryu [11] (2006) Moxa cupping Constant negative pressure: 600
Kim [16] (2010) Surface meridian/acupoint energy measurement system Constant negative pressure: 600
Kim [18] (2011) Measurement system for changes in meridians Constant negative pressure: 600
Kim [19] (2013) Electronic cupping device Constant negative pressure: 600
Cups
Table 4.
Maximum Pressure Associated with Type, Diameter and Volume of Cups (Domestic).
First author (y) Cupping device type Cup diameter (mm) Cup volume (cc) Cupping pressure (mmHg)
Sho [12] (2008) Manual cupping device Size 1: external diameter 50, internal diameter 48.8, height 71.2 Maximum negative pressure
Size 2: external diameter 44.5, internal diameter 43.7, height 68 Size 1 (B: 397.28 / C: 362.36)
Size 3: external diameter 39.7, internal diameter 39.1, height 68 Size 2 (A: 342.51 / B: 444.23)
Plastic cups Size 4: external diameter 32.7, internal diameter 32.3, height 68 Size 3 (A: 365.56 / B: 466.50 / C: 423.10)
Size 5: external diameter 30.3, internal diameter 25.5, height 66 Size 4 (A: 391.34 / B: 481.49 / C: 450.87)
Size 5 (B: 510.28 / C: 464.83)
Kim [13] (2008) Manual cupping device A: internal diameter 44.7, height 50.8 A: 70.0 Maximum negative pressure: 580-620
B: internal diameter 35.7, height 47.9 B: 36.9
Plastic cups C: internal diameter 28.3, height 47.9 C: 26.1
D: 13.8
Yi [14] (2009) Electronic cupping device Maximum negative pressure: 600 ± 10%
Cups
Yi [17] (2010) Electronic cupping device Small: external diameter 35–37 Maximum negative pressure
Seo-ryong: 600
Middle: external diameter 42–44 Noel: 600
Cups Hansol: 550
Large: external diameter 52–54 G.O.P.O.: 570
Seoul Medical: 540
Kim [20] (2018) Manual cupping device Size 1: external diameter 50, internal diameter 48.8, height 71.2 Maximum negative pressure
Size 2: external diameter 44.5, internal diameter 43.7, height 68 Dongbang Size 1: 323.2 ± 9.8
Cups Size 3: external diameter 39.7, internal diameter 39.1, height 68 DE Medical Size 1: 318 ± 7.0
Wet cupping Size 4: external diameter 32.7, internal diameter 32.3, height 68 Hansol Size 1: 381.8 ± 13.4
Size 5: external diameter 30.3, internal diameter 25.5, height 66 Daegun Size 1: 322.4 ± 9.8
Table 5.
Constant Pressure Associated with Type, Diameter and Volume of Cups (Foreign).
First author (y) Cupping device type Cup diameter (mm) Cup volume (cc) Cupping pressure (mmHg)
Teut [24] (2012) Electronic cupping device Constant negative pressure: 75-150
Silicone cups
Tham [21] (2006) Manual cupping device 50 Constant negative pressure: 75, 225 and 375
Cups
Teut [27] (2018) Electronic cupping device Constant negative pressure: 112.5-262.5
Silicone cups
Blunt [22] (2010) Cupping device 40 Constant negative pressure: 750
Cups
Table 6.
Maximum Pressure Associated with Type, Diameter and Volume of Cups (Foreign).
First author (y) Cupping device type Cup diameter (mm) Cup volume (cc) Cupping pressure (mmHg)
Huber [23] (2011) Electronic cupping device 50 168 Maximum negative pressure:
LF1: 150 ± 22.5
Glass cups LF2: 232.5 ± 22.5
AF: 420 ± 22.5
BA: 202.5 ± 12
Emerich [25] (2014) Electronic cupping device 168 Maximum negative pressure:
HV: 236.3 ± 48
Glass cups NP: 212.3 ± 40.5
WC: 224.3 ± 44.3
Duh [26] (2015) Electronic cupping device Maximum negative pressure: 60
Vacuum chamber

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