Note: this article is the first of a two-part series on acupuncture and cupping. You can read Part 2 here: Acupuncture and Cupping – Part 2: Alternative Therapies and the Placebo Effect.
At this point, you have likely heard of acupuncture and cupping. Acupuncture was practiced in Asia at least as early as 100 BCE. Hippocrates practiced cupping in Greece as early as 400 BCE. If you haven’t received acupuncture yourself, you probably know someone who has. And you’ve likely seen Michael Phelps and other athletes with purple cupping welts all over their bodies.
These ancient therapies have become increasingly common in contemporary culture. As a result, they have drawn the attention of a variety of health and wellness practitioners. Some extol their benefits. Others dismiss them as pseudoscience. In this two-part series, I look at the critiques of acupuncture and cupping. And I examine what the research tells us and compare these practices to other accepted therapies for improving health, wellness and physical performance.
Extreme and Unproven Remedies?
I recently read an article by physiology researcher Nick Tiller titled “Why do so many athletes turn to extreme and unproven remedies?” Some of the highlighted remedies fit what I expected from the title. For example:
“In 2009, Robin van Persie, widely regarded as one of the best soccer strikers of his generation, tore ligaments in his ankle while playing for his native Netherlands in a friendly against Italy. To expedite his return from injury, Van Persie visited a physiotherapist who massaged horse placenta onto his injured ankle.”
But two therapies featured prominently which I did not expect: acupuncture and cupping. For those unfamiliar with these terms, acunpuncture is a component of traditional Chinese medicine (TCM) in which a practitioner inserts thin needles into a patient’s body, most often with the intent to relieve pain. Cupping is another form of alternative medicine in which glass cups apply suction to the patient’s skin. Cupping therapists claim that the practice can help treat pain, fever and gastrointestinal and cardiovascular issues.
According to the original article, “some specific, relatively widespread practices, such as chiropractic and acupuncture, come with documented cases of injury and death.” And cupping “has been widely discredited by the scientific community, with numerous reports showing no benefit beyond basic placebo effects that hinge on the recipient’s expectation of, and belief in, the intervention’s benefits. At the same time, there is evidence that cupping is potentially harmful, causing skin burns and possible infection, making it difficult to justify the practice.”
I was intrigued. As the article points out, acupuncture and cupping are relatively widespread practices. Are they really as unproven and dangerous as this article suggests?
To start, let’s look at the evidence for the claims about acupuncture and cupping made in the article. In support of the supposed link between acupuncture and patient deaths, the article links to this paper. But while the referenced paper notes that “reports of 86 deaths after acupuncture were found,” it also acknowledges that many of these cases are “incomplete and causality may therefore be occasionally uncertain.”
People die after all sorts of activities, but that doesn’t mean that those activities are especially likely to cause death.
First of all, saying that death occurred after a certain practice is far from saying that practice caused those deaths. The referenced paper admits as much with its disclaimer about uncertain causality. People die after all sorts of activities, but that doesn’t mean that those activities are especially likely to cause death.
Second, even if a practice can lead to death, that alone doesn’t necessarily provide a reason to avoid the practice. For example, athletes frequently exercise and have surgery to repair injuries. Yet research shows that people die as a result of exercise and routine surgery. One study found that six out of every 100,000 middle-aged men die during exertion each year. And the United Kingdom’s National Health Service notes that death occurs in one of every 100,000 patients given general anesthetics for routine surgery. But very few people are arguing against exercise or routine surgery.
The larger point here is that we need to balance the frequency of injury or death from a particular practice against the benefits conferred by that practice. These results also point to the importance of using caution and seeking out expert practitioners. Exercising in extreme heat, or while dehydrated, or with a serious heart condition is more likely to result in an adverse event than exercise done under safer conditions. And untrained acupuncturists or anesthesiologists or surgeons pose a greater threat to their patients than trained practitioners.
As for cupping, the original article links to two different papers. The first notes that “the effectiveness of cupping has been demonstrated only as a treatment for pain, and even for this indication doubts remain.” The second presents a case report of a patient who was burned during a cupping session.
A quick literature search returns dozens of research papers on cupping. Given this volume of research, it’s odd that Tiller would choose a paper which asserts that cupping has been demonstrated as a treatment for pain to support his assertion that the practice “has been widely discredited by the scientific community.” Presumably, many athletes who seek cupping therapy do so for pain relief. If cupping has this benefit, it could be a vital therapy for athletes.
As for the danger of skin burns, traditional cupping involves covering the targeted body part with small glass cups. The therapist creates a suction force on the body by heating the inside of the cup. Obviously, placing any hot object on or near the skin creates the possibility of skin burns. But it is easy to purchase a cupping set in which air is sucked out of the cups and no heat is necessary. So the concern about skin burns can be easily side-stepped.
Setting those concerns aside, we now turn to the bigger question raised by the original article. Specifically, do these alternative therapies have the benefits they claim?
A 2002 review of acupuncture found that:
“Numerous randomized, controlled trials and more than 25 systematic reviews and meta-analyses have evaluated the clinical efficacy of acupuncture. Evidence from these trials indicates that acupuncture is effective for emesis developing after surgery or chemotherapy in adults and for nausea associated with pregnancy. Good evidence exists that acupuncture is also effective for relieving dental pain. For such conditions as chronic pain, back pain, and headache, the data are equivocal or contradictory. Properly performed acupuncture seems to be a safe procedure.”
Another review focused on studies using acupuncture to treat headaches. It concluded that “the majority of the 14 trials comparing true and sham acupuncture showed at least a trend in favor of true acupuncture.” In studies like these, true acupuncture refers to inserting acupuncture needles into specific points on the body which the practitioner believes will achieve the desired effects. Sham acupuncture refers to inserting needles into points near the points targeted by true acupuncture.
Since many people believe that acupuncture will fix thany benefits observed when comparing acupuncture to no therapy may beno therapy are the result of a placebo effect. For this reason, sham acupuncture offers a truer placebo than no acupuncture. A person receiving sham acupuncture believes they are receiving true acupuncture. This belief allows researchers to assess the effects of true acupuncture independent of the subjects’ beliefs.
Since many people believe that acupuncture will fix their ailments, it is possible that any benefits are the result of a placebo effect.
And comparing true acupuncture to sham acupuncture does produce conflicting conclusions. A 2010 meta-analysis of several randomized controlled trials observed that “trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects.” In other words, the difference in benefits between true acupuncture and sham acupuncture tends to be smaller than the difference between sham acupuncture and no treatment. Based on this meta-analysis, many of the benefits of acupuncture might be due to patients’ beliefs about the benefits rather than the specific placement of the acupuncture needles.
Turning to individual studies, knee osteoarthritis patients who received true acupuncture experienced significantly greater improvement in knee functionality compared to those who received sham acupuncture. Both sham acupuncture and true acupuncture reduced lower back pain and migraine headache pain compared to no therapy. However, there were no significant differences between the true and sham groups in the latter two studies.
As for cupping, a 2011 review found that cupping therapy significantly reduced low back pain and cancer pain in comparison to painkillers and other common treatments. Cupping also reduced pain from brachialgia (arm pain, usually caused by a trapped nerve). However, it did not show a significant difference between cupping and antiviral medication in treating pain from herpes zoster (shingles).
A 2012 meta-analysis found that cupping combined with TCM treatments helped cure more patients with herpes zoster, facial paralysis and cervical spondylosis compared to TCM treatments alone.
Other studies show that cupping reduces the severity of symptoms of carpal tunnel syndrome, improves pain and range of motion in athletes, and ameliorates low back pain compared to controls. However, the authors of the latter two reviews noted many of the studies involved had a high risk of bias.
Acupuncture and cupping critics point to the lack of suitable control groups in relevant research, the risk of bias in researchers performing these experiments, and the conflicting results of multiple studies. And all of these critiques have some merit.
Many studies of acupuncture fail to untangle the benefits of true acupuncture compared to sham acupuncture. Most cupping studies use a no-treatment group or alternative treatment group as a control rather than a sham cupping group. I suspect the lack of sham cupping groups is due to the imprecise nature of cupping compared to acupuncture.
True acupuncture requires practitioners to insert needles in specific points on a patient’s body. But the cups used in cupping therapy are over an inch in diameter. And the therapist often moves the cups across a patient’s skin during treatment. A sham acupuncturist attempting to treat a patient’s lower back pain could insert a needle an inch away from the point dictated by true acupuncture, and most patients would never know the difference. But this sham approach isn’t always possible with cupping therapy. A person seeking lower back treatment would likely notice if the therapist placed no cups on the site of pain during the treatment.
Sticking needles into a patient’s body often alleviates the patient’s symptoms. But it is not always clear whether those benefits are due to the needles or to the patient’s beleif about what the needles are doing.
Research on acupuncture shows that sticking needles into a patient’s body often alleviates the patient’s symptoms. But it is not always clear whether those benefits are due to the needles or to the patient’s belief about what the needles are doing. And cupping research generally lacks a similar sham control that could tease out potential placebo effects of the therapy.
Not surprisingly, research on both therapies is also subject to bias. Acupuncture and cupping practitioners are usually the people most concerned with seeing published scientific papers on these therapies. They have a vested interest in seeing their work proven beneficial. And even if their experiments are well-designed and the findings accurately represent the data, it is impossible to eradicate unconscious bias on the part of the practitioner providing therapy to the subjects.
Receiving true acupuncture instead of no treatment likely makes patients feel that they are in the capable hands of someone concerned about their well-being. This belief could contribute to a placebo effect. And acupuncturists providing true acupuncture may behave in a more hopeful, encouraging manner than those providing sham treatments. In this way, the bias of the practitioner-researcher may contribute to a placebo effect.
There is also the problem of conflicting findings that goes beyond the placebo effect. Tiller asserts that alternative therapies like acupuncture and cupping have been “widely discredited.” Yet other studies point to their benefits. There simply isn’t enough research conclusively demonstrating the benefits of these therapies to include them in the gold standard of healthcare and athletic performance.
So it seems there is some evidence to support the benefits of acupuncture and cupping. The original article’s claim that these therapies have been widely discredited appears to be overstated. That said, existing research on both practices is often conflicting and raises significant questions about proper controls and author bias.
In Part 2 of this feature, I will weigh concerns about controls and bias in acupuncture and cupping research. I’ll look at a parallel example of health research and see how similar studies address related concerns. And I’ll discuss what role, if any, acupuncture and cupping should have in healthcare and maximizing athletic performance.