Effect of Massage and Dry Cupping on Hemodynamic Parameters of Cardiac Patients: A Randomized Controlled Trial (2024)

Abstract

Objective

The aim of this study was to compare the effects of massage versus dry cupping in addition to routine care on hemodynamic parameters of cardiac patients in critical care units.

Methods

The present study was a parallel randomized controlled clinical trial that was conducted in the critical care units of Shafa Hospital in Kerman, Iran, from 2019 to 2020. Ninety eligible patients)aged 18-75 years, no cardiac arrest in the past 72 hours, no severe dyspnea, no fever, and no cardiac pacemaker) were divided into massage (n=30), dry cupping (n=30), and control (n=30) groups using the stratified block randomization method. The massage group received routine care and a head and face massage for 3 consecutive nights from the second day of admission. The dry cupping group received routine care and dry cupping between the third cervical vertebra and the fourth thoracic vertebra for 3 consecutive nights. The control group received only routine care, which included daily visits by the attending physician, nursing care, and medication. Each intervention session was performed for 15 minutes. The data collection tools included the sociodemographic and clinical characteristics questionnaire and the hemodynamic parameters form (systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and saturation of peripheral oxygen). The hemodynamic parameters were measured each night before and after the intervention.

Results

The mean systolic blood pressure, heart rate, respiratory rate, and oxygen saturation level showed no significant difference among the 3 groups. The mean diastolic blood pressure of the 3 groups varied significantly over time. The mean diastolic blood pressure of the massage group decreased significantly on the third day of intervention, while it did not change significantly in the 2 groups of dry cupping or control (P < .05).

Conclusion

According to the results of this study, dry cupping had no effect on regulating hemodynamic parameters, while only diastolic blood pressure was reduced significantly after massage on the third day of intervention. Therefore, our study did not show effects of massage and dry cupping on regulating hemodynamic parameters.

Key Indexing Terms: Cupping Therapy, Hemodynamics, Massage, Musculoskeletal Manipulations

Introduction

Heart disease is the most common cause of mortality in most countries, including Iran. Ischemic heart disease was one of the most important health-threatening problems in the last years of the 20th century and the early years of the 21st century.1 Deaths related to heart disease will reach more than 23.3 million by 2030.2 Over 80% of mortalities related to this disease occur in developing countries.3 The prevalence of this disease is increasing in Iran, and it is the first cause of mortality in people aged over 35 years old, so the age of people experiencing heart disease is declining in Iran.1 Heart disease also imposes great costs on families and health care systems in most countries,2 and it is associated with many complications.4

Patients experience stress in hospital critical care units (CCUs), which can increase blood pressure, respiratory rate, and heart rate and reduce oxygen levels.5 The rate of vital signs varies from one person to another at different times of the day and in different states of health and illness. Physiological parameters are examined regularly in CCUs, and considerable information is provided.6 In recent years, much attention has been paid to the combination of pharmacologic and nonpharmacologic treatments to control the complications of heart disease.7 Nonpharmacologic treatments may include but are not limited to hydrotherapy, leech therapy, cupping, energy therapy, massage, and dry cupping. With concern for the side effects of some existing medications, the interest in using complementary medicine is felt more and more.8

Massage is a relatively inexpensive treatment method.9 Swedish massage is one of the most common methods, which can reduce hospital costs by speeding up the healing process and reducing bed occupancy rate.7 Massage is a patterned and purposeful soft-tissue manipulation accomplished by use of fingers, hands, forearms, elbows, knees, and/or feet, with or without the use of emollients, liniments, heat and cold, hand-held tools or other external apparatus, for the intent of therapeutic change.10 Studies have shown that massage, if done properly, could transfer a sense of calm, comfort, and confidence by creating a sense of intimacy and security in a person7^,9 and may assist with lowering blood pressure, heart rate, respiratory rate,11^,12 and atrial fibrillation.9

Dry cupping, a popular method in Iran, is used for treatment of some diseases.8 Dry cupping involves stimulation of the skin by suction and is thought to increase the local circulation of blood and lymph to relieve muscle pain.13 Studies have shown positive effects of dry cupping.14, 15, 16 Dry cupping is thought to help migraines and other disorders17, 18, 19, 20 and potentially affect the cardiovascular system.21^,22 Despite the effects of complementary medicine on some of the symptoms and diseases, studies on dry cupping are still limited.

The results of some studies have shown that massage of patients in the CCU has reduced blood pressure, heart rate, respiratory rate,11^,22 and increased arterial blood oxygen level.12^,22 Some studies confirmed the ineffectiveness of massage on hemodynamic parameters,23 while others have dictated the effectiveness of massage on only some parameters such as systolic blood pressure (SBP).24^,25 A study of the effect of dry cupping on hemodynamic parameters showed that dry cupping increased the level of arterial blood oxygen at the site of suction and that it could lower SBP and diastolic blood pressure (DBP).26 Despite extensive research, limited studies have been available regarding the direct effect of dry cupping on hemodynamic parameters. However, some studies on wet cupping showed no effect on blood pressure levels.27^,28 Thus, there appear to be conflicting results regarding the effects of massage and dry cupping on the hemodynamic parameters of patients taken to hospitals.

In recent years, there has been an increase in the number of studies on cupping therapy and massage.23, 24, 25, 26, 27, 28 The increasing incidence of heart disease and its complications leads to an increase in the length of hospital stay, influences the quality of life of patients and their families, and increases the cost of treatment and bed occupancy rate. Hemodynamic parameters may affect treatment and prognosis of CCU patients.22 Therefore, various methods, including complementary medicine, should be investigated to regulate hemodynamic parameters. The present study tested the hypothesis that mean vital sign changes in CCU patients are different among the 3 groups of dry cupping, massage, and control on the first, second, and third day of the intervention. The purpose of the study was to compare the effects of massage vs dry cupping in addition to routine care on hemodynamic parameters of cardiac patients in CCUs.

Materials and Methods

Study Design and Setting

This parallel randomized controlled clinical trial was conducted in the CCUs of Shafa Hospital in Kerman from 2019 to 2020. Shafa Hospital, a heart center in Kerman, has 22 CCUs with 24 beds. This study was a part of a larger study regarding the effect of massage and dry cupping on dysrhythmia among patients admitted to the coronary care unit.29

Sample Size and Sampling

The samples were selected using convenience sampling method, and they were allocated into 3 groups (2 groups of intervention and 1 control group) by stratified block randomization method (stratum: sex). Labels A, B, or C (A=control, B=massage, and C=dry cupping) were assigned to the groups, and the block size was 6. Then, the randomization list was generated by using free online software (Simple Randomisation Service; Sealed Envelope Ltd). The fourth author generated the randomization list, and the first author enrolled the participants and assigned them to the 3 groups The inclusion and exclusion criteria were from the larger study regarding the effect of massage and dry cupping on dysrhythmia.29 The inclusion criteria were patients monitored and receiving medication, patients aged 18 to 75 years,30 no cardiac arrest in the past 72 hours, no severe dyspnea, no fever, and no cardiac pacemaker.11 Exclusion criteria were patients with coagulation disorder diagnosed by a doctor,8 those with severe obesity diagnosed by a doctor,15 those with severe vascular disease, open wound at the site of suction,31 contraindication of dry cupping with drug treatment according to the doctor's opinion,32 pregnant women with gestational age of more than 4 months, the presence of a tumor at the site of suction,33 patients with bone fracture at the site of suction,34 patients with skin disorders such as psoriasis, intubated patients, or those with central vascular catheters. Previous study was used for the estimation of sample size.12 The confidence coefficient, confidence interval, and type II error were 95%, 1.96, and 20%, respectively (study power=80%). According to the 3 study groups, the sample size was adjusted, and the number of samples needed for this study was 25 in each group. However, 30 samples were considered in each group (Fig 1) to improve the study power.

Fig 1.

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Measurements

The data collection tools in this study included the sociodemographic and clinical characteristics questionnaire and the hemodynamic parameters form. The sociodemographic and clinical characteristics questionnaire included age, sex, marital status, length of stay in CCU, level of education, job, income, address, type of disease, history of allergies, history of addiction, history of admission to CCUs, and history of admission to hospital.

There was a form for recording the patient's hemodynamic parameters, including SBP, DBP, heart rate, respiratory rate, and saturation of peripheral oxygen. A Saadat monitoring device (Alborz Co) was used to measure the hemodynamic parameters. The device was placed at the top of the patient's bed. All devices were the same and calibrated by medical engineers before the study. Saturation of peripheral oxygen and electrocardiogram waves must be properly regulated and free of the parasite to ensure the true reading of arterial oxygen saturation, and if there had been a parasite, the probe would have been placed on another area, and the arterial oxygen saturation checked. All hemodynamic parameters were measured twice at a 5-minute interval, and the mean scores were used for each measurement. The 2 researchers, critical care nurses, assessed all measurements in the 3 groups.

Data Collection and Interventions

The researcher went to Shafa Hospital in Kerman and obtained informed consent from the patients after receiving the code of ethics and the clinical trial registration code, as well as coordinating with the head of the hospital and the authorities of the CCUs. The intervention was performed from 6 to 8 PM because of the proximity of patient sleeping hours and the lower rate of staff. In addition, a male researcher and a female researcher performed all interventions (for male and female participants). One of the professors of traditional medicine at Kerman University of Medical Sciences trained the researchers in massage and dry cupping techniques. She approved the researchers’ massage and dry cupping skills after 5 training sessions.

Massage Group. In addition to routine care, the head and face massage was performed with 2 mL of sweet almond oil (100% purity from Barij Essence Pharmaceutical Co, Kashan, Iran) for 15 minutes from the second night of CCU admission for 3 consecutive nights. Brown massage therapy, a combination of effleurage and pressure massage, was used in this study. After stretching the curtains around the patient's bed, the patient was seated in a semi-sitting position (45°-60°), then the massager applied the massage stages (Fig 2).35

Fig 2.

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Fig 3.

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Control Group. Participants in the control group received only routine care. During routine care, patients were visited daily by the attending physician and received nursing care and prescribed medications. In addition, during routine care, hemodynamic parameters were monitored and recorded at regular intervals according to the physician's order. In case of changes in the hemodynamic status, the resident of the ward first visited the patient and informed the patient's condition to the attending physician, whose orders were performed by the nurse.

Data Analysis

Data were analyzed by SPSS 25 (IBM Corp., Armonk, NY). Descriptive statistics (frequency, percentage, mean and standard deviation) were used to describe patients' demographic characteristics and clinical information. Mean and standard deviation were used to describe the hemodynamic parameters. The χ² test and Fisher exact test were used to examine the similarity of the 3 groups regarding the qualitative sociodemographic and clinical characteristics variables. Kruskal-Wallis test and analysis of variance were used to examine the similarity of the 3 groups regarding the quantitative sociodemographic and clinical characteristics variables. Regarding the confirmation of parametric conditions (normal distribution and equality of variances in the 3 groups), the 2-way analysis of variance test was used to compare the changes in hemodynamic parameters within and among the 3 groups at different times. The Bonferroni post hoc test was used for multiple comparisons. Significance level was considered .05.

Ethical Considerations

Kerman University of Medical Sciences approved the study protocol (No. IR.KMU.REC.1398.150). The study protocol was registered to the Iran RCT center (No. IRCT20190325043108N1). The researcher obtained informed consent from all participants.

Results

The mean ages of the samples in the massage, dry cupping, and control groups were 57.33 ± 10.1, 61.03 ± 7.77, and 59.17 ± 9.84, respectively. No statistically significant difference was found in the mean age of the 3 groups (F=1.19; P =.31). Fifty percent (n=15) of the samples in the massage group, 56.7% (n=17) of the samples in the dry cupping group, and 40% (n=12) of the samples in the control group were men (χ²= 1.69; P=.43). Seventy-seven percent (n=23) of the samples in the massage group and 80% (n=24) of the samples in the dry cupping and control groups were married (P =.91). In addition, no statistically significant difference was found among the 3 groups in occupation (P=.13), education level (P=.11), and income (P=.75). No differences were observed in the medical history among the 3 groups (Table 1). In addition, the medication regimen was not significantly different among the 3 groups on the first, second, and third days (P > .05).

Table 1.

Comparison of Medical History in the Massage, Dry Cupping, and Control Groups

Group	Massage		Dry Cupping		Control
Variable	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	χ2 Test	P Value
History of admission in CCU
Yes	22	73.3	18	60	20	66.7	1.2	.55
No	8	26.7	12	40	10	33.3	1.2	.55
History of admission
Yes	24	80	23	76.6	25	83.3	0.42	.81
No	6	20	7	23.3	5	16.7	0.42	.81
History of addiction
Yes	14	46.7	6	20	7	23.3	6.03	.05
No	16	53.3	24	80	23	76.7	6.03	.05
History of allergy
Yes	10	33.3	6	20	11	36.7	2.22	.33
No	20	66.7	24	80	19	63.3	2.22	.33
Type of disease
Hypertension	9	30	5	16.7	12	40	10.05	.26
Chest pain	15	50	16	53.3	12	40
Arrhythmia	3	10	1	3.3	4	13.4
Valve disorders	2	6.7	5	16.7	1	3.3
Other	1	3.3	3	10	1	3.3

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CCU, critical care unit.

Table 2 shows the mean score of hemodynamic parameters in the 3 groups at different times. Only DBP was different among groups at different times (Table 3). The mean difference of DBP between the massage and dry cupping groups was -3.2 (P=.03; 95% confidence interval=-6.19 to -0.21), and the mean difference of DBP between the massage and control groups was -3.06 (P=.04; 95% confidence interval=-6.05 to -0.07). The within-subject comparisons showed that the changes in DBP of the dry cupping and control groups were not significant at the different times. The changes in DBP of the massage group were significant on the third day compared with the first and second days (Table 4). On the other hand, DBP reduced after massage on the third day (9.28 mmHg), while it was 0 and nearly 1.48 mmHg on the first and second days, respectively (Table 2).

Table 2.

The Hemodynamic Parameters of Critical Care Patients in Massage, Dry Cupping, and Control Groups at Different Times

Group		Massage (mean/SD)			Dry Cupping (mean/SD)			Control (mean/SD)
Hemodynamic parameters		Before	After	DIF	Before	After	DIF	Before	After	DIF
Systolic blood pressure	First day	122.25	120.37	-1.88	120.88	117.13	-3.75	120.8	116.37	-4.43
		-13.96	-14.21	-9.1	-13.76	-14.84	-11.17	-21.62	-17.24	-11.33
	Second day	122.28	122.62	0.33	112.33	112.68	0.35	117.05	116.87	-0.18
		-16.55	-15.38	-7.3	-12.96	-12.4	-8.66	-19.12	-16.5	-9.7
	Third day	119.28	112.55	-6.73	114.77	113.1	-1.67	116.17	114.43	-1.73
		-9.35	-10.73	-10.33	-15.57	-12.85	-10.4	-17.84	-12.29	-12.69
Diastolic blood pressure	First day	77.98	77.27	-0.72	72.27	71.78	-0.48	72.73	74.93	2.2
		-13.12	-12.03	-8.89	-12.14	-10.94	-9.91	-11.05	-10.68	-8.26
	Second day	73.9	75.38	1.48	67.52	69.18	1.67	70.48	69.9	-0.58
		-13.37	-10.76	-6.02	-9.58	-8.84	-6.08	-10.87	-8.1	-7.87
	Third day	76.92	67.63	-9.28	69.08	68.98	-0.1	71.03	70.08	-0.95
		-9.17	-8.5	-9.95	-10.92	-14.61	-9.22	-11.91	-11.24	-7.73
Pulse rate	First day	71.6	71.15	-0.45	74.35	72.37	-1.98	75.88	73.62	-2.27
		-12.49	-12.02	-7.33	-13.17	-13.18	-6.35	-15.74	-14.83	-9.59
	Second day	73.7	75.62	1.92	70.95	73.2	2.25	72.67	73.82	1.15
		-10.6	-11.79	-6.59	-9.42	-10.52	-6.61	-12.54	-11.8	-6.36
	Third day	74.23	71	-3.23	73.57	74.95	1.38	75.48	74.5	-0.98
		-12	-9.16	-8.54	-10.44	-9.48	-5.72	-14.24	-12.38	-8.84
Respiratory rate	First day	17.87	17.72	-0.15	18.05	18.18	0.13	18.12	17.92	-0.2
		-2.66	-1.9	-2.45	-3.01	-2.87	-2.15	-3.55	-2.45	-2.23
	Second day	17.57	17.62	0.05	17.07	17.48	0.42	17.93	18.17	0.23
		-2.34	-2.54	-1.56	-2.68	-3.4	-1.55	-2.43	-2.64	-1.68
	Third day	16.65	17	0.35	17.2	17.98	0.78	17.67	17.63	-0.03
		-1.71	-2.3	-1.73	-2.63	-2.56	-1.73	-3.03	-2.49	-1.84
SpO₂	First day	92.82	93.15	0.33	91.93	92.58	0.65	92.15	92.45	0.3
		-3.03	-2.73	-1.9	-3.58	-3.14	-1.36	-2.75	-2.66	-1.47
	Second day	93.62	93.88	0.27	93.15	93.4	0.25	93.02	93.15	0.13
		-2.39	-2.81	-1.08	-3	-2.63	-1.48	-2.17	-1.88	-1.44
	Third day	93.87	94.32	0.45	93.1	93.32	0.22	93.33	93.3	-0.03
		-2.24	-1.74	-1.19	-2.36	-2.82	-1.32	-1.93	-1.76	-1.23

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DIF, after minus before; SD, standard deviation; SpO₂, saturation of peripheral oxygen.

Table 3.

Comparison of Hemodynamic Parameters in Massage, Dry Cupping, and Control Groups at Different Times

Source of Change		Sum of Squares	df	F	P Value	Partial Eta Squared
Systolic blood pressure	Group time	52.44	2	0.25	.78	0.002
	Group * time	749.09	2	3.61	.03	0.03
	Error	564.37	4	1.36	.25	0.02
		27 099.47	261
Diastolic blood pressure	Group time	588.89	2	4.24	.02	0.03
	Group * time	991.03	2	7.14	.001	0.05
	Error	1207.4	4	4.35	.002	0.06
		18 109.05	261
	Group time	86.16	2	0.78	.46	0.006
Pulse rate	Group * time	567.47	2	5.13	.007	0.04
	Error	310.02	4	1.4	.23	0.02
		14 423.73	261
	Group time	10.05	2	1.38	.25	0.01
Respiratory rate	Group * time	9.11	2	1.26	.29	0.01
	Error	3.93	4	0.27	.9	0.004
		947.31	261
	Group time	3.14	2	0.8	.45	0.006
SpO₂	Group * time	2.75	2	0.7	.5	0.005
	Error	2.93	4	0.37	.83	0.006
		514.23	261

Table 4.

Adjustment for Multiple Comparisons Using Bonferroni for the Comparison of Diastolic Blood Pressure Within Massage, Dry Cupping, and Control Groups at Different Times

Group	Time (I)	Time (J)	Mean Difference (I-J)	Standard Error	P Value	95% Confidence Interval for Difference
Massage	First day	Second day	-2.2	2.15	0.92	-7.38 to 2.98
		Third day	8.57	2.15	<.001	3.38-13.75
	Second day	Third day	10.77	2.15	<.001	5.58-15.95
Dry cupping	First day	Second day	-2.15	2.15	.96	-7.33 to 3.03
		Third day	-0.38	2.15	>.99	-5.56 to 4.80
	Second day	Third day	1.77	2.15	>.99	-3.42 to 6.95
Control	First day	Second day	2.78	2.15	.59	-2.40 to 7.96
		Third day	3.15	2.15	.43	-2.03 to 8.33
	Second day	Third day	-0.37	2.15	>.99	-5.55 to 4.82

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Multiple comparisons showed that changes in DBP of the groups were not different on the first and second days. Changes in DBP of the massage group were significantly greater on the third day than that of the dry cupping and control groups (Table 5). On the other hand, the DBP of the massage group reduced on the third day (-9.28 mmHg), while that of the dry cupping and control groups was -0.1 and -0.95 mmHg, respectively (Table 2).

Table 5.

Adjustment for Multiple Comparisons Using Bonferroni for the Comparison of Diastolic Blood Pressure Among Massage, Dry Cupping, and Control Groups at Different Times

Time	Group (I)	Group (J)	Mean Difference (I-J)	Standard Error	P Value	95% Confidence Interval for Difference
First day	Massage	Dry cupping	-0.23	2.15	>.99	-5.42 to 4.95
		Control	-2.92	2.15	.53	-8.01 to 2.26
	Dry cupping	Control	-2.68	2.15	.64	-7.86 to 2.45
Second day	Massage	Dry cupping	-0.18	2.15	>.99	-5.36 to 5.00
		Control	2.07	2.15	>.99	-3.12 to 7.25
	Dry cupping	Control	2.25	2.15	.89	-2.93 to 7.43
Third day	Massage	Dry cupping	-9.18 (2.15)	2.15	<.001	-10.36
		Control	-8.33	2.15	<.001	-10.37
	Dry cupping	Control	-0.85	2.15	>.99	-6.03 to 4.33

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Discussion

The results of the present study showed that the hemodynamic parameters of the patients admitted to CCUs were within the normal range during the study. According to our results, dry cupping had no effect on regulating hemodynamic parameters, while only DBP was reduced significantly after massage on the third day of intervention. Therefore, our study did not show effects of massage and dry cupping on regulating hemodynamic parameters.

Taghizadeh et al studied the effect of massage on patients with heart attack and showed that stroke massage significantly increased arterial blood oxygen but did not reduce blood pressure. Vital signs and arterial oxygen saturation were measured before and after the intervention.22 The difference between the results of the present study and the aforementioned study is the significant effect of massage on the type of hemodynamic parameters. In the aforementioned study, massage had a significant effect on arterial oxygen saturation. In the present study, however, massage reduced DBP.

Abdi et al measured the effect of foot massage on blood pressure and heart rate of CCU patients in Iran and showed a significant difference between mean SBP and DBP, and also the pulse rate before and after foot massage in the control group showed a significant difference. There was no significant difference between the mean SBP and DBP and the number of pulses in the control group.36 The difference between the results of the aforementioned study and the present study is that the aforementioned study, in addition to the effect of the DBP massager, also had a significant effect on SBP and heart rate.

Permana and Lindayani measured the effect of foot massage on the hemodynamics of patients admitted to the intensive care unit of a public hospital in Indonesia, investigating heart rate, respiration rate, and increased oxygen saturation.37 This study, unlike the present study, reported the effect of massage on all hemodynamic parameters. Momeni et al evaluated foot massage on hemodynamic parameters of intensive care patients in Iran. The results showed that the mean arterial pressure in all 3 groups decreased 1 week after the intervention, which was not statistically significant. Mean heart rate also decreased in all 3 groups 1 week after the intervention, which was statistically significant except for family massage. Mean arterial oxygen saturation in all 3 groups decreased significantly 1 week after the intervention but remained normal. There was no significant difference among the 3 hemodynamic parameters among the 3 groups.38 The results of this study, unlike the present study, did not report the effect of massage on blood pressure.

Alivian et al measured the effect of light massage on hemodynamics of patients with heart failure and found that light massage had a significant effect on blood pressure, oxygen saturation, and respiration rate. There was no significant change in heart rate in the pre-test and post-test groups.39 The results of the aforementioned study showed that in addition to blood pressure, massage had a significant effect on oxygen saturation and respiration rate. Aourell et al measured the effect of Swedish massage on improving blood circulation, lowering blood pressure, and heart rate; it was been reported to be effective.40 Because different studies around the world have reported different results, the reason for this may be different training of researchers, different entry criteria and type of massage used, duration of use of different types of massage, and genetic differences of different races.

Ghezeljeh et al showed that 1-sided body massage for 3 days did not affect the hemodynamic parameters of the patients with burn injury.41 Unlike the present study, the aforementioned study does not confirm the significant effect of massage on any of the hemodynamic parameters. The type of massage might also have affected the results of the studies. Maryami et al showed that the mean DBP of the patients with hysterectomy did not change after foot massage, while the mean SBP decreased.25 In the aforementioned study, unlike the present study, SBP showed a significant decrease after massage. Differences in the results of existing studies and the present study can be due to differences in sample size, method, location, and number of massage sessions.

Cambron et al found that Swedish massage lowered the DBP and argued that the massage site had no effect on the results.24 Considering that the results of the aforementioned study are consistent with the present study, a conclusion can be made that massage is effective on DBP in different situations. Wang et al showed that hand and/or foot massage could reduce the respiratory rate and heart rate of postoperative patients but had no significant effect on SBP and DBP.42 Because the findings of this study strongly contradict the results of the present study.42 Differences in the results of existing studies and the present study can be due to differences in study environment, different inclusion and exclusion criteria, and hemodynamic status of participants before the study.

Hatefi et al showed that whole body massage affected the hemodynamic parameters of patients admitted to the trauma intensive care unit, which significantly reduced SBP and DBP, respiratory rate, heart rate, and increased arterial oxygen levels.12 The aforementioned study was effective on all hemodynamic parameters and, considering the extent of the significant effect of massage, also covers the results of the present study. One of the reasons for the consistency of the results of the aforementioned study with the present study was that he mentioned how the massage was performed and the similarity of the physiological structure of the participants.

Demir and Saritas studied the effect of back massage on patients undergoing liver surgery and showed that it reduced blood pressure, heart rate, and respiratory rate and increased arterial blood oxygen.43 Because different studies on different target groups in different communities reported a significant effect of massage on hemodynamic parameters, this confirms that massage can be useful and effective for all target groups.

Fazeli et al found that a 10-minute head massage in only 1session could reduce heart rate. He attributed this effect to the stimulation of the parasympathetic system. Other hemodynamic parameters were not controlled in this study.44 According to the available evidence, some studies confirm the results of the present study, and some do not support them. The reason for not confirming the results of the present study, according to the results of the aforementioned study, can be attributed to the place of massage and the mechanism of the effect of massage on the physiological processes of the body.

Cambron et al found that some massage techniques increased SBP, and their combination increased SBP and DBP, which may be due to sympathetic system stimulation caused by the pain at the intervention site. They reported that Swedish massage reduced DBP. However, such a reduction was not statistically significant. In this study, demographic indicators could also affect blood pressure. For example, younger or taller patients had lower SBP.24 Regarding the possible mechanism of the effect of massage, previous studies showed that massage caused the secretion of endorphins by creating a feeling of comfort and convenience and reduced blood pressure by dilating the arteries. In addition, massage can increase the level of arterial blood oxygen by controlling the respiratory rate and improving pulmonary circulation.45 Massage can also reduce heart rate by controlling anxiety, the sympathetic system, and parasympathetic stimulation.44^,46 The results of the aforementioned studies confirm the results of the present study. Since the analysis of different studies does not show any direct relationship between the type of massage, the place of massage and the target group, and the duration of the massage, such a conclusion can be made. Massage without considering any special conditions affects different types of hemodynamic parameters.

The results of the present study showed that dry cupping did not affect the hemodynamic parameters. Bhikha and Saville studied the effect of dry cupping on 20 patients with hypertension in South Africa and found that dry cupping reduced SBP and DBP.47 Iqbal et al, in a review study, found that dry cupping had a significant effect on SBP and DBP.15 Ting et al studied the effect of dry cupping on the infraspinatus muscle of 11 male and 2 female volunteers (aged 22.3 years old) and showed that dry cupping increased arterial blood oxygen levels at the site of suction.26 The previously mentioned evidence does not confirm the results of the present study. Differences in inclusion criteria, mean age, number of sessions, dry cupping duration, and sample size can explain differences in results. Also, the reason for the inconsistency of the results of the present study with the aforementioned studies can be attributed to the lack of studies conducted in this field.

Lee et al, in their systematic review study, believed that the positive effects of dry cupping on blood pressure could not be evaluated because of limited studies and the possibility of errors in existing studies. They recommended further studies in this field.48 Dry cupping is assumed to improve local blood circulation, relieve pressure on the heart and the lung, strengthen the function of the lymphatic system, eliminate waste materials, and possibly improve physiological parameters.15^,47

The results of the present study showed that face massage significantly reduced DBP on the third night of the intervention compared with dry cupping and routine care. Despite extensive research, no study has been found to compare the effects of massage and dry cupping on physiological parameters.

Limitations

One of the limitations of this study was that the researcher could not perform the intervention on female patients because of the religious beliefs of the researcher and the participants, and a female co-researcher did the intervention. Although the male and female co-researchers were trained similarly and approved by an expert, the interventions performed by each of them might be different due to the differences in physical structure of the male and female co-researchers. Another limitation of this study was the low experience of the researchers performing the intervention and the small number of training sessions on massage and dry cupping, which may not be approved by some experts in this field. The small sample size of participants in the control and intervention groups was another limitation. Therefore, larger sample should be used for future studies. The study samples did not represent all patients in the CCU, so the results could not be generalized to other patients admitted to the CCU. In addition, the first researcher allocated the samples into groups, which may be associated with bias.

Conclusion

According to the results of the present study, dry cupping had no effect on regulating hemodynamic parameters, while only DBP was reduced significantly after massage on the third day of intervention. Therefore, our study did not show the effects of massage and dry cupping on regulating hemodynamic parameters.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): Y.H., P.M.S., M.D.

Design (planned the methods to generate the results): Y.H., P.M.S., M.D.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): P.M.S., M.D.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): Y.H., M.M.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.D.

Literature search (performed the literature search): Y.H., M.M.

Writing (responsible for writing a substantive part of the manuscript): Y.H., M.M.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): P.M.S., M.D.

Practical Applications.

•
We compared the effects of massage versus dry cupping in addition to routine care on hemodynamic parameters of cardiac patients.
•
Dry cupping had no effect on regulating hemodynamic parameters.
•
Only diastolic blood pressure was reduced significantly after massage on the third day of intervention.
•
Our study did not show effects of massage and dry cupping on regulating hemodynamic parameters.

Alt-text: Unlabelled box

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