Alternative Therapy for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Moving Cupping Along Meridians

This protocol presents a novel approach to alleviating the symptoms and improving the quality of life of patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) by employing moving cupping along meridians therapy to stimulate the first sideline of the bladder meridian.

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory condition characterized by persistent and progressive airflow obstruction, resulting in chronic respiratory symptoms like dyspnea, cough, and sputum production, accompanied by wheezing, chest tightness, fatigue, and reduced physical activity. Under the influence of various factors, patients with COPD often experience acute exacerbations, which have a significant negative impact on the prognosis, quality of life, and life span of patients. As a branch of cupping therapy, moving cupping along meridians is an essential complementary therapy of the traditional Chinese medicine system. Cupping plays a unique role in treating and preventing many diseases by stimulating the local skin with negative pressure.

This article elaborately describes the procedure of moving cupping along meridians therapy in the treatment of AECOPD. The effectiveness and feasibility of moving cupping along meridians therapy in relieving symptoms and enhancing the quality of life is demonstrated by comparing the changes in the 36-item Short-Form (SF-36) health survey questionnaire, the modified Medical Research Council dyspnea scale (mMRC), and the COPD Assessment Test (CAT) score before and after the treatment. As a cost-effective complementary treatment, the protocol for the moving cupping along meridians treatment described in this article is expected to provide a reference for non-pharmacological treatment options for AECOPD.

Chronic obstructive pulmonary disease (COPD) is a prevalent, preventable, and treatable heterogeneous lung disease characterized by persistent, often progressive airflow obstruction resulting from abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema). It manifests chronic respiratory symptoms such as dyspnea, cough, expectoration, along with wheezing, chest tightness, fatigue, and reduced activity levels. Some patients may also experience acute exacerbations characterized by increased respiratory symptoms, which can impact their physical condition and prognosis, necessitating specific prevention and therapeutic measures¹.

According to the Global Burden of Disease Study by the World Health Organization (WHO) and the Burden of Obstructive Lung Diseases (BOLD) project, the prevalence of COPD worldwide is 10.3%, leading to approximately 3 million deaths annually, making COPD the third leading cause of mortality globally^2,3,4. In China, data from a nationwide cross-sectional study indicates an 8.6% prevalence of COPD, with a striking 13.7% prevalence among people over 40 years old. A considerable proportion of patients have not received timely diagnosis and treatment, which severely impacts public health⁵.

With the increase in smoking rates in low- and middle-income countries and the exacerbation of population aging in high-income countries, the burden of COPD is anticipated to escalate. Estimates suggest that by 2060, COPD and related diseases will claim the lives of more than 5.4 million people annually, resulting in significant economic and social burdens, including direct and indirect treatment costs. Similarly, productivity loss and premature retirement caused by the disease are also considered the main sources of indirect costs of the disease^6,7.

An acute exacerbation of COPD (AECOPD) is defined as a transient worsening of dyspnea, cough, and expectoration production lasting less than 14 days, often triggered by local and systemic inflammation caused by airway infection, pollution, or other lung injuries⁸. A population-based survey conducted in nine Asia-Pacific regions showed that 46% of patients with COPD had at least one acute exacerbation in the previous year, and 19% of patients required hospitalization⁹.

It is worth noting that COPD has imposed considerable costs on the healthcare system, mainly related to the moderate to severe stage and complications. A systematic review of COPD cost analysis reveals that AECOPD treatment costs significantly contribute to overall treatment expenses⁷. Current management strategies for acute exacerbations involve pharmacological and non-pharmacological interventions aimed at alleviating airway obstruction, combating infections, and enhancing oxygenation. However, they are still facing challenges like rising drug resistance and airway microbiome disturbances¹⁰.

Cupping therapy is an ancient traditional Chinese medicine technique with a history spanning thousands of years. Much like acupuncture, it is an essential component of complementary and alternative medicine worldwide¹¹. Cupping therapy is a non-pharmacological external treatment method that uses plastic, bamboo, or glass cups as tools. By utilizing methods such as burning, suction, or steam to create negative pressure within the cup, the cups are able to adsorb onto specific points on the body's surface, acupoints, or meridians, which can stimulate subcutaneous tissues, promoting congestion and blood stasis in the local skin, thereby achieving the goal of preventing and treating diseases¹². Moving cupping along meridians is a branch of the cupping method based on the meridian theory of acupuncture and moxibustion. Through the application of flame, the cup adheres to the skin, and with the aid of glycerin, it repeatedly moves along the pathways of the meridians, resulting in benign stimulation¹³.

This article elaborates on the operation steps, key points, and precautions of moving cupping along meridian therapy for AECOPD, including patient qualification assessment, medical equipment used, treatment site, course of treatment, posttreatment care, and adverse reaction response measures. The study employed the medical outcomes study 36-item short form (SF-36) health survey questionnaire, the modified Medical Research Council dyspnea scale (mMRC), and the COPD Assessment Test (CAT) score as efficacy evaluation indicators. The efficacy of this protocol can be assessed by comparing the scores of patients before and after treatment. With the advantages of definite curative effect, low cost, and easy acceptance by middle-aged and elderly patients, moving cupping along meridians therapy shows the potential to offer a new direction for non-pharmacological treatment of AECOPD.

This study is a before-and-after self-controlled trial with patients sourced from the People's Hospital of Xinjin District, Chengdu. Operators participating in the trial must hold qualifications as traditional Chinese medicine practitioners and have independently conducted clinical treatments for over 1 year. All of the manipulation techniques followed the national standardized manipulations of acupuncture and moxibustion - Part 5: Cupping therapy¹⁴ to ensure the specification and correctness of the manipulations. This study has been approved by the Ethics Committee of People's Hospital of Xinjin District, Chengdu (No. 2023-10). Patients were informed of the purpose and method of treatment and provided consent for the utilization of images generated during the trial for research purposes.

1. Pretreatment evaluation

1. Set the following inclusion criteria: 1) Age between 40 and 80 years old; 2) diagnosed with COPD, experiencing exacerbation of respiratory symptoms in an acute state, with disease severity classified as mild; 3) no cupping therapy received in the past 6 months; 4) conscious, mentally normal, and informed about the study; 5) not involved in other clinical studies.
2. Set the following exclusion criteria: 1) Age below 40 or above 80 years old; 2) patients with AECOPD classified as moderate or severe; 3)patients diagnosed with cardiovascular or cerebrovascular diseases, uremia, diabetes, liver diseases, mental illnesses, malignant tumors, and other acute or critical conditions, as well as infectious diseases; 4) individuals with bleeding disorders such as platelet allergic purpura or leukemia, prone to bleeding and coagulation abnormalities; 5) pregnant or lactating women, or those who have undergone childbirth or surgical procedures within the past year; 6) individuals with allergic reactions, ulcers, or edema on the back skin; 7) obese patients (BMI > 40); 8) patients undergoing other clinical trials.
   NOTE: Coagulation should be checked in patients with underlying coagulation disorders, as there is a chance that cupping therapy in such patients may lead to subcutaneous purple spots and heavy bleeding.

2. Preparation before operation

1. Maintain a quiet and sanitary environment while keeping the temperature at approximately 26 °C.
2. Select appropriate glass cups based on the patient's physique. For the cups of different sizes, refer to Figure 1.
   NOTE: Treat Individuals with larger body mass and stature with cups of an outer diameter of 6.5 cm; for those with smaller body mass and stature, provide a cup with an outer diameter of 6.0 cm.
3. Verify the availability of essential items (such as glass cups, absorbent cotton balls, hemostatic forceps, 95% alcohol, and medicinal glycerin). Disinfect the cup, verify its structural integrity, and confirm that the rim is smooth to prevent skin damage. Refer to Figure 2 for the items required for the procedure.
   NOTE: Cups are usually disinfected uniformly in advance. They are initially disinfected with a 75% alcohol solution, subsequently immersed in a chlorinated disinfectant solution, thoroughly dried, and finally arranged in a sterile treatment tray, ready for the operator's use in a clinical setting.
4. Ask the patient to take a prone position and fully expose the treatment site (waist and back).
5. Check patient information: name, bed number, patient ID, etc. Explain the detailed treatment process and methods to the patient and family members to alleviate or eliminate anxiety and fear.
6. Evaluate the patient's skin condition. Stop the procedure if there is any damage.

3. Procedure

NOTE: Course of treatment: once every 7 days, three treatments in total. Any adverse reactions observed in patients must be promptly managed and documented, and with reassessment conducted post-remission.

1. Position the treatment site-the first sideline of the bladder meridian, from Da-Zhu (BL11) to Guan-Yuan-Shu (BL26).
   NOTE: Refer to Figure 3 for the diagram of the meridians in the human body. The positioning of meridians and acupoints refers to the national standards: Nomenclature and location of meridian points¹⁵. In traditional Chinese medicine, the meridian and acupoint positioning measurement unit is ' cun.' The method of bone-length measurement is an acupoint positioning method established on the basis of a relatively stable proportion between various parts of the human body, which realizes personalized acupoint selection according to different people's heights and body shapes.
   1. The bladder meridian runs along the line 1.5 cun from the posterior midline on the back. Since the medial edge of the scapula is 3 cun from the posterior midline, use the compromise of 1.5 cun to locate the bladder meridian. Da-Zhu and Guan-Yuan-Shu are located on the bladder meridian, under the spinous process of the 1st thoracic vertebra and the 5th lumbar vertebra.
2. Clean hands thoroughly.
3. Clean the patient's skin by dipping a cotton ball in saline solution using forceps, and cleanse the skin from top to bottom along the direction of the meridians.
4. Apply an appropriate amount of medicinal glycerin on the patient's back skin.
5. Grasp the cup with one hand and keep the opening facing downward.
6. With the other hand, use hemostatic forceps to grip a cotton ball saturated with 95% ethanol. Ignite the cotton ball and swiftly insert it through the opening of the cup, perform a few rotations and gentle agitations, and remove it.
   NOTE: Do not let the cotton ball absorb too much alcohol to avoid alcohol dripping and burning the skin accidentally. Avoid burning the rim of the cup and ensure that the temperature of the cup's mouth is not too high to prevent scalding. The location where the lit cotton ball reaches into the can is the outer 1/3 and inner 2/3 of the mouth and bottom of the cup. Refer to Figure 4 for the depth and position of the cotton ball.
7. Quickly press the cup onto the skin of the treatment area, and let the cup get adsorbed onto the skin with the help of negative pressure. Control the depth of the cup's adsorption to ~7-10 mm, moving speed to ~5 cm/s, and duration to 5-8 min.
8. Monitor the patient's response, question them about any feelings experienced, and swiftly address and relieve any discomfort. If there is excessive pain due to strong suction, release some air to reduce the suction force (refer to step 3.11 for details). If the suction force is insufficient, repeat the above procedure once after lifting the cup.
9. After the cup is adsorbed, place one hand on the surrounding skin and stretch it taut while using the other hand to stabilize the cup with appropriate force. Exert a modest amount of force to smoothly move the cup down the first sideline of the bladder meridian, starting from Da-Zhu (BL11) and ending at Guan-Yuan-Shu (BL26). Move the cup in an upward and downward motion, dragging it back and forth to effectively stimulate the meridian. See Figure 5 for the cupping technique.
10. Repeat the procedure several times, with the treatment duration limited by the skin color (turning slightly red) at the treatment site and the patient's tolerance level, but not exceeding 10 min. See Figure 6 for a reaction to the cupping technique.
    NOTE: To minimize discomfort, handling the cup with gradual and steady movements is recommended. The force and distance of each push and pull should not be excessive. If increased friction or a sense of resistance is felt after a few rotations, stop the procedure and apply more glycerin.
11. To lift the cup, firmly hold the lower portion with one hand. Then, use either the thumb or fingers of the other hand to apply pressure on the skin around the rim of the cup. This will create a small space between the cup and the skin, allowing air to enter and decrease the suction. Once this is done, remove the cup.

4. Posttreatment care

1. After lifting the cup, use sterilized cotton balls or gauze to gently wipe away the small water droplets on the purplish-red spots on the cupping site.
2. Ask the patient to lie flat for 30 min and observe for any adverse reactions.
3. Keep the patient warm and the treatment area dry.
4. If the spots are slightly painful and itchy, advise the patient not to scratch them to avoid infection.

5. Data processing

1. Data collection: Have eligible patients complete the Case Report Form as soon as possible before receiving treatment and after completing the test (after the third cupping).
2. Data analysis: Use paired t-tests for self-before-and-after comparisons, with p < 0.05 indicating statistically significant differences.

This paper describes a self-controlled before-and-after trial to investigate the efficacy of cupping therapy in relieving symptoms and improving the quality of life of AECOPD patients. In this study, a total of five eligible patients participated in the trial. The data were derived from questionnaires completed by patients before and after treatment.

The medical outcomes study 36-item short form (SF-36) health survey questionnaire, the COPD Assessment Test (CAT), and the modified Medical Research Council dyspnea scales (mMRC) were used as the evaluation indexes for the efficacy of the treatment. The SF-36 is used to evaluate the overall health of patients, while CAT and mMRC are specialized evaluations of COPD. The SF-36 is a brief, self-administered questionnaire that generates scores across eight dimensions of health and has been validated by its ability to predict clinical diagnosis and medical service utilization. The effect of cupping therapy was evaluated by comparing the total scores before and after treatment. The score positively correlated with the patients' health, and the improvement in the total score indicates an improvement in health status.

The COPD Assessment Test (CAT) is used to evaluate the quality of life of the patients, and a decrease in the scores indicates an enhancement in the patient's overall COPD condition. Changes of >2 points in patients' CAT scores before and after treatment suggest that the treatment has clinical significance. The mMRC is mainly used to evaluate the degree of dyspnea in patients with COPD. Both mMRC and CAT are symptomatic assessment methods, but the content of MRC for dyspnea is more streamlined, while the CAT has a more comprehensive understanding of multiple symptoms, including dyspnea.

To reduce subjective interference, the content of the questionnaires and the scoring methods were explained to the patients by the same researcher. The patients completed the questionnaires independently without receiving any prompting reminders.

Analysis of the patients' scale scores before and after treatment revealed that the SF-36 score increased from the initial 81.80 ± 5.81 to 90.20 ± 3.56, the mMRC score decreased from 1.60 ± 0.55 to 0.6 ± 0.55, and the CAT score decreased from 22.60 ± 6.73 to 16.80 ± 5.89 (all p < 0.05, Table 1). Thus, the changes in the indicators were statistically significant, and the moving cupping along meridians therapy was able to improve the symptoms of patients with AECOPD, alleviate respiratory distress, and enhance the quality of life of the patients.

Figure 1: Glass cups of different sizes. The size of the cups is tailored to the patient's body size. Commonly utilized glass cups feature diameters of 6.5 cm, 6.0 cm, and 5.0 cm. Please click here to view a larger version of this figure.

Figure 2: Essential items for moving cupping along meridians. (A) absorbent cotton ball, (B) hemostatic forceps, (C) glass cup, (D) 95% alcohol, (E) medicinal glycerin. Please click here to view a larger version of this figure.

Figure 3: Location of meridians. (A) Schematic, (B) actual labeling on patients. Please click here to view a larger version of this figure.

Figure 4: Depth and location of the lit cotton ball. The lit cotton ball is inserted into the cup at the outer 1/3 and inner 2/3 of the cup, ensuring that the mouth of the cup is not too hot to prevent burns when it is attached to the skin. Please click here to view a larger version of this figure.

Figure 5: Specific technique of moving cupping along meridians. The operator places one hand on the surrounding skin to tighten the skin. Using the other hand to stabilize the cup with appropriate force, the cup is evenly pushed back and forth along the meridian repeatedly to stimulate the meridian. Please click here to view a larger version of this figure.

Figure 6: Local skin manifestations after the end of treatment: After cupping, redness or cyanosis is often observed in the local skin. Please click here to view a larger version of this figure.

Table 1: Comparison of questionnaires before and after cupping treatment: Table 1 illustrates the comparative analysis of the SF-36, CAT, and mMRC scores before and after cupping treatment, with paired t-tests underscoring the substantial statistical differences observed (p < 0.05).

Modern medical treatment strategies for AECOPD typically involve pharmacological interventions and respiratory support with a wide range of pharmacological interventions such as bronchodilators, various antibiotics, and oral and intravenous corticosteroids¹⁶. Even though there is high-level evidence supporting the use of antibiotics and oral/intravenous corticosteroids in improving outcomes such as recurrence rates, mortality rates, and duration of hospital stay, recent studies have indicated that prolonged use of corticosteroids is an independent risk factor for increased COPD mortality¹⁷. The duration of oral corticosteroid therapy during acute exacerbations is directly correlated to an increased risk of pneumonia and mortality¹⁸, and excessive use of antibiotics may lead to co-infections, resistant strains, dysbacteriosis, and other negative consequences^19,20. As a result, there is a growing emphasis on reducing the use of antibiotics and corticosteroids as a crucial objective in managing COPD²¹.

As a significant factor in the progression of COPD, infection is a primary trigger for acute exacerbations^22,23. Although there have been several clinical reports in China regarding the efficacy of cupping in treating infectious lung disorders and enhancing immunity, further research is needed to provide systematic reviews, meta-analyses, and high-quality clinical evidence to support its efficacy^24,25,26,27. Research conducted by Liu, Liang, Ji, and other scholars has shown that cupping therapy plays a crucial role in treating AECOPD^28,29,30, such as alleviating symptoms, enhancing oxygen saturation levels, improving quality of life and prognosis, and enhancing lung function. The underlying mechanism may involve vasodilation, increasing blood flow to enhance tissue oxygen supply, accelerating metabolism, promoting the release of local immune cells and immune factors, and stimulating local immune regulation around meridians^11,31,32,33.

Compared to static cupping, which stimulates individual or multiple acupuncture points, moving cupping along meridians therapy offers unique advantages with a larger coverage area, simultaneously stimulating multiple acupuncture points, and can be considered a combination of cupping, Gua-Sha, and massage therapy³⁴. Standardized procedures are crucial to promote the clinical use of moving cupping along meridians therapy and ensure its efficacy. This article elaborates on the procedure, with the primary aim of establishing a standardized and effective protocol for the treatment of AECOPD. Through the analysis of the data, we have preliminarily arrived at the following conclusions: moving cupping along meridians therapy has the potential to alleviate patients' clinical symptoms, alleviate dyspnea, and improve the quality of life of COPD patients. The operational methodology described in this article draws on and refines the protocol used by previous researchers^29,35,36,37, providing further elaboration on specific operational techniques, precautions, posttreatment care, prevention of adverse reactions, and response strategies, thereby formulating a more standardized treatment plan, poised to offer methodological insights for related clinical research endeavors.

The positioning of the bladder meridian (Figure 3) described in protocol step 3.11 is a critical step in this protocol. Second, medical glycerin should be applied evenly along the bladder meridian and thoroughly cover the area of moving cupping to avoid skin breakdown due to a lack of lubrication. Third, the operator's manipulation plays an important role in the treatment. The depth of the cup adsorption must be controlled to ~7-10 mm, the moving speed to ~5 cm/s, and the duration to <10 min.

Currently, the use of moving cupping along meridians therapy in treating AECOPD still faces several challenges. The therapy requires full exposure of the patient's back, posing the risk of catching a cold and exacerbating the symptoms. The evaluation criteria of this study are based on questionnaires, which are now widely used in assessing AECOPD patients' condition. Nevertheless, the selection of objective indicators will greatly enhance the reliability of outcomes. Finally, the stimulation intensity of moving cupping along meridians therapy is relatively high, and some patients may not be able to tolerate it. In addition, partial skin reactions are equally noteworthy. Slight pain, local redness, and flaky petechiae at the cupping site, which return to normal after a few moments, are normal reactions and will subside spontaneously in 1-2 days without special treatment. In case of burns or blisters on the skin, the operation should be stopped immediately. Small blisters can be self-absorbed, and large blisters can be punctured with disinfection needles, drained of fluid, disinfected with iodophor, and covered with sterilized dressing under medical supervision to prevent infection.

To enhance this protocol, the following issues can be specifically addressed. The patients must be kept warm, and the indoor temperature must be adjusted to ensure their comfort. To increase the objectivity of assessment, future researchers can include measurements of pulmonary function and inflammatory index, such as high-sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-alpha (TNF-α). A thorough assessment of the patient's condition must be made before treatment. If a patient feels discomfort during treatment, promptly cease the procedure and take appropriate measures to prevent adverse reactions.

Although the efficacy and mechanism of cupping therapy are still under exploration, the benefits demonstrated so far are commendable. Moving Cupping along Meridians therapy, with the advantages of simple operation and minimal adverse reactions, is worthy of further research and promotion. As an important complementary therapy, cupping has broad application prospects. Hopefully, a large sample size could be included in future trials to demonstrate the effectiveness of cupping, aiming to provide a clinical basis for guiding the treatment of COPD.

The authors have no conflicts of interest to disclose.

This research was supported by the 2022 "Tianfu Qingcheng Plan" Tianfu Science and Technology Leading Talents Project (Chuan Qingcheng No. 1090); The National TCM Clinical Excellent Talents Training Program (National TCM Renjiao Letter [2022] No. 1); "100 Talent Plan" Project of Hospital of Chengdu University of Traditional Chinese Medicine (Hospital office [2021] 42); Special subject of scientific research of Sichuan Administration of Traditional Chinese Medicine (2021MS539, 2023MS608); Sichuan Science and Technology Program (2023ZYD0050); and Medical research subject of Chengdu Health Commission (NO: 2022337).