Modified Dry Cupping for Back Pain in Older Adults: A Nursing Innovation in Complementary Therapy

Lisnawati Lisnawati1*, Nazaruddin Nazaruddin1, Desak Ketut Sutiari2, Anisa Purnamasari1, Amzal Mortin Andas3, I Wayan Romantika4

1Faculty of Health Science, Mandala Waluya University, Kendari, Southeast Sulawesi 93561, Indonesia

2Faculty of Science and Technology, Mandala Waluya Univesity, Sulawesi Tenggara 93561, Indonesia

3Departement of Geriatric Nursing, Faculty of Health and Pharmacy, Universitas Bani Saleh, Bekasi, Jawa Barat 17113, Indonesia

4STIKesKarya Kesehatan, Kendari, Southeast Sulawesi 93561, Indonesia

*Corresponding Author’s Email: lisnawati150290@gmail.com

ABSTRACT

Background: Back pain is a common musculoskeletal problem among older adults, leading to reduced mobility, loss of independence, and decreased quality of life. Although dry cupping therapy has been shown to alleviate pain, its conventional application requires therapist supervision, limiting accessibility for the elderly. Objectives: This study aimed to evaluate the effectiveness of a modified dry cupping therapy device with an automatic control system as an innovative complementary nursing intervention for reducing back pain and promoting self-care in older adults. Methods: A quasi-experimental two-group pretest–posttest design was conducted with 102 elderly participants in Kendari City, divided equally into an intervention and control group (n = 51 each); the analysis used a paired-sample t-test. Results: At baseline, both groups reported moderate back pain (intervention: mean = 5.12 ± 0.52; control: mean = 5.10 ± 0.36). Following the intervention, the intervention group demonstrated a significant reduction in pain intensity (mean = 2.76 ± 0.65, p < 0.001, Cohen's d = 4.01), with 98% of participants reporting mild pain. In contrast, the control group showed no significant change (mean = 5.10 ± 0.36, p = 1.000). The between-group comparison confirmed a significant difference (mean difference = 2.34, 95% CI: 2.13-2.55, p < 0.001). Conclusion: Modified dry cupping therapy with an automatic control system is an effective, safe, and practical complementary nursing intervention for reducing back pain in older adults. This innovation supports self-care independence and may be integrated into community and gerontological nursing practices.

Keywords: Back Pain; Modified Dry Cupping Therapy; Nursing Innovation; Older Adult

INTRODUCTION

Back pain is one of the most common musculoskeletal problems among older adults and can significantly reduce quality of life by limiting mobility, impairing daily activities, and increasing dependency (Davis et al., 2023). In Indonesia, back pain remains a major health complaint among older adults, contributing to mobility limitations and functional decline (Kemenkes BKPK, 2023). Data from the 2023 Indonesian Health Survey showed that 10.2% of adults aged 55–59 years experienced mobility impairment, while musculoskeletal complaints continue to increase in several regions, including Southeast Sulawesi and Kendari City (Badan Pusat Statistik Provinsi Sulawesi Tenggara (BPS-Sultra), 2024; Kemenkes BKPK, 2023).

Back pain is a widespread condition that can significantly affect quality of life in older adults, leading to limited mobility, impaired daily activities, and an increased risk of health complications. Its prevalence has been reported at 65–90% annually, with approximately 25 million older adults affected worldwide (Saes-Silva et al., 2021). In the United States, the incidence of back pain increases with age (Mu et al., 2022), while in Brazil, around 70% of the elderly experience musculoskeletal complaints associated with pain (Queiroz et al., 2022). Globally, the number of back pain sufferers is projected to reach 1.5 billion by 2025 (Koivunen et al., 2023), including a substantial burden in Indonesia.

Back pain most commonly occurs among individuals aged 30 to 60 years and above and is exacerbated by factors such as occupational posture, body weight, and sex (Habir & Sani, 2023; Li et al., 2025). If left untreated, this condition may lead to sleep disturbances, reduced quality of life, restricted mobility, and decreased productivity (Ginnerup-Nielsen et al., 2022; Yabe et al., 2022). Therefore, effective and practical therapeutic approaches are urgently needed to address back pain in the elderly.

Several interventions have been utilized to manage back pain, including pharmacological therapy, exercise, yoga, acupuncture, and cupping therapy. Previous studies by Shen et al. (2022) demonstrated that cupping therapy is effective in reducing pain among patients with low back pain (LBP) (Shen et al., 2022). Another study examined the effectiveness of cupping therapy in alleviating LBP among university lecturers. One form of this treatment is dry cupping therapy, which provides relaxation and comfort in painful musculoskeletal areas (Lisnawati et al., 2024; Naleem et al., 2024). However, the application of this therapy typically requires therapist supervision, which may become a physical and financial burden for older adults and their caregivers.

Conventional management of back pain commonly involves pharmacological therapy, physiotherapy, and medical procedures (Bertelmann et al., 2021). However, these approaches may be costly, less accessible in resource-limited settings, and associated with side effects from long-term medication use, particularly in older adults (Andas et al., 2026). Therefore, safe, affordable, and practical complementary therapies are needed to support independent pain management among older adults (Zhu et al., 2023). Dry cupping therapy has been widely reported as an effective complementary intervention for reducing low back pain and improving comfort in musculoskeletal disorders (Lisnawati et al., 2024). Nevertheless, conventional dry cupping generally requires therapist supervision and manual pressure adjustment, which may limit its feasibility for independent home use among older adults (Ampiah et al., 2024).

This study introduces a modified dry cupping therapy device equipped with an automatic control system. The innovation includes automated suction pressure regulation to maintain stable and consistent negative pressure, reduce human error, and improve patient safety and comfort during therapy. In addition, the device is designed to be simple and practical, enabling older adults or caregivers to perform therapy independently at home without continuous professional supervision. This modification also has the potential to reduce healthcare costs and improve accessibility to complementary pain management services.

Although previous studies have demonstrated the effectiveness of cupping therapy for back pain, limited research has focused on the development of technology-assisted, self-administered dry cupping devices specifically designed for older adults. Therefore, this study aims to evaluate the effectiveness of a modified dry cupping therapy device with an automatic control system in reducing back pain among older adults.

METHODOLOGY

The feasibility test of the modified dry cupping therapy based on an automatic control system was conducted through a series of technical, functional, and clinical evaluations to ensure accuracy, reliability, safety, and therapeutic effectiveness.

The technical assessment showed that the pressure control system achieved the target setpoint with an accuracy of ±8% and an average pressure fluctuation of ≤5%, with a settling time of less than 25 seconds and an overshoot below 10%, thereby meeting the therapeutic stability standards. The safety interlock feature functioned effectively, responding within ≤2 seconds under overpressure conditions or sensor failures. In addition, the data logging system successfully recorded 100% of session data without file loss.

A quasi-experimental design with a two-group pretest–posttest approach was utilized to evaluate the effectiveness of the modified Dry Cupping Therapy with an automatic control system in reducing back pain among older adults (Fety et al., 2023).

Sampling and Randomization

Participants were divided into two groups: an intervention group and a control group, with the following sample sizes (Zou & Xu, 2023).

Figure 1: G*Power Sample Size of the Study

The sample size calculation was performed using G*Power for a study design comparing two independent groups (difference between two independent means). An independent t-test with a priori analysis was applied to determine the minimum required sample size before conducting the study (Purnamasari et al., 2025). The input parameters included an effect size of 0.5, indicating a medium effect, a significance level (α) of 0.05, and a statistical power of 0.80 (80%). A one-tailed test with an equal allocation ratio between groups (1:1) was also used. The analysis indicated that the minimum required sample size was 102 participants, consisting of 51 participants in the intervention group and 51 participants in the control group. Sampling was conducted using a simple random sampling technique to ensure that each eligible older adult had an equal opportunity to be selected as a participant (Aleessawi, 2026). Initially, a list of older adults diagnosed with back pain was obtained from records at the community health center. Each potential participant was assigned a unique identification number, and the selection process was performed using a computer-based random number generator (Politano et al., 2022). Participants who met the inclusion criteria, including older adults without communication barriers and those willing to participate until the end of the study, were recruited. A total of 102 eligible participants were subsequently allocated into the intervention group and the control group (n = 51 each) using a computer-generated randomization list. This randomization procedure was conducted to minimize selection bias and ensure comparability of demographic and clinical characteristics between the two groups (Khan et al., 2023).

The intervention group received modified dry cupping therapy using a device equipped with an automatic control system. The therapy was administered for a total duration of three minutes. During the procedure, suction was applied to the skin surface for 20 seconds, followed by a 10- second relaxation period, and this cycle was repeated continuously for three minutes. All therapy parameters, including suction duration and relaxation intervals, were pre-set and automatically regulated by the modified dry cupping device to ensure consistent pressure and patient safety. Meanwhile, the control group did not receive any intervention during the study period and only underwent pain observation. For ethical considerations, the control group was offered the intervention after the study was completed.

Pain intensity was assessed using the Visual Analog Scale (VAS), a subjective measurement tool widely used to evaluate pain intensity (Koo & Yang, 2025). The VAS score ranged from 0 to 10, where 0 indicated “no pain” and 10 represented “worst pain imaginable” (Pelawati et al., 2022). In addition, observation sheets were used to document participant progress and monitor responses during the intervention.

Pain assessments were conducted at baseline (pretest) and after the intervention (posttest). The collected data was analyzed using the paired sample t-test to compare pretest and posttest pain scores within each group.

Ethical Consideration

This study was approved by the Research Ethics Committee of Universitas Bani Saleh, Indonesia, with reference number 223/II.1.AU/KET.ETIK/VIII/2021, on 24th June 2025.

RESULTS

This study involved 102 elderly respondents experiencing back pain. The characteristics of the study respondents are as follows:

1. Characteristics of Respondents

   
   

   Table 1: Distribution of Respondents Based on Respondent Characteristics

   
   

   Variable	Category	Intervention Group (51)		Control Group (51)
   		f	%	f	%
   Age	50-59 yrs	28	54.9	22	43.1
   	60-69 yrs	14	27.5	17	33.3
   	70-79 yrs	7	13.7	12	23.5
   	>79 yrs	2	3.9	0	0
   Total		51	100	51	100
   Gender	Male	13	25.5	12	23.5
   	Female	38	74.5	39	76.5
   Total		51	100	51	100
   Education	No formal education	0	0	0	0
   	Primary School	1	2.0	1	2.0
   	Junior High School	0	0	4	7.8
   	Senior High School	37	72.5	36	70.6
   	Higher Education	13	25.5	10	19.6
   Total		51	100	51	100

   Occupation	Homemaker	33	64.7	34	66.7
   	Civil Servant	6	11.8	3	5.9
   	Self-employed	6	11.8	5	9.8
   	Retired	5	9.8	4	7.8
   	Unemployed	1	2.0	5	9.8
   Total		51	100	51	100

   
   

   This study involved 102 participants aged 50 years and older experiencing back pain. Table 1 presents the distribution of demographic characteristics. In the intervention group, the majority of participants were aged 50–59 (54.9%), predominantly female (74.5%), with secondary education or higher (97.5%), and mostly homemakers (64.7%). The control group showed similar demographic patterns, with 43.1% aged 50–59 years, 76.5% female, 90.2% having secondary education or higher, and 66.7% being homemakers. No statistically significant differences were observed between groups for any demographic variable (p > 0.05), indicating successful randomization and group comparability.

2. Back Pain

   
   

   Table 2: Back Pain Scale in Older Adult Before and After Intervention

   
   

   Back Pain	Intervention (51)				Control (51)
   	Pretest		Posttest		Pretest		Posttest
   	f	%	f	%	f	%	f	%
   Mild (1-3)	0	0	50	98	0	0	0	0
   Moderate (4-6)	51	100	1	2.0	51	100	51	100
   Severe (7-10)	0	0	0	0	0	0	0	0
   Mean	5.12		2.76		5.10		5.10
   Standard Deviation	0.516		0.651		0.361		0.361
   Minimum	4		1		4		4
   Maximum	7		5		6		6

   
   

   Table 2 presents the distribution of back pain intensity before and after the intervention. At baseline, all participants in both groups reported moderate back pain (intervention: mean = 5.12 ± 0.52; control: mean = 5.10 ± 0.36). No participants in either group reported mild or severe pain at baseline. Following the intervention, the intervention group demonstrated a marked improvement, with 98.0% of participants shifting to the mild pain category and only 2.0% remaining in the moderate category. No participants reported severe pain. The mean pain score decreased substantially from 5.12 ± 0.52 to 2.76 ± 0.65. In contrast, the control group showed no change in pain distribution, with 100% remaining in the moderate category (mean = 5.10 ± 0.36 at both measurements).

3. Effect of Modified Dry Cupping Therapy Using an Automatic Control System on Back Pain in the Elderly

Table 3: Effect of Modified Dry Cupping Therapy on Back Pain in Older Adult

Table 3 presents the statistical analysis of the intervention effect. In the intervention group, the paired-sample t-test revealed a significant reduction in pain intensity (mean difference = -2.36, 95% CI: -2.53 to -2.19, t = 23.46, p < 0.001). The effect size was very large (Cohen's d = 4.01, 95% CI: 3.20-4.82). In the control group, no significant change was observed (mean difference = 0.00, 95% CI: -0.06 to 0.06, t = 0.13, p = 1.000). The independent t-test comparing the mean differences between groups confirmed a significant between-group effect (mean difference = 2.34, 95% CI: 2.13-2.55, t = 22.49, p < 0.001). The very large between-group effect size (Cohen's d = 4.45) underscores the strong therapeutic impact of the modified dry cupping intervention.

DISCUSSION

The findings of this study demonstrate that modified dry cupping therapy with an automatic control system was highly effective in reducing back pain among older adults. In the intervention group, almost all participants (98%) experienced a significant decrease in pain intensity in the mild category, whereas in the control group, pain levels remained largely unchanged. The mean back pain score in the intervention group decreased from 5.12 ± 0.52 at pretest to 2.76 ± 0.65 at posttest (p < 0.001), while the control group showed no significant difference (5.10 ± 0.36 at both measurements, p = 1.000). This clear contrast indicates that the intervention, not time or placebo effect, was responsible for the substantial reduction in pain.

The contrast between groups is consistent with findings by Chiu et al. (2020), who reported that dry cupping effectively alleviated soft tissue pain in athletes. Similarly, Lisnawati et al. (2024) found that cupping therapy significantly reduced lower back pain among lecturers. However, unlike conventional dry cupping, participants in the control group of this study who received no such intervention did not experience measurable pain relief (Lisnawati et al., 2024). The present findings reinforce this evidence by demonstrating that incorporating an automatic control system makes cupping therapy more practical, safe, and feasible for home use without requiring supervision from healthcare professionals.

Physiologically, dry cupping reduces pain through several mechanisms (Xu et al., 2025). First, the suction process applied to the skin increases blood circulation and tissue oxygenation, thereby reducing local ischemia, which is often a major cause of muscle pain (Dergaa et al., 2024). Second, the mechanical stimulation of negative pressure can activate the gate control theory of pain by engaging A-beta nerve fibers that inhibit pain signal transmission to the brain, thus lowering pain perception. Third, dry cupping stimulates the release of endorphins and other endogenous analgesic neurotransmitters that act as natural pain modulators (Silva et al., 2022). Fourth, improved microcirculation assists in the clearance of pain-inducing metabolites such as lactic acid, thereby accelerating tissue recovery (Pinto et al., 2026). Among older adults, who are generally prone to musculoskeletal degeneration, these mechanisms are particularly beneficial as they help relieve pain without the additional pharmacological burden (Zhang et al., 2024).

The statistically significant difference between the intervention and control groups underscores the potential of modified dry cupping therapy as a clinically effective complementary intervention for managing back pain in older adults. Unlike pharmacological treatments, which can cause adverse effects with long-term use, the therapy offers a safe, non-pharmacological alternative. These findings align with those of Li et al. (2025), who emphasized the value of complementary therapies in improving the quality of life among older adults with musculoskeletal disorders.

The pain-reducing effect of the modified dry cupping therapy is closely related to the working mechanism of its automatic control system. The device operates by generating controlled negative pressure through a programmed suction-relaxation cycle, in which suction is applied for 20 seconds followed by a 10-second release phase. This rhythmic pressure modulation creates repeated mechanical stimulation on the skin and underlying soft tissues, promoting intermittent vasodilation and improving local blood perfusion. The cyclic suction also facilitates muscle decompression, reduces tension in paraspinal muscle fibers, and decreases localized stiffness commonly associated with back pain (Jan & Cheung, 2026). Furthermore, the alternating negative pressure stimulates cutaneous mechanoreceptors, which modulate nociceptive signal transmission through spinal inhibitory pathways, thereby reducing pain perception. The automated regulation ensures that pressure remains constant within a safe therapeutic threshold, preventing excessive tissue strain while maximizing physiological responses that contribute to analgesia and muscular relaxation.

Moreover, this innovation addresses key limitations of traditional cupping therapy. The integration of an automatic control system ensures stable suction pressure, reduces human error, and improves user comfort (Tankha et al., 2024). This is particularly relevant for community-dwelling older adults, as shown by the control group results, where the absence of intervention maintained persistent pain levels. Therefore, this innovation not only provides clinical benefits but also supports the global trend toward home-based and self-managed care, especially in regions with limited healthcare resources (da Silva et al., 2025).

The findings of this study have important implications for nursing practice, particularly in the field of community and gerontological nursing. The modified dry cupping therapy with an automatic control system can be applied as a complementary, non-pharmacological intervention that supports pain management in older adults. From a nursing perspective, the device not only reduces pain intensity but also promotes self-care and independence, which are key elements in elderly care.

Limitations

This study has several limitations that should be acknowledged. The quasi-experimental design limited the ability to control for all potential confounding factors compared to a randomized controlled trial. The intervention was conducted in a single geographic area (Kendari City), which may limit the applicability of the findings to broader populations with different cultural or health system contexts. Pain intensity was assessed using a subjective self-reported tool (VAS), which, although widely accepted, may be influenced by individual perception and reporting bias. This study only focused on short-term outcomes and did not evaluate long-term effects, such as recurrence of pain, functional improvement, or quality-of-life changes over time.

Future Scope

Future research should focus on conducting larger multi-center trials to validate the effectiveness and safety of the modified dry cupping device across different elderly populations and settings. Further development of the device’s design, such as incorporating digital monitoring, pressure sensors, or mobile-based control systems, could enhance usability and precision. Additionally, qualitative studies exploring user satisfaction, adherence, and cost effectiveness would better understand the feasibility of implementing this innovation in routine nursing practice

CONCLUSION

This study concludes that modified dry cupping therapy with an automatic control system is an effective complementary nursing intervention for reducing back pain in older adults. The therapy supports independence, is safe for home use, and enhances quality of life by reducing reliance on long-term pharmacologic treatments. Nurses play an important role in education, initial

supervision, and evaluation of therapy outcomes, so this intervention can be integrated into community and gerontological nursing practice..

CRediT Authorship Contribution Statement

L.L: Conceptualization, Methodology, Writing – original draft, Project administration. N.N: Formal analysis, Investigation, Data Curation. D.K.S: Supervision, Writing – Review and Editing. A.P: Investigation, Resources. A.M.A: Software, Data Curation. I.W.R: Validation, Visualization.

AI Assistance Declaration

During the preparation of this manuscript, the authors used ChatGPT, a generative AI tool, to assist with language translation from Indonesian to English and for grammar correction and proofreading. After using this tool, all authors thoroughly reviewed and revised the content and take full responsibility for the final version of the manuscript. No other AI tools were used for data analysis, interpretation, or drawing scientific conclusions.

Conflict of Interest

The authors declare that they have no conflict interests.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the support provided by the Ministry of Higher Education, Research, and Technology of the Republic of Indonesia through the Directorate of Research, Technology, and Community Service (DRTPM) under the research grant scheme. This financial support was essential in facilitating the development and completion of this study.

REFERENCES

Aleessawi, D. N. (2026). Research methodology: A comprehensive textbook (1st ed.). Amjad Publishing and Distribution House. https://www.studocu.com/row/document/jomo-kenyatta- university-of-agriculture-and-technology/information-technology/research-methodology- research-methodology-comprehensive-study-material/160239481

Ampiah, P. K., Hendrick, P., Moffatt, F., & Ampiah, J. A. (2024). A physiotherapist-led biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana: a mixed-methods feasibility study. BMC Musculoskeletal Disorders, 25(1), 1014. https://doi.org/10.1186/s12891-024-08118-1

Andas, A. M., Lisnawati, L., Purnamasari, A., Romantika, I. W., & Andas, N. H. (2026). Sarcopenia screening in community-dwelling older adults in Indonesia: Implications for integrated care strategies to enhance quality of life. Creative Nursing, 32(2), 224-232. https://doi.org/10.1177/10784535261431391

Bertelmann, T., Heutelbeck, A., Bopp, S., Sagebiel, L. L., Eichberg, S., Hallier, E., ... & Hoerauf, H. (2021). Prevalence of back pain among german ophthalmologists. Ophthalmic Research, 64(6), 974-982. https://doi.org/10.1159/000517574

Badan Pusat Statistik Provinsi Sulawesi Tenggara. (2024). Provinsi Sulawesi Tenggara dalam angka 2024 (Publication No. 74000.24005; ISSN 0215-2304). Badan Pusat Statistik Provinsi Sulawesi Tenggara. https://sultra.bps.go.id/id/publication/2024/02/28/8a583ca37d59d5caef7c49b9/provinsi-sulawesi- tenggara-dalam-angka-2024.html

Chiu, Y. C., Manousakas, I., Kuo, S. M., Shiao, J. W., & Chen, C. L. (2020). Influence of quantified dry cupping on soft tissue compliance in athletes with myofascial pain syndrome. PLoS One, 15(11), e0242371. https://doi.org/10.1371/journal.pone.0242371

da Silva, K. M. P., Almeida Silva, H. J., Pontes-Silva, A., DeSantana, J. M., Avila, M. A., Barbosa, G. M., & de Souza, M. C. (2025). What are the effects of dry cupping therapy combined with the McKenzie method on clinical outcomes in chronic low back pain? A protocol for a randomized, sham-controlled trial. BMC Complementary Medicine and Therapies, 25(1), 219. https://doi.org/10.1186/s12906-025-04940-9

Davis, D. L., Almardawi, R., Beamer, B. A., Ryan, A. S., & Terrin, M. L. (2023). Shoulder pain, health-related quality of life and physical function in community-dwelling older adults. Frontiers in Aging, 4, 1176706. https://doi.org/10.3389/fragi.2023.1176706

Dergaa, I., Ghouili, H., Clark, C. C. T., Taheri, M., Fessi, M. S., Souissi, N., Guelmami, N., Ben Aissa, M., Ben Saad, H., Weiss, K., Knechtle, B., & Ben Ezzeddine, L. (2024). Impact of wet and dry cupping therapy on endurance, perceived wellness, and exertion in recreational male runners. Sports medicine and health science, 8(1), 70–78. https://doi.org/10.1016/j.smhs.2024.11.004

Fety, Y., Said, F. M., & Nambiar, N. (2023). Adolescent Knowledge About Sexuality and Reproductive Health: Validity and Reliability Tests of Research Instruments and Its Interpretation. Proceedings of the 1st International Conference on Social Science (ICSS), 2(2), 1–10. https://doi.org/10.59188/icss.v2i2.131

Ginnerup-Nielsen, E., Harreby, M., Christensen, R., Bliddal, H., & Henriksen, M. (2022). The correlation between illness perception, pain intensity and quality of life in elderly with low back pain in Denmark: a cross-sectional study. PeerJ, 10, e14129. https://doi.org/10.7717/peerj.14129

Habir, A. H., & Sani, A. (2023). Faktor-Faktor Low Back Pain (LBP) Pada Buruh Pabrik Beras UD. Lanrisang Kabupaten Pinrang. Window of Public Health Journal, 4(5), 743-754. https://doi.org/10.33096/woph.v4i5.1525

Jan, Y. K., & Cheung, W. C. (2026). Muscle oxygenation regulation in physical therapy and rehabilitation. Medical Gas Research, 16(1), 66-75. https://doi.org/10.4103/mgr.medgasres-d-24- 00149

Kemenkes BKPK. (2023). Survei Kesehatan Indonesia (SKI). In Badan Kebijakan Pembangunan Kesehatan. https://www.badankebijakan.kemkes.go.id/hasil-ski-2023/

Khan, J. A., Raman, A. M., Sambamoorthy, N., & Prashanth, K. (2023). Research methodology (Methods, approaches and techniques) (1st ed.). SAN International Scientific Publications. https://doi.org/10.59646/rmmethods/040

Koivunen, K., Pernaa, K. I., & Saltychev, M. (2023). Back pain and radicular pain after lumbar microdiscectomy. BMC Surgery, 23(1), 1–9. https://doi.org/10.1186/s12893-023-02114-3

Koo, M., & Yang, S. W. (2025). Visual Analogue Scale. Encyclopedia, 5(4), 190. https://doi.org/10.3390/encyclopedia5040190

Li, J., Jia, Y., Sun, T., Bai, Z., Dong, X., & Hou, X. (2025). Interventions used in control group against cupping therapy for chronic nonspecific low back pain: A systematic review and network meta-analysis. Complementary Therapies in Medicine, 90, 103167. https://doi.org/10.1016/j.ctim.2025.103167

Lisnawati, L., Nofitasari, N., Ari, A., Islaeli, I., Yusnayanti, C., & Masriwati, S. (2024). Effect of Cupping Therapy for Low Back Pain (LBP) in Lecturer of Mandala Waluya University. Journal of Islamic Nursing, 9(1), 13-17. https://doi.org/10.24252/join.v9i1.46584

Mu, C., Jester, D. J., Cawthon, P. M., Stone, K. L., & Lee, S. (2022). Subjective social status moderates back pain and mental health in older men. Aging & Mental Health, 26(4), 810-817. https://doi.org/10.1080/13607863.2021.1899133

Naleem, M. B., Akhtar, M. W., Shamsi, Y., Jabin, F., & Maaz, M. (2024). Evaluation of comparative efficacy of Hijama bila shart (dry cupping) and Bukhoor (steam application) in the management of low back pain. Journal of Bodywork and Movement Therapies, 40, 2042-2047. https://doi.org/10.1016/j.jbmt.2024.10.056

Pelawati, R., Widada, W., Wulandari, E., Mardiyanti, M., & Samsiah, S. (2022). Therapeutic Effect of Hijamah (Cupping Therapy) on Lipid Profiles and Apolipoprotein in Hypercholesterolemic Patients. Jurnal Keperawatan Soedirman, 17(2), 81-86. https://doi.org/10.20884/1.jks.2022.17.2.5692

Pinto, R. Z., Kongsted, A., Silva, S., Hayden, J. A., Downie, A., & Saragiotto, B. T. (2025). Recent highlights in low back pain research, Part I: Diagnosis and Prognosis. Journal of Physiotherapy, 72(1), 23–32. https://doi.org/10.1016/j.jphys.2025.12.002

Politano, P. M., Walton, R. O., & Parrish, A. E. (2022). Statistics and research methodology: A gentle conversation (3rd ed., Issue September). Hang Time Publishing, Ltd. Co.

Purnamasari, A., Said, A., Indriani, C., Lisnawati, L., & Andas, A. M. (2025). Implementing Self- Help Interventions in Nursing Practice for Children and Adolescents on Mental Health with Risk for Eating Disorders. The Malaysian Journal of Nursing (MJN), 17(1), 144-153. https://doi.org/10.31674/mjn.2025.v17i01.015

Queiroz, A. M., Estrazulas, J. A., Garnelo, L., Mainbourg, E. M. T., Fonseca, F. R., & Herkrath, F. J. (2022). Self-reported chronic back pain in the elderly living in rural riverine areas in the Amazon. Rural and Remote Health, 22(1), 1-10. https://search.informit.org/doi/10.3316/informit.411056311363468

Saes-Silva, E., Vieira, Y. P., de Oliveira Saes, M., Meucci, R. D., Aikawa, P., Cousin, E., ... & Dumith, S. C. (2021). Epidemiology of chronic back pain among adults and elderly from Southern Brazil: a cross-sectional study. Brazilian Journal of Physical Therapy, 25(3), 344-351.

https://doi.org/10.1016/j.bjpt.2020.12.005

Shen, W. C., Jan, Y. K., Liau, B. Y., Lin, Q., Wang, S., Tai, C. C., & Lung, C. W. (2022). Effectiveness of self-management of dry and wet cupping therapy for low back pain: A systematic review and meta-analysis. Medicine, 101(51), e32325. https://doi.org/10.1097/md.0000000000032325

Silva, H. J. A., Avila, M. A., Castro, K. M. S., Pinheiro, Y. T., Lins, C. A. A., Barbosa, G. M., & de Souza, M. C. (2022). Exploring patient experiences of participating in a real and sham dry cupping intervention for nonspecific low back pain: A qualitative study. PLoS ONE, 17(5), 1–12. https://doi.org/10.1371/journal.pone.0268656

Tankha, H., Gaskins, D., Shallcross, A., Rothberg, M., Hu, B., Guo, N., ... & Saper, R. (2024). Effectiveness of virtual yoga for chronic low back pain: a randomized clinical trial. JAMA Network Open, 7(11), e2442339. https://doi.org/10.1001/jamanetworkopen.2024.42339

Xu, R., Yang, Y., Yan, C., Li, Z., Zhao, C., Ma, J., & Xu, G. (2025). Dry cupping therapy combined with conventional therapy does not provide additional benefits over conventional therapy alone in patients with non-specific chronic low back pain: a randomized trial. Chiropractic & Manual Therapies, 33(1), 26. https://doi.org/10.1186/s12998-025-00588-x

Yabe, Y., Hagiwara, Y., Sugawara, Y., & Tsuji, I. (2022). Association between low back pain and functional disability in the elderly people: a 4-year longitudinal study after the great East Japan earthquake. BMC Geriatrics, 22(1), 930.https://doi.org/10.1186/s12877-022-03655-7

Zhang, Z., Pasapula, M., Wang, Z., Edwards, K., & Norrish, A. (2024). The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials. Complementary Therapies in Medicine, 80, 103013. https://doi.org/10.1016/j.ctim.2024.103013

Zhu, Z., Chiarotto, A., Enthoven, W. T. M., Bierma‐Zeinstra, S. M. A., & Koes, B. W. (2023). Does pain medication influence outcomes in elderly people seeking care for back pain? BACE cohort study. European Journal of Pain, 27(5), 611-623.https://doi.org/10.1002/ejp.2084

Zou, P. X. W., & Xu, X. (2023). Research methodology and strategy: Theory and practice (1st ed.). John Wiley & Sons Ltd. https://doi.org/10.1002/9781394190256