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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 472-479

Effect of dynamic cupping therapy vs. vibrating foam roller on pain, range of motion, function, and quality of life in elderly with subacute and chronic osteoarthritis of knee: A randomized controlled trial

Department of Geriatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission26-Sep-2022
Date of Acceptance18-Oct-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Vijayalaxmi Kanabur
Department of Geriatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi 590010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_174_22

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Background: Knee osteoarthritis (KOA) is a frequent degenerative disease of joints. The prevalence is approximately 28% among the Indian elderly. Recently complementary and alternative medicine therapies have been used in managing pain and disability. Dynamic cupping therapy is one of the forms used nowadays. Foam rolling and vibration therapy is also a popular intervention in musculoskeletal conditions such as osteoarthritis, osteoporosis, sarcopenia, and low back pain. Nowadays, these two have been combined for the development of vibrating foam rollers. Objectives: This research aimed to compare the result of dynamic cupping therapy to that of a vibrating foam roller on pain, range of motion, function, and quality of life in elderly with sub-acute and chronic KOA. Materials and Methods: The research was carried out on 45 subjects with subacute to chronic KOA who were given thrice a week sessions for 4 weeks’ intervention. Through the randomized method, subjects were divided into a conventional group, dynamic cupping group and vibrating foam roller group outcome measures Numeric Pain Rating Scale, knee range of motion, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and brief Older People's Quality of Life Questionnaire (OPQOL-brief) were used. Results: Wilcoxon rank test revealed a pre-post difference in all three groups with significant P-values which were <0.05 and heterogeneously favored different outcome measures used. Kruskal–Wallis test revealed no difference between the groups. Conclusion: This study concluded that dynamic cupping therapy and vibration foam roller protocols used for the management of KOA are equally effective.

Keywords: Dynamic cupping, elderly, knee osteoarthritis, vibrating foam roller

How to cite this article:
Kanabur V, Muragod AR. Effect of dynamic cupping therapy vs. vibrating foam roller on pain, range of motion, function, and quality of life in elderly with subacute and chronic osteoarthritis of knee: A randomized controlled trial. MGM J Med Sci 2022;9:472-9

How to cite this URL:
Kanabur V, Muragod AR. Effect of dynamic cupping therapy vs. vibrating foam roller on pain, range of motion, function, and quality of life in elderly with subacute and chronic osteoarthritis of knee: A randomized controlled trial. MGM J Med Sci [serial online] 2022 [cited 2023 Mar 28];9:472-9. Available from: http://www.mgmjms.com/text.asp?2022/9/4/472/365982

  Introduction Top

Osteoarthritis is a common degenerative disease of bones and joints characterized by pain, joint stiffness, and disability, especially in the elderly age group. The prevalence is approximately 28% among the Indian elderly. In elders, Osteoarthritis of the knee joint is very prevalent. Knee osteoarthritis (KOA) concerning causative factors can be divided into Primary and secondary.[1]

Radiographic alterations and clinical examination are used to diagnose KOA. Radiographic diagnosis is based on the Kellgren and Lawrence scale for osteoarthritis,[1] whereas the clinical diagnosis is done by the clinical criteria of the American College of Rheumatology (ACR).[2] The ACR clinical criteria are as follows:

  • Presence of crepitus, presence of stiffness in the morning for more than 30 min, and the presence of Knee enlargement due to bony growth

  • Presence of crepitus, presence of stiffness in the morning for more than 30 min/

  • Absence of crepitus and presence of Knee enlargement due to bony growth.[2]

  • The American College of Rheumatology provides guidelines that recommend 14 nonpharmacological treatments and 7 pharmacological treatment options for the management of Osteoarthritis of the knee joint.[3] Owing to the complications associated with the gastrointestinal system, cardiovascular system, Kidney, liver, and skin in Pharmacological therapies patients with OA are opting for complementary and alternative medicine (CAM). The choice of CAM for OA in recent years is prevalent largely among approximately 40%–64.8%.[4]

    Cupping therapy forms a major part of CAM. Cupping involves quick, rapid, and coordinated strokes application which helps in the reduction of various chronic pains thus enhancing quality of life.[5] Cupping causes comfort and relaxation at the regional levels which stimulate endogenous opioid production and result in pain relief.[6] Hao et al. stated the antiviral mechanism of cupping therapy, they state that cupping reduces the number of lymphocytes and increases the number of neutrophils in the local blood circulation which reduces the pain.[7] Cupping time varies between 5 and 10 min in KOA, and can go up to 20 min.[2]

    Dynamic cupping therapy is one of the forms of dry cupping used nowadays. It involves the application of lubricants like essential oil, and Vaseline to the skin before the placement of cups, then the cup is moved along the fascial orientations.[8]

    Self myofascial release with a foam roll or roller massager has been shown to increase joint ROM in the short term while having no negative impact on muscle performance.[9] Approximately 81% of the practitioners recommend a foam roller for self-myofascial release in their daily practice. Foam rolling is supposed to increase vascular endothelial function and reduce arterial stiffness, all of which indirectly increased flexibility. Studies suggest that foam rolling for 1–5 min gives short-term benefits (≤10 min) of increased joint motion without decreasing muscle performance.[10]

    Vibration treatment is another prominent intervention with a wide range of applications in common musculoskeletal disorders such as osteoarthritis, osteoporosis, sarcopenia, low back pain, and rehabilitation after cartilage damage. Foam rolling and vibration therapy are found to have a beneficial effect in improving joint range of motion and pain relief. These two technologies have now been combined to create vibrating foam rollers. Several models with varied frequencies and roller densities have been produced. The local effect of vibrating rollers on lower extremity joint mobility and muscular discomfort is favorable in the elderly. The 20–50 Hz frequency range is ideal for affecting musculoskeletal systems.[10]

    Both dynamic cupping therapy, as well as vibrating foam roller, are said to be useful in the reduction of pain, enhancing the range of motion, function, and quality of life in elderly with KOA. But there is a paucity of literature about the effects of dynamic cupping therapy when compared to the vibrating foam roller in reducing pain and increasing the range of motion and function. Therefore this study has been taken up.

      Materials and methods Top

    Design of the research

    The research was conducted as a randomized controlled trial, with concealed envelope allocation method for randomizing 45 subjects into three groups of 15 each:

    The study included both male and female subjects in and around Belagavi city, with subacute and chronic KOA cases within the age of 60–85 years satisfying the ACR Clinical Criteria for OA. Subjects who voluntarily gave written consent for participation were included. Subjects with open wounds, skin disease, known bleeding and vascular disorders, sensory deficits, lower limb fractures in the past 6 months, osteoporosis, and rheumatoid arthritis were excluded.

    Measurement of the outcome

    Pain using the numeric pain rating scale

    The Numeric Pain Rating Scale (NPRS) is a subjective technique for determining the severity of pain. The NPRS is an 11-point scale ranging from 0 to 10, with 0 representing “no pain” and 10 representing “severe pain.” Between these extremes, different adjectives or numbers (1–10) indicate distinct levels of pain intensity and are arranged in order of pain severity. The patient marks the value which corresponds to his/her pain intensity in the last 24 h. The reliability is established as 0.92.[11]

    Knee flexion and knee extension range of motion

    Goniometer was used for measuring the ROM for Knee Flexion, Extension.

    Function using WOMAC scale:

    The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is a self-administered questionnaire that is commonly used to assess KOA. There are 24 items in all, separated into three subscales: pain, stiffness, and physical function. Activities of daily living, functional mobility, gait, general health, and quality of life are the main areas of assessment. Worse pain, stiffness, and functional impairments are associated with higher WOMAC scores.[12]

    Quality of life using older people’s quality of life scale-brief questionnaire

    This is a shorter version of the well-established 35-item OPQOL Questionnaire. This shorter version consists of 1 preliminary item on global quality of life and 12 other items on quality of life. This scale is scored on a 5point scale with scores ranging from 13 to 65. Greater scores greater the quality of life. The validity and reliability of this tool are 0.6 and 0.85, respectively.[13]

      Procedure Top

    Ethical clearance was obtained from Institutional Ethical Committee. All safety precautions were taken as per Indian Council of Medical Research (ICMR) guidelines in light of the current pandemic. The participants were randomly divided into the following groups and the preintervention values of the outcome measures were assessed.

    • Group A: Conventional therapy.

    • Group B: Conventional therapy along with dynamic cupping therapy.

    • Group C: Conventional therapy along with vibrating foam roller.

    • Group A was given only conventional therapy for KOA which includes thermotherapy using hydro collator pack, IFT (vector 90 modes, 4 poles, 90 Hz beat frequency) for 20 min, and knee strengthening exercises for 20 min [Figure 1] and [Figure 2].
    Figure 1: Knee isometric exercises

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    Figure 2: Interferential therapy for knee

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    Group B was given conventional therapy followed by Dynamic cupping after the application of a lubricant to the skin for the tendons of three vastus muscles and gastro soleus muscle for 15 min [Figure 3]. Group C was treated with conventional therapy followed by a vibrating foam roller at low intensity for 3 sets of 30 s each for the quadriceps and hamstring muscles. This intervention was given thrice a week for 3 weeks [Figure 4]. Post-intervention values of the outcome measures were recorded and the data was subjected to statistical analysis.
    Figure 3: Dynamic cupping

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    Figure 4: Vibration foam roller

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      Results Top

    To verify the results, the statistical analysis for this study was done using the SPSS version 22. Mean, SD, and significance tests such as “One-way ANOVA” and paired “t test” were used with a significance threshold of P = 0.005.

    Gender distribution

    In Group A, there were six male participants and nine female participants. The total number of male participants in Group B was five, and the total number of female participants was ten. The total number of male participants in Group C was five, and the total number of female participants was ten. In total, 64.44% of the participants were females and 35.56% were males, yielding a chi-square value of 0.1940 and a P = 0.9080.

    Age distribution

    One-way ANOVA was used to examine the mean difference in age and body mass index (BMI) among all individuals. The mean age of the participants in this study was 71.47 5.4 for Group A, 71.33 5.68 for Group B, and 70.33 6.42 for Group C, with a P = 0.8465. The mean BMI of the individuals in Group A was 27.74 4.95, Group B was 27.77 3.13, and Group C was 28.74 3.90, with a P = 0.7472 indicating that all three groups had a homogeneous distribution.

    Within-group analysis

    Within-group analysis of pre–post values for all three groups was done using the Wilcoxon matched-pair test. In terms of NPRS, Group A had a percentage of change of 43.37%, Group B had a percentage of change of 48.19%, and Group C had a percentage of change of 46.51%. For all of the groups, the P-value was equal to 0.001. As a result, all three groups are beneficial in reducing pain. In terms of knee flexion, Group A had a –4.68% chance, Group B had a –4.64% chance, and Group C had a –5.52% chance [Table 1].
    Table 1: Within-group comparison

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    Group A had a P = 0.0033, Group B had P = 0.0038, and Group C had P = 0.0006. As a result, all three groups improved their knee flexion range in the same way. In terms of knee extension, Group A had a change of –4.99, Group B had a change of –4.64, and Group C had a change of –5.52. Group A had P = 0.0039, Group B had P = 0.0038, and Group C had P = 0.0006. As a result, all three groups improved their knee extension range in the same way.

    In terms of WOMAC, Group A had a percentage of change of 29.62%, Group B had a percentage of change of 41.03%, and Group C had a percentage of change of 37.58%. Group A had P = 0.001, Group B had a P = 0.001, and Group C had P = 0.002. As a result, all three groups improved Function in the same way.

    In terms of OPQOL-brief, Group A had a –3.97 percentile change, Group B had a –4.46 percentile change, and Group C had a –6.17 percentile change. For Group A, the P-value was 0.0015.

    Between-group analysis

    Between-group analysis for all three groups was done using Kruskal–Wallis ANOVA.

    The mean difference between the three groups was 2.40 ± 1.06, 2.67 ± 0.82, and 2.67 ± 1.11. The P values of the three groups were 0.9221, 0.8151, and 0.7531 about NPRS indicating equivocal results.

    The mean difference between the three groups was 5.67 ± 6.21, 5.53 ± 6.20, and 6.60 ± 5.82. The P-values of the three groups were 0.9067, 0.8082, and 0.8722 for Knee Flexion whereas the mean difference between the three groups was 6.07 ± 6.81, 5.53 ± 6.20, and 6.60 ± 5.82. The p- values of the three groups were 0.8445, 0.6450, and 0.8979 for knee extension indicating the equal effect of the three interventions on a range of motion.

    The mean difference between the three groups was 11.53 ± 5.66, 16.93 ± 5.66, and 15.53 ± 12.19, and The P-values of the three groups were 0.7874, 0.6487, 0.2022, respectively, concerning WOMAC indicating the equal effect of the three interventions on function.

    The mean difference in Group A was 1.93 ± 1.91, Group B was 2.27 ± 2.28, and Group C was 3.13 ± 3.23. The P-values of the three groups were 0.4628, 0.1753, and 0.4156, respectively, concerning the OPQOL brief indicating the equal effect of the three interventions on quality of life [Table 2].
    Table 2: Between-group comparison

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      Discussion Top

    The goal of this 3-week randomized controlled trial was to compare the effects of traditional therapy, dynamic cupping, and vibrating foam roller on pain, range of motion, function, and quality of life. KOA is a common degenerative disease in the 50–100 years of age with a prevalence ranging from 22% to 39% and a mean age to be 60.00 ± 10.50 years.[14] Our study is not by this finding, with a mean age of 71.04 ± 11.53 years, the possible reason being our involvement in the constricted age group of 60–85 years only. Our study showed the mean BMI of the involved population to be 28.04 ± 3.04 kg/m2 according to Asian classification and was to the findings of Samma et Al. who found that majority of KOA patients have greater ended BMI with a mean value being 25.7 ± 1.8 according to classification by World Health Organization.[15] The reason for this finding is attributed to the increasing load on the Knee joint with increasing weight and waist circumference.[16]

    To the NPRS the three groups were effective in giving effective post-test values with P = 0.0001. In the literature, we find that pain relief due to cupping therapy is effective with P = 0.0001, due to the release of endorphins and enhancing blood circulation in the local area.[17],[18] vibration foam rollers are shown to improve pain significantly with P = 0.0001, due to the reduction of the soreness in the muscles by enhancing local blood circulation. Although these two interventions are effective in relieving pain there is no evidence stating which is the superior, possibly due to a similar mechanism of action.[19],[20] This justifies our finding of equivocal results between both interventions.

    Regarding the range of motion the three groups had effective outcomes post 3 weeks with P = 0.0033 for knee flexion as well as extension. Previous studies which involved cupping intervention for a range of motion in various musculoskeletal disorders also found similar significant P-values (0.005).[16],[21],[22] The vibration foam roller also showed a significant effect on the range of motion with P = 0.0006 for flexion as well as extension. Look M conducted a meta-analysis on the effect of cupping and static stretching on hamstring tightness in adults. The study concludes that cupping improved passive straight leg raise, whereas static stretching favored active knee extension, thus concluding that both the techniques were effective but with no clear evidence on which had greater benefits.[23] The possible reason being initially soft tissue release needs superficial focus and later deeper fascia needs to be released. In our case, age-associated contraindications due to blood vessel integrity and bone density level in the elderly deeper tissues, couldn’t be approached either by cupping or vibration foam roller.[23],[24] Although pre-post improvements have been established, there is no literature stating better results when compared to other myofascial release techniques in musculoskeletal disorders, thus supporting our findings too.[24],[25],[26],[27]

    Park SJ and colleagues conducted a study of the literature on the effects of vibration foam rollers on joint range of motion. Healthy individuals and athletes involving studies were analyzed for all the major joints of the upper limb and lower limb. When analyzed for knee joint there was an immediate effect on flexibility and range when checked through the passive test but the active knee bending test, sit and reach test used to check the flexibility of the hamstring showed a weak positive result.[26] To function assessed by WOMAC our study had effective pre-post outcomes by 3 weeks, with a significant P-value for cupping, existing evidence also has shown similar results on WOMAC when treated with cupping and pharmacotherapy, dry cupping and wet cupping, cupping, and ischemic compression. The possible reason is improvement in pain and elasticity of the muscles. Vibrating foam roller (VFR) also had an effective result on function, thus under the findings of Weiwelhove T who analyzed the works on VFR and concluded that VFR was good than NVFR.[23]

    The WOMAC scale includes the major components as pain and difficulty in basic activities, since these factors are related to pain and hamstring flexibility, it is justified that with improvement in pain and muscle length there is an improvement of function too. Due to the same mechanism of interrelation between symptoms, there are similar results achieved between both groups.[28],[29],[30]

    Hughes G conducted a review to establish an adequate duration of myofascial release with the foam roller. The duration was checked for pain, range, and performance. The study established 90 s as adequate to achieve an effect. The study revealed a temporary effect on pain, and a wide heterogeneous short-term effect on range whereas long-term range and performance showed insignificant results. This supports our results of heterogeneous differences post 3 weeks intervention protocol in KOA elderly.[28]

    Regarding the quality of life, our study showed improvements in the post-intervention values in all three groups. Evidence relating to the quality of life and sleep quality in elderly people with osteoarthritis suggests that myofascial release techniques improve the quality of life in musculoskeletal conditions by improving range of motion and reducing pain, both of which influence daily activities and thus improve quality of life, as well as controlling age-related comorbidities that affect sleep.[31]

    Though these two techniques when used alone showed no difference between them, the literature suggests that such myofascial release techniques show better results when used in combination. Nasb et al.[27] conducted a study that showed that cupping and ischemic compression when applied alone had no difference between them but when applied in combination had a greater significance than the latter.

    This adds to the existing evidence that all CAM therapies are equally effective in treating the symptoms of KOA with heterogeneous favoring of different symptoms of musculoskeletal disorders.

    The study faced certain limitations. First, post-intervention values after each session were not considered which may have established a better comparison. Second, objective measures like an ultrasonography study would give a clear result on the magnitude of change in such long-term studies. Future studies should focus on strength training interventions in combination with these protocols for better results and comparative studies analyzing the individual combined effects of these therapies should be taken up.

      Conclusion Top

    This study concluded that dynamic cupping therapy and vibration foam Roller protocols used for the management of KOA are equally effective and can be used as adjuncts to conventional therapy.

    Ethical consideration

    This study has been verified and permitted by the Research and Ethics Committee of the KAHER Institute of Physiotherapy, Belagavi, India vide letter No: 624 dated December 21, 2021.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Not applicable.

    Conflicts of interest

    There are no conflicts of interest.

      References Top

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      [Figure 1], [Figure 2], [Figure 3], [Figure 4]

      [Table 1], [Table 2]


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