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

Summary

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.

Abstract

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.

Introduction

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.

Protocol

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.

Results

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 Resea...

Discussion

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...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
95% alcohol	Sichuan Yijie Medical Technology Co., LTD	20190079
absorbent cotton ball	Cofoe Medical Technology Co.,Ltd	20222140061
glass cup	Cofoe Medical Technology Co.,Ltd	20150041
hemostatic forceps	Shanghai MEDICAL Instruments (GROUP) Co., Ltd	20222201228
medicinal glycerin	Henan Huakai Biotechnology Co., LTD	20231002