The Influence of Dry Cupping Therapy on Musicians with Chronic Neck Pain: an Initial Case Series

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The Influence of Dry Cupping Therapy on Musicians with Chronic Neck Pain: An Initial Case Series

A thesis presented to

the faculty of

the College of Health Sciences and Professions of Ohio University

In partial fulfillment

of the requirements for the degree

Master of Science

Aaron S. Ngor

August 2018

This thesis titled

The Influence of Dry Cupping Therapy on Musicians with Chronic Neck Pain: An Initial Case Series

AARON S. NGOR

has been approved for

the School of Applied Health Sciences and Wellness

and the College of Health Sciences and Professions by

Jeffrey A. Russell

Assistant Professor of Athletic Training

Randy Leite

Dean, College of Health Sciences and Professions 3

Abstract

NGOR, AARON S., M.S., August 2018, Athletic Training

The Influence of Dry Cupping Therapy on Musicians with Chronic Neck Pain: An Initial

Case Series

Director of Thesis: Jeffrey A. Russell

Background: To our knowledge, no study has yet specifically evaluated the effects that dry cupping therapy may have on musicians suffering from chronic neck pain associated with playing−related musculoskeletal disorders. Purpose: The purpose of this study was to determine the effect of retained, dry cupping therapy on reducing pain−related disability in collegiate−level musicians with chronic neck pain. Main outcome measures: Baseline and postintervention follow−up data collection for visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder, and Hand

(QuickDASH), and Neck Disability Index (NDI), and active cervical range of motion.

Methods: A total of 5 musicians received 5 dry cupping therapy treatments with 4 days of rest between treatment sessions. Results: Both pain−related disability and active cervical range of motion improved in most participants after a series of 5 dry cupping therapy treatments on 3 acupuncture points in a musician population with chronic neck pain. Conclusion: Dry cupping therapy may be effective for improving pain, disability, and cervical range of motion in a musician population with chronic neck pain. Additional research must be conducted to further validate the findings of this study. 4

Preface

Chapter 3 contained within the thesis document serves as a prepublication manuscript. This manuscript has been formatted to meet the guidelines set forth by the

Journal of Athletic Training and Thesis and Dissertation Services at Ohio University. The reference citation style follows the guidelines of the AMA Manual of Style (10th ed.,

2007).

Dedication

My gratitude goes out to my family and loved ones for supporting me from a distance, the SHAPe Clinic patients and staff for giving me purpose, and to the men of 237 for picking me up when life became difficult. 6

Acknowledgments

I would like to thank the Ohio University School of Music for their support and participation in this research. I would also like to thank Dr. Jeffrey Russell, Dr. Timothy

Law, and Dr. Janet Simon for their guidance and belief in me during this research endeavor.

Table of Contents

Page

Abstract ...... 3

Preface...... 4

Dedication ...... 5

Acknowledgments...... 6

List of Tables ...... 10

List of Figures ...... 11

Chapter 1: Introduction ...... 12

Research Question and Hypothesis ...... 14

Independent Variable(s) ...... 16

Dependent Variable(s) ...... 16

Assumptions ...... 16

Limitations ...... 17

Delimitations ...... 17

Chapter 2: Review of Literature ...... 18

Introduction ...... 18

Neurobiology of Chronic Pain ...... 19

Diagnosis of Chronic Neck Pain ...... 21

Musicians and Neck Pain ...... 22

Treatment for Chronic Neck Pain ...... 24

Western Medicine Approach ...... 24 8

Conservative Treatment Methods ...... 24

Eastern Medicine Approach ...... 26

Acupressure Points and Meridians...... 27

Cupping Therapy ...... 29

Dry Cupping Therapy ...... 30

Adverse Effects of Cupping Therapy ...... 31

Safety Recommendations...... 31

Clinical Assessment of Chronic Neck Pain ...... 32

Visual Analog Scale (VAS) ...... 32

Neck Disability Index (NDI) ...... 33

Shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) ...... 34

Cervical Range of Motion (CROM) ...... 35

Conclusion ...... 37

Chapter 3: The Influence of Dry Cupping Therapy on Musicians with Chronic Neck Pain:

An Initial Case Series...... 39

Methods...... 43

Participant Demographics ...... 43

Procedures ...... 45

Outcome Variables...... 48

Statistical Analysis ...... 48

Results ...... 48

Cervical Range of Motion Outcome Measures ...... 49 9

Patient−Reported Outcome Measures...... 49

Treatment Compliance ...... 51

Adverse Events ...... 51

Discussion ...... 66

Pain Perception ...... 67

Cervical Range of Motion ...... 69

Patient−Reported Outcome Measures...... 70

Comparison of Interventions...... 70

Limitations ...... 71

Clinical Implications ...... 72

Areas of Future Research ...... 73

Conclusion ...... 73

Chapter 4: Conclusion...... 82

References ...... 84

Appendix A: Specific Aims ...... 99

Appendix B: Procedures Checklist ...... 104

Appendix C: Data Collection and Surveys ...... 105

Appendix D: Instrument Reliability...... 114

List of Tables

Page

Table 1: Participant Group Descriptive Statistics ...... 44

Table 2: Individual Participant Demographics ...... 44

Table 3: VAS Pain at Rest ...... 55

Table 4: VAS Pain While Playing ...... 55

Table 5: Neck Disability Index Scores ...... 56

Table 6: Quick Disiabilities of the Arm, Shoulder, Hand Scores (QuickDASH) ...... 56

Table 7: QuickDASH Performing Arts Module Scores ...... 57

Table 8: Cervical Flexion...... 58

Table 9: Cervical Extension ...... 58

Table 10: Cervical Right Lateral Flexion ...... 59

Table 11: Cervical Left Lateral Flexion...... 59

Table 12: Cervical Right Rotation ...... 60

Table 13: Cervical Left Rotation ...... 60

List of Figures

Page

Figure 1: Neck pain region diagram...... 22

Figure 2: Cun unit of measure...... 28

Figure 3: Dry cupping therapy over neck region...... 31

Figure 4: Diagram of acupuncture points...... 46

Figure 5: Subject 1 PROM data...... 61

Figure 6: Subject 1 CROM data...... 61

Figure 7: Subject 2 PROM data...... 62

Figure 8: Subject 2 CROM data...... 62

Figure 9: Subject 3 PROM data...... 63

Figure 10: Subject 3 CROM data...... 63

Figure 11: Subject 4 PROM data...... 64

Figure 12: Subject 4 CROM data...... 64

Figure 13: Subject 5 PROM data...... 65

Figure 14: Subject 5 CROM data...... 65

Chapter 1: Introduction

As complementary and integrative health practices emerge into clinical settings as therapeutic treatments, clinicians have the opportunity to provide options for satisfying patient care.1,2 The efficacy and safety of contemporary therapeutic modalities continues to be an area of frequent research whose results benefit both the clinician and patient. In the pursuit of delivering effective and quality health care, investigating the advantages and limitations of alternative treatment options relative to customary care is necessary to advance the practice of pain management. Such is the case with cupping therapy (CT), a form of traditional Chinese medicine that has been practiced for thousands of years, but has yet to enjoy concrete evidence to support its role in providing therapeutic benefits in musculoskeletal disorders.3–5 Of the various forms of CT, Cao et al6 reported that wet CT randomized controlled trials make up a majority (57.8%) of the CT literature.

For athletic trainers (ATs), a majority of the existing CT literature remains inapplicable to retained dry cupping, a noninvasive procedure that ATs may perform in their scope of practice. While, to our knowledge, no previous study has identified any 13 detrimental health benefits associated with dry cupping, clinicians should strive to critically analyze current practice methods and establish evidence−based protocols to support the use of CT for musculoskeletal injuries and disorders in an athletic training setting.

ATs in the performing arts setting may encounter patients with chronic musculoskeletal pain acquired from the accumulation of repetitive musculoskeletal activity.10,11 In musicians this can be referred to as playing−related musculoskeletal disorders (PRMDs), defined as an inability to play or perform due to pain, weakness, numbness/tingling, or other interfering symptoms.12 One systematic review estimated the prevalence of PRMDs in musicians to be 39% to 87% in adult musicians and 39% to 62% in secondary school music students.12 Health detriments and disability caused by the acquisition of PRMDs can negatively influence performing artists’ economic welfare and overall quality of life.13–15

Of these PRMDs, neck and shoulder complaints were frequent areas of complaint for musicians.12,13 In a cross−sectional study, Kok et al17 observed a 12−month prevalence of neck and shoulder complaints to be 2.6 times higher in music academy students compared to medical students. Of these students with PRMDs, only 46.3% visited a healthcare professional.17 This statistic brings light to the limited access to health care, possible distrust between clinician and patient, along with unfamiliarity as a medical community to treat the specific demands related to a musician population. As a general statement, there is public awareness regarding the unique demands required of an athlete to play a sport, but the same is not true when assessing the demands of a musician. 14

Previous research describes the need for equitable access to healthcare along with appropriate medical interaction and treatment for the musician population.1,18

The management of pain has become tightly integrated into quality patient care delivery. Treatment options for chronic pain in a traditional athletic training setting have been limited to electrical stimulation, local thermal therapy, manual therapy, and therapeutic exercise programs.19–24 Given the results from previous studies on CT for musculoskeletal pain, musicians and instrumentalists may yield benefits from multiple treatment sessions.7,25–28

Despite previous studies, English standardization of dry cupping parameters has not yet been established or validated for chronic nonspecific neck pain in a musician population.29,30 By implementing dry CT interventions into clinical practice for medically underserved populations such as performing artists, athletic trainers can utilize a cost−effective modality to supplement rehabilitative protocols. Considering the lack of current evidence, the purpose of this study was to determine the effect of retained, dry CT on reducing pain−related disability in university−level musicians with chronic nonspecific neck pain.

RESEARCH QUESTION AND HYPOTHESIS

1. Does dry CT decrease chronic neck pain in musician patients, as measured by a

visual analog scale (VAS)?

a. Immediately after the first treatment intervention, participants’ pain scores are

expected to decrease by a minimum of 14 mm out of 100 mm on the VAS

when compared to baseline values. 15

b. After a series of 5 CT treatments over the course of 3 weeks, participants’

pain scores are expected to decrease by a minimum of 14 on a 100 mm on the

VAS when compared to baseline values.

2. Does dry CT increase active cervical range of motion, as assessed with a dual

digital inclinometer in musician patients experiencing chronic neck pain?

a. Immediately after the first treatment intervention of dry CT participants’

active cervical flexion, extension, lateral side bending, and rotation are

expected to improve, if they are not already achieving full cervical range

of motion.

b. After a series of 5 CT treatments over the course of 3 weeks, participants

active cervical flexion and extension are expected to improve, if they are

not already achieving full cervical range of motion.

3. Does dry CT improve patient−related outcome measure scores for chronic neck

pain in musician patients?

a. After the first treatment intervention of dry CT participants will show no

difference in outcome scores for the Neck Disability Index (NDI) and

Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) with

Performing Arts subscale when compared to baseline measurements.

b. At 1−month follow−up after the last treatment intervention of dry CT,

participants will show no difference in outcome scores for the NDI and

QuickDASH with Performing Arts subscale when compared to baseline

measurements. 16

INDEPENDENT VARIABLE(S)

1. Time

a. Baseline data collection (week 1)

b. Posttreatment 1 (week 1)

c. Pretreatment 5 (week 3)

d. Posttreatment 5 (week 3)

DEPENDENT VARIABLE(S)

1. Visual Analog Scale (VAS)–0 to 100 points (on a 100 mm scale)

2. Neck Disability Index (NDI)–0 to 50 points

3. Short Form Disabilities of the Arm, Shoulder, and Hand Index (QuickDASH)–0

to 100 points

4. Active cervical flexion range of motion–degrees of motion

5. Active cervical extension range of motion–degrees of motion

6. Active cervical right lateral flexion range of motion–degrees of motion

7. Active cervical left lateral flexion range of motion–degrees of motion

8. Active cervical right rotation range of motion–degrees of motion

9. Active cervical left rotation range of motion–degrees of motion

ASSUMPTIONS

1. Evaluation of eligibility for participants remained consistent.

2. All participants abstained from any additional physical activity outside of normal

during the study. 17

3. Administration of treatments were performed by the same clinician to ensure

intrarater reliability.

4. All participants abstained from pain reducing and nonsteroidal antiinflammatory

medication use during the study.

LIMITATIONS

1. Participants with mild neck pain may see little to no changes in their scores and

clinical outcomes due to the floor effect.

2. Subject recruitment yielded a small sample size for statistical analysis; therefore,

the results of this study may not be generalizable.

3. Physical activity and instrument−related practice hours were not controlled for in

this study which could confound subjective interpretations of playing−related

pain.

4. No sham or control group was utilized in this study due to the small sample size

and side effects incurred by undergoing dry CT.

DELIMITATIONS

1. Participants were college−aged music students enrolled at Ohio University.

2. Baseline measurements will be obtained immediately before the first treatment

session.

3. Participants were compared against themselves.

Chapter 2: Review of Literature

INTRODUCTION

When working with a musician population, health practitioners can expect musculoskeletal complaints of the neck to be frequent and enduring.12,17 Due to the repetitive nature and occupational demands of instrumentalists, these performing artists may develop playing−related musculoskeletal disorders (PRMDs) that severely limits their overall performance technique and ability to earn a living.12 If musicians cannot work due to a PRMD, they may experience great financial loss and a shortened musical career. While musicians may wish to seek further medical care for their condition, their health care providers may be unfamiliar with a musician’s occupational demands. This may result in poor patient experiences; thus, musicians may choose to continue playing through pain, which is generally accepted within the performing arts culture.

Patients suffering from chronic pain report a higher frequency of complementary and integrative medicine use than the general population.31 Therefore, musicians suffering from chronic pain may actively seek nonconventional therapies to relieve pain and/or discomfort accumulated from PRMDs.12 Musicians are increasingly seeking out complementary and integrative health approaches to relieve suffering that results from

PRMDs1 because pain can interfere with their ability to play at their usual levels and can have devastating consequences on the professional, personal, social, and financial aspects of their lives.18,32

Given the lack of evidence−based practice methods of complementary and integrative therapies, the various types of traditional Chinese medicine applications 19 continue to be an area demanding research.33,34 Cupping therapy (CT), a form of traditional Chinese medicine, has yet to enjoy concrete evidence supporting its role in providing therapeutic benefits to patients who sustain musculoskeletal disorders.3–5 Given the high risk for functional disability and potential for fiscal insecurity incurred by developing PRMDs, further research evaluating CT as an evidence−based treatment intervention for musicians may prove advantageous. The following review of the current literature establishes several themes related to CT research in musicians: playing−related musculoskeletal disorders (PRMDs), diagnosis of chronic neck pain, conservative treatment for chronic NSP, differences between Western and Eastern medicine, theory of acupressure points and meridians, effects of CT, effects of local thermal therapy, and patient− and clinician−rated outcome measures used in this study.

NEUROBIOLOGY OF CHRONIC PAIN

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”35(p94) While experiencing pain is a normal process of life, the ability to regulate and maintain health can be compromised when the body is met with overloaded stress. Chronic dysregulation of physiological processes can result in aberrant nociceptive information leading to maladaptive spinal plastic changes.35,36 The transition from acute pain to chronic pain is multifaceted and complex in nature. For the purposes of this literature review, we will examine the neurobiology of the chronic pain phenomenon. 20

In patients suffering with chronic pain, central sensitization of nociceptive neurons occurs because of chronic inflammation and subsequent effects along the peripheral and central nervous system.37 It makes distinguishing differences from mechanosensitive information and nociceptive stimulation almost impossible. Musial et al37 hypothesized that naturopathic reflex therapies such as gua sha, cupping, and classical massage aim to influence perception and response to pain via ascending spinal pathways to the brain.

CT results in visible tissue trauma to the skin, resulting in increased local circulation which signal other chemical mediators (ie, histamine, serotonin, potassium ions, prostaglandins, bradykinin, interleukins, and tumor necrosis factor) to activate nociceptive responses which stimulate Aδ−fibers and C−fibers.9,37 Therefore, we can expect involvement of the spinothalamic−cortical pain pathway to be followed which can result in cortical (somatosensory cortex) and subcortical reorganization in response to chronic pain stimuli.33 Interestingly, Spohn et al38 suggested that cortical influences created from patient expectation and level of therapeutic alliance with the practitioner contribute to overall pain perception. Thus, attempting to control and eliminate these factors would be counterintuitive since these influences play a role in the therapeutic net effect and are integrated into clinical practice. Chronic pain state affects psychological processing and behavior changes in perception, attention, mood, motivation, learning, and memory.39 A recent systematic review conducted by Mansfield et al40 found a significant relationship between pain, leisure, work time habits, and physical activity.

This review claimed that participants experiencing chronic neck pain were less likely to 21 participate in physical activity whether it be related to leisure or work.40 This self−limiting disability may only further the detrimental effects of inactivity and impact overall physical and mental health. Therefore, effective management of chronic neck pain conditions should address overall health status and well−being since local treatment may not prove to be effective enough.

The central nervous system’s neuroplastic ability can be both adaptive and maladaptive for optimal performance. In the realm of musculoskeletal injuries, Roy et al41 commented on recent evidence to support how peripheral injuries must not only be treated at the joint level, but treatment should also consider neural feedback mechanisms that play role into the motor control output clinicians see during assessment. Therefore, maladaptive motor strategies may be an output of a reorganized central nervous system as an attempt to protect and minimize pain. These neurobiological changes can be further reinforced in patients with chronic neck pain by central sensitization mechanisms.

DIAGNOSIS OF CHRONIC NECK PAIN

Approximately 116 million American adults suffer from chronic pain and struggle to secure medical care that may cure or improve their health−related quality of life.29

Chronic neck pain is a multifactorial condition that embodies a wide spectrum of disorders ranging from self−reported pain to more definitive clinical diagnoses.42 There is a lack of general consensus about what constitutes “chronic” pathology; however, previous studies examining participants with chronic neck pain note that symptoms and/or pain persist for at least 3 months.7,25,43–45 In an attempt to characterize the severity of the pain experienced by chronic neck pain participants, setting a lower limit inclusion 22 criteria of anywhere from at least 3025,46 to 4518 on a 100 mm VAS pain intensity scale is technique used in research. Takasawa et al47 described the symptoms as muscular tightness that may result in pressure and pain spanning across the base of the occiput to the spine of the scapula, which can be seen through an easily interpretable figure demonstrating the defined anatomical geography (see Figure 1). Our research incorporated this definition to aid in the recruitment of potential study participants.

Figure 1. Neck pain region diagram.

MUSICIANS AND NECK PAIN

An estimated 85% of musicians experience a pain affecting their playing performance over a lifetime, with the highest reported areas within the neck and low back.48 When compared to the general population, musicians and instrumentalists are 23 reported to have an increased rate of neck pain (25.5%) compared to the prevalence in the world population (6%−22%). Musicians frequently exhibit neck pain; Kok et al15 observed higher rates of neck pain in music academy students (46%) compared to medical students (27%) at 12−month point prevalence. Accessibility and utilization of health care resources among collegiate musicians trying to manage their pain is still unknown.

Development of chronic neck pain is partially influenced by a musician’s posture dynamics and repetitive strain of the upper extremity while playing.49 Over time, the repetitive nature and postural strain incurred by these performers can result in the development of overuse syndromes, which have been projected to be the most common musculoskeletal complaint by musicians.50 These types of injuries can be characterized as playing−related musculoskeletal disorders (PRMDs), defined as pain or musculoskeletal complaints among musicians.9 A systematic review of PRMDs by Zaza10 estimated a

PRMD prevalence of 39% to 87% in adult musicians and 39% to 62% prevalence in secondary school music students. Health detriments and disability caused by the acquisition of PRMDs can negatively influence the performing artists’ economic welfare and overall quality of life.11,12 The musician population exhibits a high prevalence of upper extremity PRMDs.15,16,51,52 Of the musculoskeletal ailments afflicting musicians, chronic neck pain resulting from PRMDs is of particular interest due to the dynamic postural playing positions these artists must sustain to create music.10,42

TREATMENT FOR CHRONIC NECK PAIN

Western Medicine Approach

The evolution of medicine and healthcare systems across the world have monumental implications to the patients they serve. Different regions and eras are associated with their own concepts of how medicine should be delivered along with a distinctive ideology behind the clinical decision−making process. Western and Eastern medicine practitioners take different methodological approaches to the delivery of patient care, which may stem from varying epistemologies and schools of thought.

Western health systems have been identified collectively as a market of incentives for health care providers that results in costly medical expenses for patients.53 The United

States Bone and Joint Institute54 recognizes the large economic impact that management of chronic musculoskeletal disease has on the current healthcare system. To help solve this crisis, more research has been proposed to establish well−validated instruments that measure both the value and cost−effectiveness of disease prevention and management programs.54 Western medicine has focused on a disease−oriented approach, with a slow paradigm shift toward patient−centered care. Technological advances allowing for the discovery of germs, causes of disease states, and a disease classification system have provided the foundation of Western medicine and sciences.55 While medical advances develop, the ability to create efficient and cost−effective healthcare delivery lags behind.

Conservative Treatment Methods

A systematic review by Gross et al56 supported the effectiveness of conservative treatments (manual therapies, physical medicine methods, medication, and patient 25 education) on mechanical neck disorders. Of the 88 randomized control trials assessed, the authors determined that the use of therapeutic exercise combined with mobilization/manipulation and intramuscular lidocaine injections resulted in intermediate or long−term benefits.56 Other systematic reviews have reached similar conclusions about the effectiveness of manual therapy combined with therapeutic rehabilitation57,58 and even of manual therapy alone21 for reducing mechanical neck pain and increasing short−term patient satisfaction. Celenay et al57 observed decreases in Neck Disability

Index scores exceeding the MCID value after 4 weeks of progressive cervical and scapulothoracic exercise programming with conjunctive manual therapy (cervical and scapular mobilizations). However, the authors expressed concerns about the clinical significance of their findings due to the overlap seen in their 95% confidence intervals. A study by D’Sylva et al58 further elaborated on the low−level quality of evidence available comparing manual therapy when compared to conventional physiotherapy, general practitioner care, and exercise alone protocols. Given the complex etiology and the time commitment necessary to treat chronic neck pain, it is no surprise that patients suffering from chronic pain report a higher frequency of complementary medicine use compared to the general population.29 An estimated 116 million Americans are currently suffering from chronic pain, with approximately 40% of that population failing to achieve any sort of adequate relief from conventional medicine practices.29 For these chronic pain patients, complementary and integrative health practices offer another opportunity to seek improvements toward their pain, function, and overall quality of life.

Eastern Medicine Approach

Eastern medicine is rooted in cultural and ideological theories that result in a holistic approach often implementing the use of complementary and integrative health treatments. Previous literature recognizes that patients use both conventional and complementary and integrative health for the treatment of chronic musculoskeletal disease.59 Complementary and integrative health therapy or “unconventional therapy” have become increasingly popular among the general population. A national telephone survey conducted in 1997 and 1998 found that in participants reporting back or neck pain, 37% visited a conventional provider while 54% sought complementary therapy.60 A

CDC survey conducted in 2007 reported that approximately 40% of all adults in the U.S. already use some form of complementary medicine.61 Musicians, as part of the performing arts community, often describe the need for equitable access to healthcare along with appropriate medical interaction and treatment for the musician population.16

Health care practitioners must be adequately versed in the wide array of both traditional and non−traditional modalities available to treat and manage musculoskeletal pain in a highly, specialized occupational group as with the case in musicians. Conventional hospital visits and expensive diagnostic screenings may not be financially viable or accessible to a majority of this population.16,30 As conventional Western medical services become increasingly inaccessible, alternative therapies may offer musicians the ability to functionally return to playing with significantly decreased financial/economic burden.50

Traditional Chinese medicine (TCM) falls under the umbrella of complementary and integrative health treatments, including, but not limited to herbal medicine, 27 acupuncture, CT, massage or tui na, and moxibustion.62 The TCM clinical practice paradigm revolves around individualized patient care and TCM syndrome differentiation rooted in a holistic−approach to medicine.62,63 The ideology and principles governing the practice of TCM are derived from Chinese philosophy and culture. The theories and concepts of Yin−Yang, 5 Elements, Zang−fu, Qi (vital energy), and meridians have yet to be validated by western medicine practitioners or elucidated by high−quality scientific evidence.62 In recent years, a trend of non−Asian countries have recognized the practice and therapeutic benefits of TCM as another option for treatment to aid in health maintenance.31

Acupressure Points and Meridians

Acupuncture is a form of TCM that involves the use of sterile, filiform needles that are placed on specific anatomic locations—known as meridians—to stimulate various acupuncture points.31,62 These meridians are thought to exist along longitudinal sectors on the body that may resemble myofascial trigger point and dermatome patterns.62–64 The meridian system outlines the constellations of acupressure points that are specifically related to certain body parts, organs, or systems reflecting the purpose of acupuncture treatment.65 For example, SI 15 jianshongshu is associated with shoulder pain, back pain, and coughing.23 A proposed theory behind the mechanism of action of acupuncture focuses on the stimulation of the neuroendocrineimmune network, which is a result of a cascade of neurobiological processes that effect the central nervous system’s ability to process pain and cell function.66

To pinpoint the superficial anatomical location of each acupressure point, 28 clinicians use a proportional unit of measurement referred to as cun (see Figure 2). By using the patient’s own finger width along with anatomical landmarks, clinicians can account for the variations in body type and structure; however, if the practitioner and patient have equal finger width, it may be more feasible for the practitioner to use his/her own fingers for reference. Cupping therapy (CT), another form of TCM, is also predicated on the location of the acupressure points, which is the primary intervention of this study.

Figure 2. Body/proportional cun as a unit of measure.67 Identifying the location of acupuncture points is individualized based on the patient’s finger width. Each section of the body is divided into quantifiable units of measurements using a combination of structural anatomical landmarks and specified body/proportional cun measurements.

CUPPING THERAPY

Cupping therapy (CT) is a form of TCM that has been practiced for the past 2,000 years. It is often applied for pain, cardiovascular diseases, immune system disease, and various types of metabolic diseases.3,68 The physiology and mechanism of action for CT have not been scientifically explained; but, research suggests that the placement of the cups on acupressure points may result in therapeutic benefits.30,68 The cups themselves can be made from different materials such as bamboo, glass, or earthenware.68

While various forms and combinations of CT exist, there are seven types that are most commonly practiced in China: (1) Retained cupping, (2) Wet “bleeding” cupping,

(3) Kinetic “moving” cupping, (4) Empty cupping, (5) Needle cupping, (6) Medicinal

“herbal” cupping, (7) Water cupping.68 The suction created by the negative pressure exerted on the dermis produces hyperemia around the treatment area.62 A systematic review conducted by Cao et al68 noted that wet cupping and retained cupping were the most evaluated primary interventions, having been the subject of 58% and 17% of prior studies, respectively. Conclusions drawn from this systematic review suggest that the overall evidence is not strong enough to draw concrete clinical recommendations due to the high variation in methodology among studies.68 Although these forms of cupping have received research attention, Fung et al31 identified the lack of uniformity associated with TCM research and attempts to adapt evidence−based medicine principles into practice. Without proper peer−reviewed randomized clinical trials, practitioners of CT risk drawing biased conclusions from the current literature.

Dry Cupping Therapy

CT has gained increased popularity in recent decades and has regained much popularity within the mid−20th century.69 General public interest and commentary on this ancient practice was heightened even further when a notable Olympic swimmer was seen to have obscure, round bruising along his body as he toppled previous world records in the 2016 Rio Olympics in Rio de Janiro, Brazil.69,70 Dry cupping, otherwise known as retained cupping, can be described as a method of applying a heated or suction type cup on specific superficial anatomical point on the patient’s body to facilitate increased blood flow and healing.8,9 When the cups are applied, a negative−pressure difference is created which allows for suction of the skin upwards toward the top of the cup.8,71 An example of how the procedure appears can be seen in Figure 3. Previous research in this field has identified potential therapeutic benefits when incorporating CT into the management of musculoskeletal pain.72 When compared to existing modalities for the treatment of musculoskeletal pain, for example electrical stimulation73 or stretching,74 dry CT continued to demonstrate positive outcomes for pain, disability, and overall health status.

However, it is worthy to note that the quality and level of evidence gained from systematic review of the available literature concludes that no professional clinical recommendations can be made to support the use of CT in the management of musculoskeletal disorders. With this understanding, more high−quality research studies need to be conducted to further elucidate the benefits or lack of benefit dry CT can have for patients suffering with musculoskeletal diseases.

Figure 3. Dry cupping therapy over the neck region.

Adverse Effects of Cupping Therapy

The most common adverse effects of dry CT are the resultant erythema, edema, and ecchymosis present after treatment application.3,4,75 Skin markings after therapy are expected, but not harmful, and patients should be educated to prevent apprehension.

Although CT has not reported any association with keloid formation in the Chinese population, there has been one documented case in the United States.76 Another case report demonstrated a risk of postinflammatory hyperpigmentation as a rare complication after receiving CT on the lower back.3,75 A risk of developing these types of skin disorders is present, but the chances of permanent harm to the patient are rare. Risks such as skin burns and cross−contamination are present in flash “fire” and wet “blood” CT practices respectively; thus, they do not pertain to the manual suction of dry CT practices.4 As future research moves forward, standardization of CT protocols may reduce the occurrence of adverse events and help establish recognized health and safety measures.5,30,77

Safety Recommendations

Safety procedures and protocols for TCM modalities (i.e. gua sha, wet cupping, 32 and dry cupping) have been recommended. Given the expectation of skin surface trauma caused by dry CT, providing a rest period of 2 to 4 days between CT sessions would be a wise choice.44 Also, if clinicians practice with reuseable cupping ware, the equipment should be cleaned immediately after use and disinfected with a registered hospital−grade disinfectant. It is recommended that clinicians wear appropriate personal protective equipment such as gloves during the treatment procedures.77

CLINICAL ASSESSMENT OF CHRONIC NECK PAIN

Visual Analog Scale (VAS)

The Visual Analog Scale (VAS) is a highly reliable and commonly used instrument to assess overall pain intensity.78,79 The VAS self−reported graphical rating used in research to determine the pain severity perceived by the participant taking the survey. Endpoint values of the VAS were labeled “no pain” and “worst imaginable pain”.

Participants are instructed to place a vertical mark within the continuum between the marked endpoints.

Pain and injury are closely associated with participation in highly repetitive movements associated with being a classical musician.80 Clinical assessment of pain is complex and is difficult to find absolute certainty how much pain should be expected in a given pathological state.81 However, the following can help clinicians interpret scores reported via VAS: 1–30 = mild pain, 31–54 = moderate pain, and greater than 54 = severe pain.82 When interpreting outcomes data collected over a period of time, a score of

30 points or less after receiving treatment can be considered an acceptable symptom state for most patients.83 A consensus statement issued by the Initiative on Methods, 33

Measurement, and Pain Assessment in Clinical Trials (IMMPACT)79 further clarified the meaning of change scores into minimally important (10–20% decrease), moderately important (30% decrease), and substantially important (50% decrease).

In a study that evaluated patients with rotator cuff disease, researchers demonstrated that the minimal clinically important difference (MCID) will be a 14−point improvement on the VAS outcome measure.83 The MCID for VAS scoring in patients with chronic pain must be a difference greater than 10 mm (10%) relative to initial baseline measurements. Although Bird et al84 recommended an MCID of 13 mm, the participants in their study consisted of a convenience sample of emergency department patients and is not a suitable comparison for the purpose of the proposed investigation.

When looking at the validity and reliability the VAS in patients with chronic musculoskeletal injury, Boonstra et al78 concluded that reliability for pain is good

(Spearman’s correlation coefficient range 0.60−0.77) while the validity for disability will be not confirmed. Overall, the VAS can be trusted for subjective measurements of pain.

Neck Disability Index (NDI)

The Neck Disability Index (NDI) is the most clinically researched and frequently used patient−related outcome measure that evaluates cervical neck pain and functional limitations.43,85,86 This measure comprises a total of 10 items where a maximum score of

50 points and a minimum of 0 points can be achieved; a higher score indicating more disability and a score of 0 resulting in no disability.87 Each section of the NDI is graded on a 6−point scale and the total score can be summed up out of a total of 50 points, although some evaluators may express the final score as a percentage to possibly account 34 for unanswered items.86,88 A higher score on the NDI indicates greater disability associated with the participant’s neck disorder.43,88 A high level of test−retest reliability

(ICC = 0.89) and internal consistency will be demonstrated by the NDI.88

The MCID for the NDI is a raw score of 9.5 (19% change) in whiplash patients,85 but a raw score of 7 points based on a systematic review of literature in patients with chronic neck pain.86 Although the minimal detectable change (MDC) can range from 2 to

10 points,87,89 a 5−point (10% change) difference is acceptable in patients with uncomplicated neck pain.26,86 The NDI has been shown to be a reliable, valid, one−dimensional measurement tool with which to assess patients with cervical pain and functional disability.86,90

Shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH)

The QuickDASH is an 11 question, patient−related outcome measure that reports the physical function and level of disability in patients with musculoskeletal disorders in the upper extremity.91 This measure is adapted from the original 30−item Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure. Scores from the QuickDASH can be calculated by adding all the circled responses, dividing by the total number of items, subtracting a value of one from the result, and finally multiplying the value by 25 to achieve a score out of 100; a higher score indicating increased disability.92 The

QuickDASH can be calculated when a respondent leaves a question unanswered; however, no more than 2 missing responses are allowed. The QuickDASH does not include any form of neck specific questions and cannot provide a clear assessment of neck disability.91 An advantage of the QuickDASH is that it offers optional work and 35 sports/performing arts modules. However, no research could be located that indicates these modules have been validated in a musician population.

According to the DASH and QuickDASH User’s Manual,93 both instruments can be used for clinical and/or research purposes. The DASH has been previously used by occupational therapists to evaluate the disability sustained by collegiate−level musicians and will be found to be clinically relevant.94 Although the QuickDASH is a shorter inventory of items, it is reliable, valid, and responsive in patients with upper−extremity joint injuries when compared to the full DASH.92 In one research study conducted on 102 patients undergoing non−operative treatments, MCID for the QuickDASH will be estimated to be 14 points.95 Another study conducted by Franchignoni et al96 estimated an

MCID of 16 and an MDC of 13 for the QuickDASH. Both authors recommend that

MCID values should be used with caution due to the high population variation when implemented to monitor individual change.95,96

Cervical Range of Motion (CROM)

A systematic review conducted by deKonig et al97 determined that a single inclinometer and a Cybex electronic digital instrument (EDI−320) has the best overall clinimetric properties in regards to reproducibility, validity, and responsiveness in patients with nonspecific neck pain. However, Cupon et al98 cited recent editions of the

AMA Guides to the Evaluation of Permanent Impairment that endorse the utilization of a dual digital inclinometer to measure spinal range of motion. The use of a dual digital inclinometer also is supported by Yong et al99 to measure active cervical range of motion when quantifying joint position sense. 36

Cervical range of motion measurements will be assessed with a dual digital inclinometer (Acumar Model ACU002, Lafayette Instrument, Lafayette, IN,

USA). For reach range of motion measurement, a total of 3 trials will be taken with the mean of the 3 trials during each time point assessment used for statistical analysis.

To measure flexion and extension, the participant will be seated with his or her head in a neutral start position. The clinician will instruct the participant to close his or her eyes as the dual digital inclinometer is placed at the top of the head in the sagittal plane and on the C7 spinous process. After proper placement, the ZERO button on the dual digital inclinometer will be pressed and the participant will be instructed to perform either maximal cervical flexion to cervical extension. The participant then will be asked to return the head to neutral position.

To measure lateral right and left cervical flexion, participants will be seated with their head in a neutral start position. The clinician will instruct the participant to close his or her eyes as the dual digital inclinometer is placed at the top of the head in the frontal plane and on the T1 spinous process. After proper placement, the ZERO button on the dual digital inclinometer will be pressed and the participant will be instructed to perform either maximal right or left cervical flexion. The participant then will be asked to return the head to neutral head position. During the total arc cervical range motion assessment, the clinician will inquire at which degree does the participant experience neck and/or shoulder pain with the performed movement.

To measure right and left cervical rotation, participants will lay supine on a flat examination table with the head in a neutral start position. The clinician will instruct the 37 participant to close his or her eyes as a single digital inclinometer is placed at the top of the forehead oriented in the transverse plane. After proper placement, the ZERO button on the dual digital inclinometer will be pressed and the participant will be instructed to perform either maximal right or left cervical rotation. The participant then will be asked to return their head to neutral head position.

CONCLUSION

Dry CT was developed over 2,000 years ago and used to treat various medical diseases and conditions. With the emergence of dry CT in Western clinical practice, clinicians are challenged by the proposed benefits this modality has to offer. Given the current economic climate, the management of chronic pain has shifted toward mitigating opioid addiction and emphasizing other cost−effective therapeutic approaches of treatment. While dry CT may have benefits in the treatment of systemic disease based on traditional methodology, there is a need to clearly identify outcomes related to the treatment and management of chronic musculoskeletal disease.

To our knowledge, there is no current evidence to establish the therapeutic benefits of dry CT for musicians with chronic neck pain. Minimal evidence exists supporting the use of CT for musculoskeletal conditions; however, the quality and bias associated with previous research limit the conclusions drawn from the results. Among musicians, poorly managed chronic neck pain may not limit performance, but certainly would be a distraction. However, significant time loss is associated with the development of playing−related musculoskeletal disorders in musicians. Combined with prior research 38 performed on other chronic musculoskeletal conditions, current investigation of CT on chronic neck pain is promising.

Attempts to standardize the application of CT in clinical settings will be beneficial to current practitioners who wish to provide evidence−based patient care. Further research is needed to understand which patients will best respond to treatment. Also, investigation regarding the frequency and intensity of application of CT for certain musculoskeletal injuries and conditions is warranted to further advance clinical care.

Integration of Eastern medicine concepts such as acupuncture points and meridians through a noninvasive form of treatment, such as CT, may be a potential opportunity to improve clinical practice and treatment methods for chronic musculoskeletal disorders.

Chapter 3: The Influence of Dry Cupping Therapy on Musicians with Chronic Neck

Pain: An Initial Case Series1

Context: Up to 84% of musicians experience pain affecting playing ability.

Playing−related musculoskeletal disorders, like chronic neck pain, can be debilitating and inhibit optimal performance in musicians. Cupping therapy has entered musculoskeletal medicine as a possible treatment for chronic neck pain. Some studies have examined therapeutic benefits of cupping on patients with chronic neck pain; however, high quality clinical trials focused on treatment of chronic nonspecific neck pain are still warranted.

Objective: To determine the effect of retained, dry cupping therapy treatments on collegiate musicians’ perception of pain and upper extremity function. Design: Case series. Setting: University clinical setting. Participants: Five collegiate musicians (age =

19 ± 2 years, height = 170 ± 9.4 cm, weight = 82.1 ± 21.8 kg), with chronic nonspecific neck pain. Data Collection: Preparticipation surveys were sent to university musicians.

Eligible participants attended 5 dry cupping treatment sessions for the neck. Patient pain perception at rest and while playing his/her instrument were assessed by visual analog scale (VAS). The Neck Disability Index (NDI) and Quick Disabilities of the Arm,

Shoulder, and Hand (QuickDASH) were used to assess upper extremity function. Active

1 This chapter represents a prepublication manuscript to be submitted to the Journal of Athletic Training (August 2018). Authors are: Aaron S. Ngor, AT (School of Applied Health Sciences and Wellness, Ohio University, Athens); Janet E. Simon, PhD, AT (School of Applied Health Sciences and Wellness, Ohio University, Athens); Timothy D. Law, Sr., DO, MBA (Heritage College of Osteopathic Medicine, Ohio University, Athens); and Jeffrey A. Russell, PhD, AT, FIADMS (School of Applied Health Sciences and Wellness, Ohio University, Athens). 40 cervical range of motion (ACROM) for flexion, extension, lateral flexion, and rotation were also evaluated. Data collection timepoints included baseline measurements, immediately after the first treatment, and before and immediately after the fifth (last) treatment. Data Analysis: Descriptive statistics (mean, median, range, standard deviation, and 95% confidence intervals) were calculated for each dependent variable for the entire group across time. Additionally, individual analysis was conducted by for each participant for all dependent variables across time. Inferential statistics were not calculated due to the small sample size. Results: Group differences for pain at rest and active cervical range of motion improved in most participants posttreatment.

Conclusions: Dry cupping therapy may be effective for improving pain and ACROM in musicians with chronic neck pain. However, these effects do not seem to benefit musicians with high amounts of playing−related stressors. This suggests that the mechanism of cupping may be inhibited when cognitive and psychological risk factors are present.

Key Words: performing artist, traditional Chinese medicine, inclinometer, playing−related musculoskeletal disorder

Key Points

• Dry cupping therapy is an overall safe and effective therapeutic modality for

musicians with chronic neck pain.

• Musicians with increased levels of stressors and high perception of pain may

not respond to a series of dry cupping treatments; therefore, further

assessment and treatments may be warranted. 41

As complementary and integrative health practices emerge into clinical settings as therapeutic treatments, clinicians have the opportunity to provide options for satisfying patient care.1,2 The efficacy and safety of contemporary therapeutic modalities continues to be an area of frequent research whose results benefit both the clinician and patient. In the pursuit of delivering effective and quality health care, investigating the extent and limitations of alternative treatment options is necessary to advance the practice of pain management. Such is the case with cupping therapy (CT), a form of traditional Chinese medicine that has been practiced for thousands of years, but has yet to enjoy concrete evidence in its role in providing therapeutic benefits in musculoskeletal disorders.3–5 Of the various forms of CT, a systematic review of literature conducted by Cao et al6 reported that wet CT randomized controlled trials make up a majority (57.8%) of the CT literature.

Wet cupping is an invasive procedure that requires laceration of the superficial dermis to allow for bloodletting.7 The perceived purpose of this form of cupping assumes that the area being treated has an imbalance of qi and healthy blood circulation. Therefore wet cupping is often used to remove blood congestion and increase lymphatic circulation.6,7 For athletic trainers (ATs), a majority of the existing CT literature remains inapplicable to retained dry cupping, a noninvasive procedure that ATs may perform in their scope of practice. While, to our knowledge, no previous study has identified any detrimental health benefits associated with dry cupping, clinicians should strive to critically analyze current practice methods and establish evidence−based protocols to 42 support the use of CT for musculoskeletal injuries and disorders in an athletic training setting.

Athletic trainers in the performing arts setting may encounter patients with chronic musculoskeletal pain acquired from the accumulation of repetitive musculoskeletal activity.8,9 In musicians this can be referred to as playing−related musculoskeletal disorders (PRMDs), defined as an inability to play or perform due to pain, weakness, numbness/tingling, or other interfering symptoms.10 Of these PRMDs, neck and shoulder complaints are frequent areas of complaint for musicians.12,13 In a cross−sectional study, Kok et al13 observed a 12−month prevalence of neck and shoulder complaints to be 2.6 times higher in music academy students compared to medical students. Of significant concern is that only 46.3% of those students reporting neck and shoulder complaints visited a healthcare professional.13 Health detriments and disability caused by the acquisition of PRMDs can negatively influence performing artists’ economic welfare and overall quality of life.12,14,15

As a general statement, there is public awareness regarding the unique demands required of an athlete to play a sport, but the same is not true when assessing the demands of a musician. Previous research describes the need for equitable access to healthcare along with appropriate medical interaction and treatment for the musician population.1,16

The management of pain has become tightly integrated into quality patient care delivery.

Treatment options for chronic pain in a traditional athletic training setting have been limited to electrical stimulation, local thermal therapy, manual therapy, and therapeutic exercise programs.17–22 Given the results from previous studies on CT for neck pain, 43 musicians and instrumentalists may derive benefits from multimodal treatment techniques.7,23–26

Despite previous studies, English standardization of dry cupping parameters has not yet been established or validated for chronic nonspecific neck pain in a musician population.27,28 By implementing dry CT interventions into clinical practice for medically underserved populations such as performing artists, athletic trainers can utilize a cost−effective modality to supplement rehabilitative protocols. Considering the lack of current evidence, the purpose of this study was to determine the effect of retained, dry CT on reducing pain−related disability in university−level musicians.

METHODS

Participant Demographics

We enrolled 1 male and 4 female university level musicians 18 years or older with chronic neck pain. The sample population completed the informed consent agreement, initial questionnaires, met the inclusion/exclusion criteria, and were from the university’s music department. At the end of the study, all participants were offered the opportunity to continue the treatment if they wished to do so. Ohio University’s Institutional Review

Board approved this study’s protocol.

Table 1. Participant Group Descriptive Characteristics Mean ± SD

19 ± 2 Age (years)

Height (cm) 170 ± 9.4

Body mass (kg) 82.1 ± 21.8

Table 2. Individual Participant Demographics Previously treated with Sex Instrument BMI (kg/m2) dry cupping Subject 1 Female French Horn, 49.2 No Mellophone Subject 2 Male Vocalist 58.3 No

Subject 3 Female Violin 39.1 No

Subject 4 Female Trumpet 56.5 Yes

Subject 5 Female Viola 34.9 Yes

To be eligible for this study, participants were required to meet the following inclusion criteria: male or female age 18 years or older (if female, they must have reported not being pregnant); enrolled either part−time or full−time at the university; participated in music classes, rehearsals, and/or performances at least 15 hours per week on average; had at least 5 years of playing experience; were currently experiencing chronic, nonspecific neck pain within the last year that had not been relieved during the past 3 months or longer1−6; and presented with a minimum score of 40 mm intensity on a 45

100 mm visual analog scale (VAS) for either pain at rest or with movement in the neck area.

Volunteers were excluded from the study if they reported a history of whiplash−associated disorders, head injuries, or invasive treatments of the spine

(acupuncture, injections, spinal surgery, etc.) within the last 4 weeks2−4,6; were diagnosed with a neck pathology, including, but not limited to disc protrusion, cervical radiculopathy/neuropathy, inflammatory rheumatologic disease, active oncologic disease, fracture, infection, congenital malformation of the spine2−4,6; reported signs of weakness or numbness in the upper extremities; declared use of substances containing caffeine, tobacco, or nonsteroidal antiinflammatory medication within 4 hours prior to baseline and final measurements4,5; or did not agree to abstain from analgesic medications during enrollment in the study.

Procedures

Questionnaire. Participants were given a questionnaire via the Qualitrics online survey system (Qualtrics, Inc., Provo, UT) to determine their eligibility for the study.

Participants were then asked to complete the following surveys during data collection time points: Visual Analog Scale (VAS), Neck Disability Index (NDI), and Quick

Disabilities of the Arm, Shoulder, and Hand (QuickDASH), including the Sports and

Performing Arts Module. Height and weight measurements were obtained for each participant. 46

Equipment. Testing procedures were conducted in a university athletic training clinic for performing artists. Cervical range of motion data were obtained with a digital inclinometer (Acumar Model ACU002, Lafayette Instrument, Lafayette, IN, USA).

Acupuncture Points. Based on data and procedures from previous studies on CT, 3 acupuncture points on the posterior, bilateral paraspinal areas of the neck(EX−HN1529,

SI−1523,29, and GB−2123,29) were used.. Figure 3 shows these pictorially and uses 1 cun as a standard measurement of reference for this procedure, the width of the interphalangeal joint of the thumb at its widest point was used to locate the individualized acupuncture points in combination with standard anatomical landmarks. To locate GB−21, the clinician identified the spinous process of C7 and the most lateral tip of the acromion, then selected the midpoint of the highest level of the trapezius within the sagittal plane.

The clinician then pinpointed SI−15 by beginning at the spinous process of C7 and tracing the area 2 cun lateral to the lower border of the spinous process of C7. Finally, the clinician determined the location of EX−HN15 after locating the spinous process of C7 and identifying the area 2 cun superior to the C7 vertebrae and 1 cun lateral to the midline.

Figure 4. Diagram of acupuncture point locations for chronic neck pain treatment. 47

Dry Cupping Procedure. Prior to enrollment as part of the medical disclaimer all participants were presented with a visual graphic of the cupping procedure along with a written description explaining the side effects and risks of undergoing treatment. The intervention consisted of 5 total treatments, with 4 days of rest in between treatment sessions to allow for ecchymotic dermal cupping marks to fade away.30 All clinical measures were completed first as a baseline score before initial treatments were administered during the first treatment session, immediately after the first treatment, prior to the final treatment session, and again immediately after the final treatment session.

Follow−up measurements were recorded at 1 month (approximately 25 to 30 days) following the last treatment session.

Sterile, reusable medium dry cupping cups (Hansol Medical Co., Ltd. Seoul,

Korea) of 4 cm (for the GB−21 and SI−15 acupuncture points) and 3 cm (for the

EX−HN15 acupuncture point) in diameter were used.5,23 The cups were then cleaned immediately after use with a registered hospital−grade disinfectant.5,31 Clinicians wore appropriate personal protective equipment such as gloves during the treatment procedures.31

Participants were asked to lay prone on a treatment table with their upper torso bared, with upper neck and shoulder exposed (women wore a sports bra or other appropriate garment that exposed the treatment area).24,30 The CT was performed by the principal investigator, a licensed athletic trainer who is trained in cupping and regularly performs cupping in a clinical setting. The cupping procedure was conducted as follows:

(1) An alcohol wipe was used to prepare the treatment area of the skin; (2) a 48 hand−operated mechanical suction device was attached to the cup prior to the cup’s placement on the treatment area; (3) the cups were placed over the 3 acupuncture points in quick succession bilaterally starting with GB−21 to SI−15 to EX−HN15 by applying 2 full pumps of mechanical suction32; and (4) the cups were removed after 10 minutes of application. The entire treatment time totaled 10 minutes for each side of the body, a duration within parameters found in the existing cupping literature.23,24,29,30

Outcome Variables

The independent variable of this study was application session over time.

Dependent variables were points on the VAS, points on the NDI, points on the

QuickDASH (both the main section and the sports and performing arts section), and active cervical range of motion measurements for flexion, extension, right lateral flexion, left lateral flexion, right rotation, and left rotation in degrees of motion.

Statistical Analysis

Descriptive statistics (mean, median, range, standard deviation, and 95% confidence intervals) were calculated for each dependent variable for the entire group across time. Additionally, individual analysis was conducted by for each participant for all dependent variables across time. Inferential statistics were not calculated due to the small sample size.

RESULTS

Group means, standard deviations, range, and 95% confidence intervals for all dependent variables are shown in Tables 2 through 12. Individual analyses for all dependent variables across time are displayed in Figures 6 through 15. 49

Cervical Range of Motion Outcome Measures

When comparing changes in active cervical range of motion from baseline to immediately after the fifth CT session, group differences across all time points yielded range of motion increases in all directions. Taking the values from Tables 6 through

Table 12, we can observe an increase of 13° for cervical flexion, 15° for cervical extension, 13° for right lateral flexion, 11° for left lateral flexion, 25° for right rotation, and 24° for left rotation. The standard deviations associated with each variable have considerable overlap; therefore, it would be ill−advised to use these values as a standard benchmark or expectation when performing dry CT over the neck and shoulder region.

Patient−Reported Outcome Measures

The Visual Analog Scale (VAS) for baseline pain at rest ranged from 24 to 58, corresponding to mild to severe pain during the week before the study. When comparing

VAS baseline to immediate postintervention, group statistics for pain at rest demonstrated an average decrease of 20 mm. At 4 days following the first CT session, group statistics for pain while playing an instrument demonstrated an average decrease of 10 mm when compared to baseline scores. Observations at the individual level revealed that 4 out of 5 participants met the minimum clinically important difference (MCID ± 14 mm) for pain; however, of those 4 participants, 3 subjects (Subject 1−3) experienced decreases in pain while 1 subject (Subject 5) experienced increased pain severity. After the completion of the 5−series retained, dry CT intervention, the data show greater differences when comparing changes from baseline as opposed to immediately after the first treatment application of CT. When further analyzing the data at the individual level, all subjects 50 displayed greater than 20 mm changes. It is important to note that of those same subjects,

1 subject (Subject 5) demonstrated an increase in pain rather than a decrease in pain severity.

The Neck Disability Index (NDI) baseline scores for all participants ranged from

7 to 19, with a higher score indicating greater disability. Group differences in NDI score from baseline compared to 4 days after the first CT displayed a 3−point decrease. To assess meaningful change at the individual level, an MCID of ± 7 was used based on previous literature.33,34 Two subjects (Subject 1, 4) the MCID level 4 days after the first

CT application. Group differences in NDI score from baseline compared to prior to the fifth treatment session showed a larger decrease of 6.8 points. Using this same reference point, 3 subjects (Subject 1, 3, 4) met the MCID values prior to the fifth treatment session.

The mean Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores ranged from 13.6 to 34.1, with a higher score indicating higher disability. Group statistical analysis revealed a decrease of 9.1 points from baseline to 4 days after subjects received the first round of the cupping intervention and a decrease of 13.2 points from baseline to before the fifth treatment session. An MCID of ± 16 points was used to determine meaningful upper extremity functional change.35 The results revealed that only

1 subject (Subject 1) met the MCID when comparing changes from baseline to 4 days after the first treatment application. After series of 4 CT sessions only 2 subjects (Subject

1, 2) met the MCID when compared to baseline scores. 51

The QuickDASH Performing Arts Module scores ranged from 25 to 62.5, with a higher score indicating higher disability. While the subscale scores 4 days after the first treatment ranged from 6.25 to 50, group statistical analysis revealed a decrease of 17.5 points from baseline to 4 days after subjects received the first round of the cupping intervention and a decrease of 27.5 points from baseline to before the fifth cupping intervention. To our knowledge, no MCID values have been established and validated for a collegiate musician population with chronic neck pain.

Treatment Compliance

All subjects adhered to the study timeline and no attrition of subjects occurred.

Adverse Events

No patient reported any treatment−specific adverse musculoskeletal events during treatment and subsequent follow−up sessions.

Individual Results and Analysis

Subject 1 was a female French horn and mellophone player with no previous history of receiving CT as a therapeutic treatment. Prior to the beginning of the study, she reported having previously engaged in resistance training regularly, but onset of chronic neck pain had severely limited her ability to maintain her training regimen. However, at the end of the series of 5 CT interventions, this subject reported being able to begin resistance training again with minimal to no pain.

Also, this participant was familiar with the athletic trainer administering the treatment as he treated her during marching band rehearsals and performances. When comparing baseline postintervention values, subject 1 demonstrated a 93% decrease 52

(baseline = 40, postintervention = 3) for pain at rest as assessed by the VAS. For active cervical range of motion measurements, differences in right rotation demonstrated the greatest improvement (+52°) while cervical extension demonstrated the least improvement (+5°) from baseline to immediately after the fifth CT session. Observation of the patient−reported outcome measures collected against data collection time points

(see Figure 6) reveal a steady decrease in scores, suggesting that both pain and decreased disability were obtained. A rise in active cervical range of motion can be seen (see Figure

7), with a relative plateau near the end of the data collection time points suggesting that near maximal range of motion was achieved.

Subject 2 was a male vocalist with no previous history of receiving CT. Prior to the beginning of the study, this subject noted to the investigator that maintaining proper singing posture had been a difficult challenge to overcome. At 4 days after the initial CT session he reported a noticeable change in postural endurance and delayed onset of pain while singing. When comparing baseline values to those collected postintervention, subject 2 demonstrated an 88% decrease (Baseline = 24, Postintervention = 3) for pain at rest as assessed by the VAS. For active cervical range of motion measurements, differences in left rotation exhibited the greatest improvement (+57°) while cervical extension yielded the least improvement (+8°) from baseline to immediately after the fifth CT session. The patient−reported outcome measures (see Figure 8) appear relatively similar across all time points. A rise in active cervical range of motion can be seen (see

Figure 9), with consistent values observed for cervical right and left rotation. 53

Subject 3 was a female violinist with limited experience regarding CT. Her knowledge of CT treatment was confined to one of her colleague’s prior experience and anecdotal evidence regarding the experimental treatment. When comparing baseline values to those recorded after the 5−series intervention, subject 3 had a decrease of 89%

(Baseline = 55, Postintervention = 6) for pain at rest as assessed by the VAS. For active cervical range of motion measurements, mean differences in extension had the greatest improvement (+22.7°) while right lateral flexion displayed the least improvement (−9.7°) from baseline to immediately after the fifth CT session. Observation of the patient−reported outcome measures collected against data collections time points (see

Figure 10) revealed a large decrease in scores, but relatively minimal changes pertaining to active cervical range of motion (see Figure 11) may suggest a plateau effect, as well.

Subject 4 was a female trumpet player with no previous history of receiving CT.

She reported a history of playing sports throughout high school (basketball, softball, and volleyball) on top of playing in the marching band. This subject participated on a recreational softball team during the time of this study. When comparing baseline values to after the 5−series intervention, she experienced a decrease of 62% (Baseline = 58,

Postintervention = 36) for pain at rest as assessed by the VAS. For active cervical range of motion measurements, cervical left rotation and right rotation resulted in the greatest improvement (+37.3°, +36.7°, respectively) while cervical flexion and extension demonstrated the least improvement (+8.7°, +9°, respectively). Patient−reported outcome measures (see Figure 12) illustrate greater changes in functional disability than 54 changes in pain. When taking active cervical range of motion (see Figure 13) into account, very minimal fluctuations between values were recorded.

Subject 5 was a female viola player who has prior experience with CT of greater than 1 year. Also, she was familiar with the athletic trainer administering the treatment as he treated her during the past year prior to her enrollment in this study. However, there had been over a 6−month gap since she last received any form of treatment. Subject 5 reported increases in muscle tension and pain over the upper back and neck region; presumably these were associated with a rise in her work and school−related demands.

After the initial CT, she reported an increase in pain and discomfort of the raised, circular welts caused by the vacuum suction of the cups. When comparing baseline values to her values postintervention, this subject experienced a 70% increase in pain (Baseline = 43,

Postintervention = 73). For active cervical range of motion measurements, differences in flexion showed the greatest improvement (+12.7°) while cervical left rotation demonstrated the least improvement (+3°) from baseline to immediately after the fifth CT session. Figure 14 suggests the treatments yielded no benefit to this participant. This is true on inspection of the active cervical range of motion data (see Figure 15), as well.

Patient−Reported Outcome Measures

Table 3. Visual Analog Scale at Rest (Range 0 to 100 mm)

4 Days Immediately After Before Immediately After Treatment Treatment After Baseline Treatment 1 1 5 Treatment 5

Mean 44 33 29 27 24

SD 14 29 18 24 31

Median 43 25 21 18 6

Range 34 71 44 57 70

95% CI 27, 61 −4, 69 7, 52 −3, 57 −14, 62 (Lower Limit, Upper Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 4. Visual Analog Scale While Playing (Range 0 to 100 mm)

4 Days After Before Baseline Treatment 1 Treatment 5

Mean 52 42 33

SD 22 25 30

Median 60 38 21

Range 57 56 73

95% CI (Upper 25,79 11,73 −5,70 Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 5. Neck Disability Index Outcome Score (Range 0 to 50)

4 Days After Before Baseline Treatment 1 Treatment 5

Mean 13.6 10.6 6.8

SD 5.4 6.6 30.0

Median 15 8 21

Range 12 15 73

95% CI (Upper 6.9, 20.2 2.4, 18.8 −2.3,15.9 Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 6. Quick Disabilities of the Arm, Shoulder, and Hand Outcome Score (Range 0 to 100)

4 Days After Before Baseline Treatment 1 Treatment 5

Mean 26.8 17.7 13.6

SD 8.7 11.8 16.3

Median 29.6 13.6 6.8

Range 20.5 19.6 40.9

95% CI (Upper Limit, 16.0, 37.6 3.1, 32.3 −6.6, 33.9 Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 7. Quick Disabilities of the Arm, Shoulder, and Hand – Performing Arts Medicine Module (Range 0 to 100)

4 Days After Before Baseline Treatment 1 Treatment 5

Mean 45.0 27.5 17.5

SD 16.1 16.9 19.5

Median 50.0 25.0 12.5

Range 37.5 43.8 50.0

95% CI (Upper 24.9, 65.1 6.5, 48.5 −6.7, 41.7 Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Active Cervical Range of Motion Measurements

Table 8. Cervical Flexion (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 32.4 39.5 47.7 45.3

SD 10.6 11.1 8.8 11.4

Median 33.3 42.3 48.0 42.0

Range 26.7 24.7 24.3 27.3

95% CI 19.2, 45.6 25.6, 53.4 36.8, 58.6 31.1, 59.4 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 9. Cervical Extension (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 33.1 35.6 44.6 47.6

SD 13.6 10.5 10.4 9.8

Median 31.7 34.3 43.7 43.7

Range 38.0 27.3 29.0 22.7

95% CI 16.3, 50.0 22.5, 48.7 31.6, 57.6 35.4, 59.8 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 10. Cervical Right Lateral Flexion (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 43.6 46.1 51.3 56.5

SD 16.2 13.6 9.0 9.1

Median 35.7 44.7 53.7 59.0

Range 40.0 37.3 23.7 24.3

95% CI 23.5, 63.7 29.2, 63.1 40.2, 62.5 45.2, 67.9 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 11. Cervical Left Lateral Flexion (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 42.5 49.3 49.1 54.0

SD 11.0 13.6 13.3 7.8

Median 39.3 43.0 43.7 51.7

Range 29.0 33.3 34.0 18.0

95% CI 28.9, 56.2 32.4, 66.1 32.6, 65.6 44.3, 63.7 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 12. Cervical Right Rotation (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 53.0 65.9 76.9 78.1

SD 20.2 18.9 12.2 13.2

Median 51.0 62.3 83.7 81.0

Range 53.3 44.3 28.3 33.0

95% CI 28.0, 78.0 42.5, 89.4 61.7, 92.0 61.8, 94.5 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Table 13. Cervical Left Rotation (Degrees)

Immediately 4 Days After Before After Baseline Treatment 1 Treatment 5 Treatment 5

Mean 56.0 73.8 77.9 79.8

SD 23.9 14.7 11.7 15.5

Median 51.3 69.3 83.0 85.0

Range 60.7 39.7 28.3 39.0

95% CI 26.3, 85.7 55.5, 92.1 63.4, 92.4 60.5, 99.1 (Upper Limit, Lower Limit) Abbreviations: SD = standard deviation, CI = confidence intervals.

Figure 5. Patient−reported outcome measures plotted across all study time points for subject 1. Abbreviations: VAS = Visual Analog Scale, NDI = Neck Disability Index, QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.

Figure 6. Active cervical range of motion measurements plotted against all study time point for subject 1.

Figure 7. Patient−reported outcome measures plotted across all study time points for subject 2. Abbreviations: VAS = Visual Analog Scale, NDI = Neck Disability Index, QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.

Figure 8. Active cervical range of motion measurements plotted against all study time point for subject 2. 63

Figure 9. Patient−reported outcome measures plotted across all study time points for subject 3. Abbreviations: VAS = Visual Analog Scale, NDI = Neck Disability Index, QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.

Figure 10. Active cervical range of motion measurements plotted against all study time point for subject 3. 64

Figure 11. Patient−reported outcome measures plotted across all study time points for subject 4. Abbreviations: VAS = Visual Analog Scale, NDI = Neck Disability Index, QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.

Figure 12. Active cervical range of motion measurements plotted against all study time point for subject 4. 65

Figure 13. Patient−reported outcome measures plotted across all study time points for subject 5. Abbreviations: VAS = Visual Analog Scale, NDI = Neck Disability Index, QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.

Figure 14. Active cervical range of motion measurements plotted against all study time point for subject 5. 66

DISCUSSION

The purpose of this study was to determine the effect of retained, dry CT on reducing pain−related disability in university−level musicians. To our knowledge, this is the first study on the effectiveness of dry CT on the pain and function of musicians with chronic nonspecific neck pain. The primary findings were that for most participants, dry, retained CT reduced pain at rest and pain while playing an instrument immediately after treatment. This decrease in pain was also reported by many of the participants following

5 CT treatments. When observing changes from baseline to 4 days after the initial treatment, patient reported outcome scores such as the NDI and QuickDASH did not demonstrate minimal clinically important differences. However, the QuickDASH performing arts subscale did yield clinically important differences. This may suggest that the subscale is sensitive to change in a musician population. Analysis of range of motion data concluded that cervical flexion and cervical left rotation increased in all participants immediately after the first CT intervention. Only cervical flexion, extension, left lateral flexion increased in all participants after the completion of the 5−series of CT treatment.

For the data demonstrating decreased range of motion, none of the participants demonstrated more than a 10° loss of cervical range of motion.

We hypothesized that:

1. Dry, retained CT would decrease pain (at rest and/or while playing an

instrument) by a minimum of 14 on a 100 mm on the VAS immediately after

the first treatment intervention was applied; 67

2. After a series of 5 CT sessions, pain scores would decrease by a minimum of

14 on a 100 mm on the VAS when compared to initial baseline measurements;

3. Dry, retained CT would improve active cervical range of motion immediately

after the first CT treatment intervention, if the participants were not already

achieving full cervical range of motion;

4. After a series of 5 CT sessions, participants’ active cervical flexion, extension,

lateral side bending, and rotation would improve, if they were not already

achieving full cervical range of motion; and

5. Dry, retained CT would improve functional outcomes after a series of 5 CT

sessions, with participants demonstrating a minimum change of 7 out of 50

points on the NDI and/or a minimum change of 14 out of 100 points on the

QuickDASH.

Pain Perception

Although we hypothesized that dry, retained CT would decrease pain (at rest and/or while playing an instrument) by a minimum of 14 on a 100 mm on the VAS immediately after the first treatment intervention was applied, this result was only achieved in 2 out of 5 participants. In fact, VAS for pain at rest increased for 1 participant

(Subject 5) by 34 mm. This contrasts the pain score of another participant (Subject 3) whose VAS for pain at rest decreased by 49 mm. Chi et al23 conducted single−blind experimental design trial using CT as the primary intervention for patients with chronic neck pain and found a decrease in neck pain intensity by 6.1 after treatment. Our findings revealed a much higher group difference for VAS pain at rest (33 ± 28 mm); 68 however, given our small sample size the large range of differences posttreatment is a limitation.

When evaluating pain at rest after a series of 5 CT sessions, all but one participant

(Subject 5) exhibited a decrease of at least 14 mm when compared to baseline measurements. In this case, increased personal and school−related stressors were reported by the participant as potential contributors to her heightened pain state before, during, and after treatment. It is of no coincidence that musicians encounter significant levels of stress. Wu and colleagues14 concluded that other risk factors for predisposing a musician for musculoskeletal injury includes gender, less years of playing experience, type of instrument played, stress (self−pressure, academic), playing−related tension (long hours, over−practicing), lack of preventive behaviors, or previous trauma. Other previous studies that evaluated risk factors for musculoskeletal pain further specified that female musicians who played either a stringed instrument or keyboard were at higher risk for developing musculoskeletal complaints than any other type of musician.36–39 Subject 5 was a female viola player with chronic nonspecific neck pain that was developed over the years from her continued musical training. Therefore, she exhibited multiple risk factors that made subjective measurements of pain highly vulnerable to both internal and external stimuli. CT, as it exists as a form of manual therapy, should follow similar recommendations from current research that recommend manual therapy should not be used in isolation. This concept is further elaborated on in the comparison of interventions section of this discussion.

Cervical Range of Motion

This study also evaluated whether dry, retained CT improves active cervical range of motion, as assessed by a digital inclinometer, immediately after 1 treatment of CT and after a series of 5 dry CT sessions. Yim et al40 found that CT improved cervical range of motion (cervical flexion, extension, and right and left lateral flexion) significantly compared to McKenzie stretching in a cross−over design study with college students. Our study did not report similar findings at the individual level for range of motion immediately after the first CT session. However, it appears that most of the participants

(3 out of 5) experience increased active range of motion in all recorded directions after the series of 5 CT session. Differences from baseline to immediately after the first CT session for cervical right lateral flexion and left lateral flexion revealed mixed results. For cervical right lateral flexion, 3 participants demonstrated decreased cervical right lateral flexion (mean = 3°) while 2 participants demonstrated increased cervical right lateral flexion (mean = 11°). Although most participants displayed decreased cervical right lateral flexion, the difference was minimal compared to the participants’ increased range of motion. For cervical left lateral flexion, 3 participants demonstrated increased cervical left lateral flexion (mean = 12°) while 2 participants demonstrated decreased cervical left lateral flexion (mean = 7°). It is difficult to ascertain why this phenomenon occurred given the number of variables researchers must consider when applying treatment in a clinical context. Although we would like to see cervical range of motion improve in all directions, the significance of such improvement must be weight against the functional capacity gained. Thus, the answer to such circumstance is beyond the scope of this study. 70

Patient−Reported Outcome Measures

To our knowledge, no other study implementing the use of retained, dry CT on patients with chronic neck pain have included active cervical rotation as part of their outcome measures. The research presented provides preliminary clinical application procedures build evidence−based practice methods using dry CT. This information aimed to deepen the overall body of literature regarding the effectiveness of CT in the treatment of chronic nonspecific neck pain.

In terms of functional outcomes measures, this study was unable to definitively conclude whether after a series of 5 CT sessions will result in a minimum change of 7 out of 50 points on the NDI and/or a minimum change of 14 out of 100 points on the

QuickDASH. Results and data collection from the conclusion of this study will be published later as this part of the study is currently ongoing.

Comparison of Interventions

Previous studies conducted on patients with chronic neck pain are abundant, with a majority of randomized controlled trials and systematic reviews supporting the practice of mobilization/manipulation combined with exercise therapy.41–45 A systematic review by D’Sylva et al43 analyzed 31 publications and concluded that combine manual therapy

(manipulation, mobilization, and soft−tissue techniques) combined with exercise produced long term benefits in measures of pain and function. Another trial conducted by

Celenay et al44 observed superior benefits for pain and function when implementing a

4−week stabilization regimen with manual therapy compared to stabilization exercises only on 102 adult patients with mechanical neck pain. 71

Tsakitzdis et al41 reported that multimodal treatments such as exercises in combination with passive treatments (mobilization/manipulation) and patient education can affect pain in both short− and long−term disability from chronic, nonspecific neck pain. The current literature on dry CT also supports and advocates that clinicians combine this technique with other therapeutic modalities and rehabilitative exercise to gain maximum benefit. However, our study aimed to study dry CT as an isolated treatment protocol to highlight standardization of parameters and effectiveness in a highly specialized population. A similar study conducted by Lauche et al30 applied 5 dry CT sessions over a period of 2 weeks on patients with chronic nonspecific neck pain. Their study elicited substantial improvements in subjective and objective measures among the treatment group when compared to the control group that did not receive treatment. Our findings were consistent with theirs, although our 5 dry CT sessions were spread out almost 1 week longer to allow for adequate healing between treatment sessions.

Limitations

The most obvious limitation of this study was its small sample size. Inferential statistics were not calculated and results from this study cannot be generalized beyond the study group. Inherent to CT research, it is difficult to blind participants to treatment; therefore, no sham treatment group was included. Due to the unfamiliarity of CT among a musician population, patient perception and expectation may have influenced the subjective outcomes reported after therapy.

Additionally, this study did not have a control group to which to compare the results of our experimental treatment. However, a systematic review conducted by Cao et 72 al46 found moderate evidence to support the use of CT compared to no treatment and even other conventional treatments (eg, heat therapy, medication) in reducing short−term pain. Therefore, the conclusions made from this study should warrant future investigation to the degree of therapeutic healing and positive outcomes CT may provide.

With the treatment protocol utilized in this study, it is interesting to note that the plastic cups occasionally did not retain their vacuum suction for the full duration of a treatment. Thus, reapplication of the vacuum may have influenced the outcomes of the study variables. Furthermore, without a true measure of intracup pressure, there was no control over the amount of pressure applied to the area of treatment. The researchers also could not control for the physical activity and rehearsal/practice schedule of the musicians who participated in the study.

Clinical Implications

In this study, both a single and a series of 5 CT interventions demonstrated their effectiveness in improving pain perception, cervical range of motion, and functional outcome scores in musicians with chronic neck pain. Although this investigation evaluated the effectiveness only of a CT intervention, it is recommended that treatment be followed−up with or applied in conjunction with therapeutic exercises and other modalities to promote long−term recovery. Musicians are at risk for playing−related musculoskeletal disorders and often suffer episodes of chronic pain.8–10 Dry CT may offer these performers an opportunity to practice with less pain and sustain their musical careers. Despite the limitations present in this research, our findings are unique and add to the body of literature for clinical practice in performing arts medicine. Dry CT is a 73 relatively safe and economically advantageous myofascial treatment modality that clinicians may choose to apply in the context of overall patient care.

Areas of Future Research

To provide more evidence for this technique, future studies should examine dry

CT techniques against commonly employed techniques such as functional active movements, static stretching, or supervised exercises. A comparison to other instrument−assisted soft tissue mobilization methods may be warranted to assess the competing theories of myofascial decompression and myofascial compression therapies.

Future research should also aim to further develop standardized protocols for the safe application of dry CT for various musculoskeletal disorders. Also, because this study was performed on a single body region in musicians with chronic pain, further research on the effects of CT in other areas of the body and in similar populations with pathological impairments is warranted. Lastly, it would be of great benefit to both musicians and clinicians if future research aimed to incorporate music instructors’ or directors’ feedback about the quality of playing performance before and after a treatment protocol is applied, as well as determining the extent to which clinical signs of improvement match functional needs and outcomes in musicians.

CONCLUSION

This study aimed to determine the effect of retained, dry CT on reducing pain−related disability in university−level musicians using acupuncture points. To our knowledge, this is the first study on the effectiveness of dry CT on the pain and function of musicians with chronic nonspecific neck pain. Our results suggest recipients of this 74 treatment realize a short−term decrease in pain. This finding is consistent with previous studies evaluating the therapeutic benefits of CT for chronic neck and back pain. It is worth noting that our results are consistent with those of other researchers. Central sensitization created by chronic pain states can be difficult to assess and treat within a clinical setting. Future research should investigate and consider the psychological and cognitive affects surrounding CT as a method to further evaluate the merit of therapeutic healing.

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Chapter 4: Conclusion

This study aimed to determine the effect of retained, dry CT on reducing pain−related disability in university−level musicians using acupuncture points. To our knowledge, there is no current evidence to establish the therapeutic benefits of dry CT for musicians with chronic neck pain. Minimal evidence exists supporting the use of CT for musculoskeletal conditions; however, the quality and bias associated with previous research limit the conclusions drawn from the results. Among musicians, poorly managed chronic neck pain has not been previously proposed to limit performance. However, significant time loss is associated with the development of playing−related musculoskeletal disorders.

With prior research performed on a variety of chronic musculoskeletal conditions, current investigation of CT on chronic neck pain is promising. Results from this study clearly suggest a short−term decrease in pain along with general increase in active cervical range of motion in patients who receive a series of 5 CT treatments. This finding is consistent with prior studies evaluating the therapeutic benefits of CT for chronic neck and back pain. It is worth noting that our study is consistent with those of other researchers in identifying the limitation that dry CT has as a therapeutic modality. Central sensitization created by chronic pain states can be difficult to assess and treat within a clinical setting.

Future research should investigate and consider the psychological and cognitive effects surrounding CT to further evaluate the merit of therapeutic healing elicited by CT.

Of equal importance, attempts to standardize the application of CT in a clinical setting 83 would benefit current practitioners who wish to provide evidence−based patient care.

Additional research is needed to understand which patients best respond to treatment.

References

1. Brodsky M, Hui KK. An innovative patient−centered approach to common

playing−related pain conditions in musicians. Med Probl Perform Art.

2004;19(4):170−173.

2. Ismail MA, Atwa H, Saleh A, Salem MF. Studying complementary and alternative

practices in Bedouin community: family based study, North Sinai, Egypt. J Fam

Med. 2012;10(6):26−34.

3. Chen B, Li MY, Liu PD, Guo Y, Chen ZL. Alternative medicine: an update on

cupping therapy. QJM. 2015;108(7):523−525. doi:10.1093/qjmed/hcu227.

4. Rozenfeld E, Kalichman L. New is the well−forgotten old: the use of dry cupping

in musculoskeletal medicine. J Bodyw Mov Ther. 2016;20(1):173−178.

doi:10.1016/j.jbmt.2015.11.009.

5. Nielsen A, Kligler B, Koll BS. Safety protocols for gua sha (press−stroking) and

baguan (cupping). Complement Ther Med. 2012;20(5):340−344.

doi:10.1016/j.ctim.2012.05.004.

6. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS

ONE. 2012;7(2):e31793. doi:10.1371/journal.pone.0031793.

7. Arslan M, Gökgöz N, Dane Ş. The effect of traditional wet cupping on shoulder

pain and neck pain: A pilot study. Complemen Ther Clin Prac. 2016;23:30−33.

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professional orchestra musicians in Scotland: a prevalence study using a validated

instrument, the Musculoskeletal Pain Intensity and Interference Questionnaire for

Musicians (MPIIQM). Med Probl Perform Art. 2016;31(2):79−86.

doi:10.21091/mppa.2016.2015.

11. Steinmetz A, Seidel W, Muche B. Impairment of postural stabilization systems in

musicians with playing−related musculoskeletal disorders. J Manipulative Physiol

Ther. 2010;33(8):603−611. doi:10.1016/j.jmpt.2010.08.006.

12. Zaza C. Playing−related musculoskeletal disorders in musicians: a systematic

review of incidence and prevalence. CMAJ. 1998;158(8):1019−1025.

13. Wu SJ. Occupational risk factors for musculoskeletal disorders in musicians: a

systematic review. Med Probl Perform Art. 2007;22(2):43−51.

14. Baadjou VAE, Roussel NA, Verbunt JAMCF, Smeets RJEM, de Bie RA.

Systematic review: risk factors for musculoskeletal disorders in musicians. Occup

Med. 2016;66(8):614−622. doi:10.1093/occmed/kqw052.

15. Dawson WJ. Upper−extremity problems caused by playing specific instruments.

Med Probl Perf Arts. 2002;17(3):135-140.

16. Ackermann B. Managing the musculoskeletal health of musicians on tour. Med

Probl Perf Arts. 2002;17(2):63−67. 86

17. Kok LM, Nelissen RGHH, Huisstede BMA. Prevalence and consequences of arm,

neck, and/or shoulder complaints among music academy students: a comparative

study. Med Probl Perform Art. 2015;30(3):163−168.

18. Guptill C. The lived experience of working as a musician with an injury. Work.

2011;(3):269–280. doi:10.3233/WOR−2011−1230.

19. Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for chronic

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Appendix A: Specific Aims

Musicians and instrumentalists are at high risk for developing repetitive movement disorders, which can contribute chronic pain and functional disability.1 Health detriments and disability caused by the acquisition of playing-related musculoskeletal disorders (PRMDs) can negatively influence performing artists’ economic welfare and overall quality of life.2,3 Previous research describes the need for equitable access to healthcare, depth of understanding from the healthcare provide, and appropriate medical intervention for the musician population.4 Conventional hospital visits and expensive diagnostic screenings may not be financially viable or accessible to a majority of this population.3,5 Thus, alternative therapies may offer musicians the ability to functionally return to playing with significantly decreased financial/economic burden.6

As complementary and integrative health practices emerge into clinical settings as a form of therapeutic treatment, clinicians can offer and apply novel interventions to treat their patients. This brings to question whether these therapies offer any significant or clinical therapeutic benefit in the face of current standard of care treatment protocols.

Regardless, clinicians continue to apply such treatments without evidence-based parameters that withstand quality peer-reviewed sources. Such is the case with cupping therapy (CT), a form of traditional Chinese medicine that has been practiced for thousands of years, but has yet to provide concrete evidence in its role in providing therapeutic benefits in musculoskeletal disorders.7,8

Current available evidence has not specifically looked at how musicians can obtain both short- and long-term benefits, if any, from these alternative treatment 100 therapies.9–12 Of the musculoskeletal ailments afflicting musicians, chronic nonspecific neck pain resulting from PRMDs is of particular interest.13,14 Factors including awkward posture, type of instrument, movement repetition frequency, and incurred muscular fatigue are occupational barriers that limit a musician to achieve optimal health and wellness.2–4,15,16 Despite previous studies, standardization of dry CT parameters have not yet been established for chronic nonspecific neck pain in a musician population.12,17

While no life threatening reports of harm have been identified for dry CT at this time, clinicians should strive to critically analyze the available evidence-based protocols to determine the efficacy of CT for musculoskeletal injuries and disorders in an athletic training setting.9,18–20

My research is intended to determine if chronic nonspecific neck pain will respond to dry CT placed on pre-determined acupuncture points in musicians with chronic neck pain. My long-term goal is to understand how to effectively treat various musculoskeletal conditions by implementing a standardized method of application, which has not been previously studied before to our knowledge. My objective is to evaluate whether dry CT can improve pain, cervical range of motion, and functional outcome measures that will relate to increased performance ability.

Aim 1: To determine the effectiveness of cupping therapy on patient-oriented and clinician oriented outcome measures in collegiate-level musicians. To achieve this aim, participants will be asked to complete the following questionnaires and measurements before the first treatment is applied. Measures will be collected again at various time points during the course of 3 weeks.21 At the end of the study, data collected will be statistically analyzed to determine if any significant changes occurred. 1.1 Patient-oriented outcome measures used will compose of the visual analog scale (VAS, 0mm-100mm), neck disability index (NDI, 0-50 score), and Quick Disability of the Arm, Shoulder and Hand (QuickDASH, 0-100 score).22–25 101

1.2 Clinician-oriented outcome measures used will compose of active cervical range of motion (cervical flexion, extension, lateral flexion, rotation) measured by a digital inclinometer.26 Subjects will have measurements taken during baseline data collection, immediately following the first treatment, before the final treatment, and again after the final treatment.

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neck pain - a randomised controlled pilot study. BMC Complement Altern Med. 2011;11(1):63. doi:10.1186/1472-6882-11-63.

22. Boonstra AM, Preuper HRS, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008;31(2):165-169.

23. Chan Ci En M, Clair DA, Edmondston SJ. Validity of the neck disability index and neck pain and disability scale for measuring disability associated with chronic, non-traumatic neck pain. Man Ther. 2009;14(4):433-438. doi:10.1016/j.math.2008.07.005.

24. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61(5):623-632. doi:10.1002/art.24396.

25. Beaton DE, Wright JG, Katz JN, Amadio P. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038-1046.

26. de Koning CHP, van den Heuvel SP, Staal JB, Smits-Engelsman BCM, Hendriks EJM. Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review. Eur Spine J. 2008;17(7):905-921. doi:10.1007/s00586-008-0656-3.

104

Appendix B: Procedures Checklist

TASK TIME ➢ Consent Form and Disclaimer Form 5 Minutes ➢ Baseline Measurements ❖ Visual Analog Scale (VAS) for Pain at Rest ❖ VAS for Pain while Playing ❖ Neck Disability Index (NDI) 10 Minutes ❖ Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) ❖ QuickDASH Performing Arts Module ➢ Active Cervical Range of Motion Recordings ❖ Flexion ❖ Extension ❖ Right Lateral Flexion 5 Minutes ❖ Left Lateral Flexion ❖ Right Rotation ❖ Left Rotation ➢ Dry Cupping Treatment over 3 Acupuncture Points 10 Minutes ➢ Post-Treatment Measurements ❖ VAS for Pain at Rest 7 Minutes ❖ Active Cervical Range of Motion Recordings ➢ Pre-Treatment Measurements ❖ Visual Analog Scale (VAS) for Pain at Rest ❖ VAS for Pain while Playing ❖ Neck Disability Index (NDI) 10 Minutes ❖ Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) ❖ QuickDASH Performing Arts Module ➢ Post-Treatment Measurements ❖ VAS for Pain at Rest 7 Minutes ❖ Active Cervical Range of Motion Recordings ➢ Follow-Up Measurements ❖ Visual Analog Scale (VAS) for Pain at Rest ❖ VAS for Pain while Playing ❖ Neck Disability Index (NDI) 15 Minutes ❖ Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) ❖ QuickDASH Performing Arts Module ❖ Active Cervical Range of Motion Recordings Session 1 & 5: 42−45 minutes, Session 2−4: 15 minutes 105

Appendix C: Data Collection and Surveys

Participant Baseline Tx 1: Post- Tx 1: 1 Tx 5: Pre- Tx 5: Post- Scores Intervention Week Post Intervention Intervention Subject ID: VAS-Rest: VAS-Rest: VAS-Rest: VAS-Rest: VAS-Rest: 001 VAS-Move: VAS-Move: VAS-Move:

NDI: NDI: NDI:

QuickDAS QuickDASH: QuickDASH: H:

QD-PAM: QD-PAM: QD-PAM: C FLEX: C FLEX: C FLEX: C FLEX: C EXT: C EXT: C EXT: C EXT: C RT LF: C RT LF: C RT LF: C RT LF:

C LT LF: C LT LF: C LT LF: C LT LF: C RT ROT: C RT ROT: C RT ROT: C RT ROT:

C LT ROT: C LT ROT: C LT ROT: C LT ROT:

106

Q1 Are you 18 years of age or older?

o Yes (1)

o No (2)

Skip To: End of Survey If Q1 = No

Q2 Are you part-time or full-time enrolled at Ohio University?

o Yes (1)

o No (2)

Skip To: End of Survey If Q2 = No

Q3 Do you have at least 5 years of music playing and/or performance experience?

o Yes (1)

o No (2)

Skip To: End of Block If Q3 = No

107

Q4 Do you practice, rehearse, and/or perform at least 15 hours a week on average?

o Yes (1)

o No (2)

Skip To: End of Block If Q4 = No

Q5 Do you currently have neck pain located within the shaded area in the diagram below?

According to the International Association for the Study of Pain, "pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.g tSave

o Yes (1)

o No (2)

Skip To: End of Survey If Q5 = No

108

Q10 Based on the neck pain you are experiencing within the diagram below please move the slider on the scale that best represents your current level of neck pain. The scale rating is as follows: 0mm = No pain at all, 100mm = Worst pain imaginable

SaveSave

0 10 20 30 40 50 60 70 80 90 100

Neck Pain at Rest (1)

Neck Pain with Playing (2)

Skip To: End of Survey If Q10 <= Neck Pain at Rest Skip To: End of Survey If Q10 <= Neck Pain with Playing

Q6 Has your current neck pain been caused by a traumatic accident or pre-identified medical condition?

o Yes (1)

o No (2)

Skip To: End of Survey If Q6 = Yes

109

Q7 Has your current neck pain been present for 3 consecutive months or longer within the last year?

o Yes (1)

o No (2)

Skip To: End of Survey If Q7 = No End of Block: Default Question Block

110

111

112

113

114

Appendix D: Instrument Reliability

When looking at the validity and reliability the VAS in patients with chronic musculoskeletal injury, Boonstra et al1 concluded that reliability for pain is good

(Spearman’s correlation coefficient range 0.60-0.77) while the validity for disability will be not confirmed. Overall, the VAS can be trusted for subjective measurements of pain, but caution must be taken when minor details are changed.2

A high level of test-retest reliability (ICC = 0.89) and internal consistency will be demonstrated by the NDI indicating its further applications to a wide audience range.3

The QuickDASH has demonstrated high test-retest reliability and internal consistency when compared to the full DASH outcome measure.4 Cronbach alpha values for the QuickDASH range from 0.92 to 0.954,5 and the ICC values range from 0.90 to

0.944–6 which are considered clinically useful.

Reliability of the EDI-320, expressed by the intraclass correlation coefficient

(ICC) will be good with ICCs of 0.89 or higher in all 3 planes of motion for inter-rater reliability.7

References

1. Boonstra AM, Preuper HRS, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008;31(2):165-169.

2. Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2(2):175-184. doi:10.1016/0304-3959(76)90113-5.

3. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manip Physiol Ther. 1991;14.

4. Beaton DE, Wright JG, Katz JN, Amadio P, al et. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038-1046. 115

5. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. doi:10.1186/1471-2474-7-44.

6. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009;18(6):920-926. doi:10.1016/j.jse.2008.12.015.

7. Hoving JL, Pool JJ, van Mameren H, et al. Reproducibility of cervical range of motion in patients with neck pain. BMC Musculoskelet Disord. 2005;6(1). doi:10.1186/1471-2474-6-59.

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