https://orcid.org/0000-0003-2185-4059
Figures
Abstract
Background
The current quality of evidence supporting dry cupping for individuals with chronic low back pain (CLBP) is low and suggests that nonspecific factors impact experiences reported by patients. Therefore, this study assessed the impacts of social and professional support on the experience of individuals with CLBP treated with dry cupping or sham.
Method
This is an observational study with qualitative approach. Twenty-four individuals with CLBP who received dry cupping or sham in a previous clinical trial were invited. Data was collected using a semi-structured interview conducted by a trained researcher. Content analysis was used to analyze experiences, systematic procedures, and description of the content of messages. The dimensions of “pain”, “general perceptions”, and “perceived social and professional support” guided the analysis.
Results
Answers of both groups converged on similar perceptions, especially regarding pain. Physical condition was the most fragile aspect. We also observed an influence of perceived social and professional support on painful symptoms. Thus, the experience of individuals with CLBP treated with dry cupping or sham indicated that factors related to social and professional support impacted results.
Citation: Almeida Silva HJ, Avila MA, Castro KMS, Pinheiro YT, Lins CAA, Medeiros Barbosa G, et al. (2022) Exploring patient experiences of participating in a real and sham dry cupping intervention for nonspecific low back pain: A qualitative study. PLoS ONE 17(5): e0268656. https://doi.org/10.1371/journal.pone.0268656
Editor: Fatih Özden, Mugla Sitki Kocman Universitesi, TURKEY
Received: August 17, 2021; Accepted: May 4, 2022; Published: May 19, 2022
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001.
Competing interests: All authors declare that there is no conflict of interest related to this manuscript.
Introduction
Chronic low back pain (CLBP) is a public health problem in several countries associated with high levels of pain and disability [1–3]. This condition is highly prevalent in males and females and negatively impacts quality of life [4]. In this sense, a multi-professional approach (including physiotherapists) is recommended for individuals with this condition [5].
Among therapeutic possibilities, dry cupping has been used [6, 7] to reduce pain [8, 9], improve physical function [8, 10], and promote better quality of life of individuals with CLBP [11, 12].However, the current quality of evidence supporting the technique is low [10], and its effects may not be superior to sham [7, 13]. Therefore, improvements observed in individuals with CLBP after dry cupping may be due to nonspecific factors, such as therapeutic alliance. This notion is defined as the positive connection between therapist and patient, generated by a collaborative relationship based on professional support, empathy, and mutual respect [14], which may improve therapeutic intervention results and influence psychological and general health status, physical function, and perception of patients to the treatment [15–17].
Although specific interventions may not fully explain therapeutic results [18], the influence of nonspecific factors (including therapeutic alliance) on therapeutic results of individuals with CLBP must be assessed [19]. In this sense, comprehending all components responsible for clinical outcome alterations may help understand therapeutic changes, improve professional practice, and develop more effective approaches [20].
Therefore, this study aims to analyze the perceived experience of individuals with CLBP submitted to real dry cupping treatment or sham and its association with the dimensions of pain, physical condition, and perceived social and professional support.
Materials and methods
Design
This exploratory and descriptive study with a qualitative approach explored opinions and representations on the topic investigated. The content analysis proposed by Bardin [21] was used to analyze experiences, systematic procedures, and objectives for describing the content of messages. In this study, content analysis was structured in thematic categories, categorized, and grouped.
The Consolidated Criteria for Reporting Qualitative Research was used to ensure a complete and transparent reporting of this study [22]. All participants provided written informed consent, and the research ethics committee of the Federal University of Rio Grande do Norte, Faculty of Health Sciences of Trairi (FACISA/UFRN) approved the study (number:XXXXXXX).
Participants, recruitment, and sample size
Between February and July 2020, participants from an ongoing randomized controlled trial (RCT) study [23] (ClinicalTrials.gov–NTC03909672) who completed a 2-month intervention were consecutively invited to participate in this qualitative study. People were eligible for inclusion if presented low back pain for ≥ 3 months, pain intensity between 3 and 8 on a numerical pain rating scale, age between 18 and 59 years, and body mass index of < 35 kg/m2. Exclusion criteria were: individuals who had ever been treated with dry cupping or were undergoing physiotherapy; presence of any contraindication for dry cupping therapy; presence of neurological, vestibular, visual, or auditory deficits that could interfere with assessments; signs of fractures, inflammatory diseases, infection, or tumors in the spine; radiating lumbar or sacroiliac pain; rheumatic diseases (e.g., fibromyalgia or ankylosing spondylitis); travel plans in the next two months; and those unable to properly complete the assessment for any reason.
Sample size was calculated based on saturation of responses obtained with participants since new interviews would add few elements to the discussion. Nevertheless, sample size could be defined according to the experience of researchers and theoretical understanding of what is proposed in the study [24]. From 90 participants (45 per group) enrolled in the RCT, a maximum of 33.3% (n = 30) was estimated to compose the sample. However, 24 patients agreed to participate in the study.
Data collection
A semi-structured interview was performed between February and July 2020 (six months after the and off the intervention) to collect data regarding the experiences of individuals with CLBP submitted to dry cupping or sham. Data obtained were evaluated according to Bardin [17] and Minayo [20].
Pre-interview interventions
The intervention protocol was published in detail elsewhere [25]. Initially, participants were informed about objectives and procedures of the study, followed by the intervention (dry cupping or sham). An experienced physiotherapist applied interventions individually in a quiet university outpatient clinic, with the participant positioned prone and relaxed [25]. Dry cupping therapy was applied using two acrylic size 1 cups (4.5 cm internal diameter) with a distance of 3 cm between each cup, bilaterally, and parallel to L1–L5 vertebrae. The real dry cupping group performed two suctions for 10 min, once per week, for eight weeks. Sham group received the same protocol; however, cups were prepared to release the negative pressure in a few seconds [25]. During the study, interactions between therapists and patients occurred only during application of the technique (Fig 1).
Real Dry cupping sites during (A), after (B) intervention; Sham Dry cupping Sham during (C) and after (D) intervention. The black circles(C) demonstrate the sites with holes.
Post-intervention interview
Interviews were performed to obtain information regarding experiences and understand the perception of individuals regarding the technique (dry cupping or sham) six months after the protocol. All interviews were conducted by an experienced physiotherapist not involved with other study procedures. She was a graduate student and research volunteer at the time of the study.
Data were collected by telephone, and participants were also allowed to write impressions, photograph, and send to researchers using messaging applications. Technological resources captured responses in full and provided information to create a qualitative database. Pseudonyms were assigned to participants for confidential purposes, and all answers were stored in folders and individually analyzed. Participants were allowed to report perceptions, without time or character limitation, while responding to the following questions: 1) “Tell us a little about the experience with dry cupping treatment”; 2) “How do you perceive social and professional support during the treatment?”. The way of directing questions encouraged participants to freely express perceptions regarding the treatment in the dimensions of pain, general perceptions, and perceived social and professional support. These dimensions were defined based on reports and complaints of participants during the intervention and reflections consulted previously [26–28].
Data analysis
Reports were transcribed and reviewed according to consistency of established questions. In the end, another researcher (KMSC) described and categorized opinions into the following dimensions of treatment effects: pain, general perceptions, and perceived social and professional support. Subsequently, we identified dimensions corresponding to perceptions, highlighted in the text, and grouped using an analytical framework. As suggested by Minayo [20], statements were carefully interpreted, and investigated contexts were considered to decompose data and identify relationships between perceived experience and dimensions.
Results
Twenty-four individuals (16 female and 8 male, mean age of 23 ± 6.3 years) were included; eleven individuals completed high school. As shown in Table 1, twelve individuals composed each group.
Categorization, grouping, interpretation, and data presentation using a qualitative approach were valuable for this study since the perceived effects varied between participants. Thus, the design of treatment dimensions was related to descriptions during treatment (Box 1).
As shown in Boxes 2 and 3, results regarding treatment perception were analyzed following the order of data description, analysis, and interpretation. Participants from real dry cupping group were assigned with the acronym RG followed by a number, whereas perceptions of participants from sham group were identified using the acronym SG followed by a number.
Pain and general perceptions
Perceptions of participants from both groups were similar, especially regarding pain since it is a notorious context easily perceived through positive or negative impacts. In this sense, expressions were intentionally directed to the dimension of pain, while the dimension of general perceptions was ignored or intrinsic to pain. It is worth noting that the real dry cupping group (RG) indicated pain relief during the procedure, and the return of symptoms was less intense. Complaints regarding unsuccessful results were also reported, but to a lesser extent, in the face of expectations for treatment. Although other participants received a sham approach, the reported experience and benefits in the dimension of pain were satisfactory and recommendable to other people. As expected, some participants did not report any symptom change.
Therefore, general perceptions and perceived support indicated that physical condition was the weakest aspect in this study since dry cupping presented visible physical repercussions (i.e., purple marks) that could result in dissatisfaction. However, improvements inherent to general perceptions (i.e., flexibility, sleep quality, relaxation, and relief from daily exhaustion) also deserve attention.
Perceived support: Social and professional
Regarding the dimension of perceived social and professional support, the influence of support received by people involved in the personal or professional context on painful symptoms was substantial. The considerable involvement of participants of both groups with this dimension can also be highlighted, such as “family support as a determining factor for treatment continuation”, “friends support”, “social stratification regarding the technique used”, “horizontal therapist-patient relationship”, “reception, ethics, and clarifications”, and “listening, dialogue, and encouragement”. Participants considered these aspects as fundamental elements in the care process, with positive impacts on physical, well-being, and emotional and psychological condition.
Discussion
To our knowledge, this is the first qualitative study aiming to understand the influence of social and professional support on experiences of individuals with CLBP treated with dry cupping. All individuals reported positive and similar perceptions in all dimensions after treatment, regardless of the technique used (real or sham).
The perception of pain improvement reported by most individuals of both groups can be explained by the expectation created before treatment [29] and other nonspecific factors, such as therapist-patient relationship [30], regression to the mean [31], and placebo effect [32]. To date, only one quantitative study observed significant improvements in pain after dry cupping compared with sham [8]. However, the study presented several methodological limitations (e.g., flaws in the randomization process and small sample size) that led to a questionable conclusion. In this sense, we conducted a clinical trial with good methodological quality to reduce bias observed in previous studies [23], in which we observed that the application of real or sham dry cupping showed no difference in the clinical improvement of patients with CLBP.
A recent systematic review also suggested that dry cupping reduced pain in patients with CLBP [7]; however, only two studies with high heterogeneity and without a comparative sham group were included in the review. Conversely, a small number of individuals receiving dry cupping therapy reported negative experiences in our study, probably due to the expectation created before treatment. This negative interpretation may be present in patients with pain since it is an individual experience influenced by other external factors [27, 33].
Regarding physical condition, many participants reported no positive effects, which led us to believe that dry cupping did not favor this outcome. Nevertheless, it is worth noting that this aspect is strongly influenced by psychological, social, and physical factors [34, 35]. A quantitative study observed that physical condition improved significantly after dry cupping compared with sham; however, the study also presented methodological limitations, such as inadequate randomization and lack of sample size calculation, blinding, and intention to treat analysis [7]. These biases may overestimate effects and generate doubtful results.
Individuals with CLBP, regardless of the technique received, reported satisfactory experiences about the received social and professional support. This may explain the positive results observed in the dimensions of pain and general perceptions since individuals receiving social support may present better results [36, 37]. Reports regarding the presence of bruise or lack of previous experience with the technique corroborate with the study of Rossetini et al. [38], who stated that “new” or “innovative” therapies administered on the skin and with high marketing characteristics presented a great placebo effect. Therefore, the positive experience reported by individuals with CLBP treated with dry cupping or sham led us to understand the mechanisms of the technique and how participants perceived this “new” treatment. We also identified that the association between dry cupping and social and professional supports are essential for therapeutic success; thus, encouraging treatment continuation and, consequently, symptom relief.
The therapist-patient alliance can also be emphasized in our study. Both groups positively reported the presence of the physiotherapist in the symptom improvement process. Literature shows how this alliance benefits patients with CLBP [14]. It is worth mentioning that the treatment was individualized and performed in a temperature-controlled and cozy room [25]. As a result, attention was entirely focused on the individual, a factor that may generate positive effects.
This study presents limitations. We did not develop a focus group to understand the perceptions of collective efficacy or accurately identify divergences and convergences between therapeutic processes and treatment effects on CLBP symptoms. Despite this, our results can assist clinicians with CLBP management by understanding factors unrelated to the technique that also impact treatment success. Last, the presence of memory bias cannot be ruled out since the study was conducted six months after the clinical trial. Nevertheless, participants felt free to report experiences.
Our findings demonstrated that individuals with chronic low back pain presented similar perceptions of the effects of dry cupping and sham treatment. Therefore, improvements reported indicate that contextual factors, such as social and professional supports, potentiate the experience of participants.
Acknowledgments
We thank all study participants who made this work possible. We also thank the Faculty of Health Sciences of Trairi / Federal University of Rio Grande do Norte for all the support provided. The authors thank Probatus Academic Services for providing scientific language revision.
References
- 1. Ekman M, Johnell O, Lidgren L. The economic cost of low back pain in Sweden in 2001. Acta Orthop 2005; 76: 275–284. pmid:16097556
- 2. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis and Rheumatism 2012; 64: 2028–2037. pmid:22231424
- 3. Vos T, Abajobir AA, Abbafati C, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1211–1259. pmid:28919117
- 4. Manchikanti L, Singh V, Falco FJE, et al. Epidemiology of low back pain in Adults. Neuromodulation 2014; 17: 3–10. pmid:25395111
- 5. Van Middelkoop M, Rubinstein SM, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011; 20: 19–39. pmid:20640863
- 6. Aboushanab TS, AlSanad S. Cupping Therapy: An Overview from a Modern Medicine Perspective. JAMS Journal of Acupuncture and Meridian Studies 2018; 11: 83–87. pmid:29436369
- 7. Wood S, Fryer G, Fon Tan LL, et al. Dry Cupping for Musculoskeletal Pain and Range of Motion: a systematic review and meta-analysis. J Bodyw Mov Ther. Epub ahead of print 2020. pmid:33218554
- 8. Volpato MP, Breda ICA, de Carvalho RC, et al. Single Cupping Thearpy Session Improves Pain, Sleep, and Disability in Patients with Nonspecific Chronic Low Back Pain. JAMS J Acupunct Meridian Stud 2020; 13: 48–52. pmid:31760207
- 9. Akbarzadeh M, Ghaemmaghami M, Yazdanpanahi Z, et al. The Effect Dry Cupping Therapy at Acupoint BL23 on the Intensity of Postpartum Low Back Pain in Primiparous Women Based on Two Types of Questionnaires, 2012; A Randomized Clinical Trial. Int J community based Nurs midwifery 2014; 2: 112–20. pmid:25349852
- 10. Wang YT, Qi Y, Tang FY, et al. The effect of cupping therapy for low back pain: A meta-analysis based on existing randomized controlled trials. Journal of Back and Musculoskeletal Rehabilitation 2017; 30: 1187–1195. pmid:28946531
- 11. Huang CY, Choong MY, Li TS. Effectiveness of cupping therapy for low back pain: A systematic review. Acupuncture in Medicine 2013; 31: 336–337. pmid:23886511
- 12. Teut M, Ullmann A, Ortiz M, et al. Pulsatile dry cupping in chronic low back pain—A randomized three-armed controlled clinical trial. BMC Complement Altern Med 2018; 18: 115. pmid:29609566
- 13. Cramer H, Klose P, Teut M, et al. Cupping for Patients With Chronic Pain: A Systematic Review and Meta-Analysis. J Pain 2020; 0: 1–14. pmid:31982686
- 14. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theory, Res Pract 1979; 16: 252–260.
- 15. Martin DJ, Garske JP, Katherine Davis M. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. J Consult Clin Psychol 2000; 68: 438–450. pmid:10883561
- 16. Horvath AO, Symonds BD. Relation Between Working Alliance and Outcome in Psychotherapy: A Meta-Analysis. J Couns Psychol 1991; 38: 139–149.
- 17. Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Phys Ther 2010; 90: 1099–1110. pmid:20576715
- 18. Ambady N, Koo J, Rosenthal R, et al. Physical therapists’ nonverbal communication predicts geriatric patients’ health outcomes. Psychol Aging 2002; 17: 443–452. pmid:12243386
- 19. Ferreira PH, Ferreira ML, Maher CG, et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther 2013; 93: 470–478. pmid:23139428
- 20. Green J, Dunn G. Using intervention trials in developmental psychiatry to illuminate basic science. British Journal of Psychiatry 2008; 192: 323–325. pmid:18450651
- 21.
Bardin L. Análise de Conteúdo. São Paulo: Edições 70. São Paulo: Edições 70.
- 22. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Heal Care 2007; 19: 349–357. pmid:17872937
- 23. Almeida Silva HJ, Barbosa GM, Scattone Silva R, et al. Dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with non-specific chronic low back pain: a randomised trial. J Physiother 2021; 67: 132–139. pmid:33757719
- 24. Fontanella BJB, Luchesi BM, Saidel MGB, et al. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27: 388–394. pmid:21359475
- 25. Silva HJ de A, Saragiotto BT, Silva RS, et al. Dry cupping in the treatment of individuals with non-specific chronic low back pain: a protocol for a placebo-controlled, randomised, double-blind study. BMJ Open 2019; 9: e032416. pmid:31871257
- 26. Perreault K, Dionne CE, Rossignol M, et al. What are private sector physiotherapists’ perceptions regarding interprofessional and intraprofessional work for managing low back pain? J Interprof Care 2018; 32: 525–528. pmid:29589780
- 27. Tagliaferri SD, Miller CT, Owen PJ, et al. Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective. Pain Practice 2020; 20: 211–225. pmid:31610090
- 28. Kawi J. Chronic low back pain patients’ perceptions on self-management, self-management support, and functional ability. Pain Manag Nurs 2014; 15: 258–264. pmid:23232149
- 29. Bishop MD, Bialosky JE, Cleland JA. Patient expectations of benefit from common interventions for low back pain and effects on outcome: Secondary analysis of a clinical trial of manual therapy interventions. J Man Manip Ther 2011; 19: 20–25. pmid:22294850
- 30. O’Keeffe M, Cullinane P, Hurley J, et al. What influences patient-therapist interactions in musculoskeletal physical therapy? Qualitative systematic review and meta-synthesis. Physical Therapy 2016; 96: 609–622. pmid:26427530
- 31. Menezes Costa LDC, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: A meta-analysis. Cmaj 2012; 184: E613–E624. pmid:22586331
- 32. Vase L, Vollert J, Finnerup NB, et al. Predictors of the placebo analgesia response in randomized controlled trials of chronic pain: A meta-analysis of the individual data from nine industrially sponsored trials. Pain 2015; 156: 1795–1802. pmid:25955965
- 33. McIntosh A, Shaw CFM. Barriers to patient information provision in primary care: Patients’ and general practitioners’ experiences and expectations of information for low back pain. Heal Expect 2003; 6: 19–29. pmid:12603625
- 34. La Touche R, Perez-Fernandez M, Barrera-Marchessi I, et al. Psychological and physical factors related to disability in chronic low back pain. J Back Musculoskelet Rehabil 2019; 32: 603–611. pmid:30584119
- 35. Chenot JF, Greitemann B, Kladny B, et al. Clinical practice guideline: Non-specific low back pain. Dtsch Arztebl Int 2017; 114: 883–890. pmid:29321099
- 36. Oraison HM, Kennedy GA. The effect of social support in chronic back pain: number of treatment sessions and reported level of disability. Disabil Rehabil 2019; 20: 211–225. pmid:31564167
- 37. Krahé C, Springer A, Weinman JA, et al. The social modulation of pain: Others as predictive signals of salience—a systematic review. Frontiers in Human Neuroscience 2013; 7: 386. pmid:23888136
- 38. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders 2018; 19: 1–15. pmid:29357856