Cupping Therapy: A Modern Take on an Ancient Technique

Cupping, a practice that dates back to ancient China and Egypt, has undergone a renaissance in the US in recent years, sparked in part by the positive experiences of prominent athletes like Olympic gold-medalist Michael Phelps (Photo: Yana Perelotova/Shutterstock)

For thousands of years cupping therapy—the placement of special cups over areas of pain or restriction and creating negative pressure (vacuum) to disrupt the stagnation–played an important role in medicine. This ancient practice spanned from Egypt, to China, Greece, Europe and the Americas. 

Though most commonly used for musculoskeletal pain relief, the clinical applications are numerous. The Ebers Papyrus, and ancient Egyptian medical text dating back to 1500 BC, describes cupping as a treatment for pain, vertigo, irregular menstruation, maldigestion (lack of appetite and constipation), pulmonary issues, and more. 

From Egypt the concept and practice of cupping spread to the Greeks. Hippocrates, often lauded as the father of Western medicine, used cupping for back pain and gynecological disorders. From Greece, it then spread throughout Europe, and to the Americas.

A parallel movement happened in Asia. Ge Hong (281-341 AD), an herbalist and Taoist philosopher from China, is credited with practicing cupping in his search for immortality. He and his contemporaries utilized horn cups placed over injuries, to speed healing. They also used the technique to draw out foreign materials. Placement of cups over energy meridians and acu-points to move stagnant blood and Qi (life force/energy), was often prescribed in conjunction with acupuncture. 

In the United States through the 19th and early 20th centuries, cupping was considered a viable, non-invasive approach to pain management until the rise of pharmacology. The rapid growth of drug-based medicine and the evolution of surgery quickly marginalized cupping to the realm of “folk remedies.” By the 1930s, most allopathic physicians considered it “quackery.” Today, most Americans are unaware of it, except perhaps as an historical curiosity.

But in 2016, the cupping marks on Olympic gold medalist Michael Phelps—a record-breaking swimmer who is the most decorated Olympian of all time–drew national attention, and sparked a resurgence of cupping therapy in the West. Phelps, and many other top-tier athletes use the technique regularly as an aid to recovery. According to a New York Times report following Phelps’ revelations, several university competitive swimming teams began incorporating cupping for their swimmers.

Cupping, Then and Now

Throughout the centuries, many different materials have been used to make the cups used to create the suction essential to cupping therapies. Horn, bamboo, metal, glass, and various types of ceramics have all been used, and many of these materials are still in use today.

The traditional technique involves using an open flame to create a vacuum inside each cup, and then quickly applying the cups to the areas of the body to be treated. The suction thus created pulls tissue up into the cup and draws blood to the skin surface.

A systematic review and meta-analysis of 18 randomized controlled neck pain trials showed that, overall, patients who underwent cupping therapies received significant relief from neck pain with few adverse side effects, compared with those who received no treatment or had other non-pharma pain relief interventions

In modern times, silicone and plastic cups have largely replaced the horn and ceramic ones, and practitioners create suction with vacuum hand pumps rather than open flames. But fire-cupping with glass cups is still widely popular, especially in acupuncture/TCM practices. Fire-cupping does require higher levels of education and skill than suction pump techniques. Consequently, fire-cupping is generally not covered under liability insurance for practitioners.

Dry vs Wet Cupping

More popular in Eastern and Middle Eastern medicine, wet cupping—known as Hijama– consists of breaking the skin with pinpricks or a scalpel, placing a cup over the area and creating suction. This draws stagnant “old” blood out of the body. The blood that oozes from these lesions has a gel-like consistency. The theory is that by puncturing the skin and removing stagnant blood, the body can detoxify and create fresh blood. This in turn increases circulation, restores the flow of blood and Qi, and brings the body into balance. 

Over the centuries, various theories have been proposed to explain why this type of treatment might be beneficial. A very recent review on the subject includes an interesting proposition that suggests wet cupping mimics the mechanism of an artificial kidney. 

Authors Shabi Furhad and Abdullah Bokhari, of the McLaren Oakland Hospital, Michigan State University write: “Where an in vivo kidney filters hydrophobic materials through the glomeruli via normal pressure filtration, wet cupping filters both hydrophilic and hydrophobic material through high-pressure filtration. The high pressure from suction leads to increased blood volume, increased capillary filtration rate, and the expulsion of filtered and interstitial fluid in the area. Filtered fluid collected contains disease-related and disease-causing substances as well as prostaglandins and inflammatory mediators.”

They add that, “Scratches made with the scalpel increase innate and acquired immunity by stimulating inflammatory cell migration and endogenous opioid release. This action leads to improved blood flow, removal of toxins, restored neuroendocrine balance, improved oxygen supply, and tissue perfusion.” (Furhad S, Bokhari AA. StatPearls. 2022)

In Europe and the Americas, dry cupping is by far the more common technique. It also utilizes suction to bring up blood from underlying tissue, but it does not involve pricking or incising the skin in any way. The purported principle behind dry cupping is that the stagnant blood containing toxins and cellular waste is drawn from the underlying tissue and carried to the lymph system, where it is cleaned, and recirculated. Toxins and metabolic waste are eliminated through the normal waste system in the body. 

Modern dry cupping includes both static and gliding techniques. As the name implies, static cupping consists of placing a plastic or glass cup onto an area and leaving it there for the duration of treatment, usually 3-15 minutes. Gliding is done with silicone cups of various sizes. After application of some type of lubrication such as massage or coconut oil, and once the vacuum seal is created within the cup, the practitioner gently lifts it and creates a gliding movement along the areas of tension. This technique is effective in breaking up fascia.

Uses of Cupping

According to the Advanced Continuing Education (ACE) Institute, an organization that offers online and in-person training and conferences on cupping, dry cupping techniques are applicable in the context of:

  • Assisting with weight loss programs
  • Athletic performance enhancement
  • Detoxification – movement of stagnation
  • Enhancing the results of surgical procedures
  • Joint mobilization
  • Lymph drainage
  • Pain reduction
  • Preoperative and postoperative therapy (to shorten recovery time)
  • Releasing tight and contracted muscle tissue
  • Scar reduction
  • Skin toning and firming
  • Cellulite reduction
  • Contouring the face & body

Specific conditions that may respond to cupping include: Arthritis, Asthma & Pneumonia, Athletic Stress & Injury, Bursitis, Fibromyalgia, Insomnia & Anxiety,

Lung Inflammation & Congestion, Menopausal symptoms, Migraine, Tension Headaches, Sinusitis, Muscular Aches, Neuralgia, Sciatica, Scoliosis, Sluggish Colon & IBS, Lymphedema, TMJ Dysfunction, or Tendonitis.

Aftercare

There’s no question that cupping treatment will leave marks, known affectionately by fans of the treatment as “cup kisses.” In traditional practice, the color of the marks conveys important information about the degree of stagnation, and the patient’s overall health.

Most marks resolve within 1-10 days. Those lasting longer than 10 days indicate low circulation to the area (s) in question, and should be further addressed with massage, more cupping, and exercise. 

Cupping can be an excellent complement to allopathic treatments, as well as to other holistic or naturopathic therapies. But is not a substitute. People should be wary of any practitioners who claim it to be a “one true cure-all” for every ailment, and anyone who is practicing outside his or her licensed scope

Following a treatment session, patients should keep the treated areas covered and protected from wind, sun, heat, and cold. It’s also a good idea to avoid strenuous exercise, saunas, hot tubs, and hot showers or baths for 24 hours following treatment. Cupping, like massage or other bodywork, is a demand on the body. It is necessary for clients to drink plenty of water, gently stretch or walk, and rest.

Is There Any Science?

The evidence to support cupping, like many other ancient healing techniques, is largely anecdotal and historical. Since it is a hands-on, individualized treatment, it is difficult if not impossible to standardize for the purposes of pharma-style clinical trials.

As is the case with acupuncture, it is impossible to blind patients about whether or not they’re receiving the treatment. Further, large-scale clinical studies are very expensive and few entities outside the pharmaceutical industry and the federal government have the resources to fund them. Cupping “equipment” is minimal. There are no patentable substances or technologies involved. Put simply, there’s little financial incentive to study the technique in formal clinical settings.

Consequently, there is much controversy in Western medicine as to why and how cupping works–if it works at all. Conventional medical orthodoxy has essentially dismissed it, and most allopathic physicians consider it to be a placebo phenomenon at best.

Though cupping has not been studied as extensively as some would like, there are a few studies that have shown benefits.

For example, a German research team at the University of Duisberg-Essen compared twice-weekly home-based cupping versus a self-directed progressive muscle relaxation (PMR) technique in 61 patients with chronic, recurrent neck pain. After 12 weeks, both interventions reduced pain intensity scores, but those in the cupping group showed greater improvements on measures of pressure-associated pain thresholds, and overall wellbeing (Lauche R, et al. PLoS One. 2013).

More recently, a systematic review and meta-analysis of 18 randomized controlled neck pain trials showed that, overall, patients who underwent cupping therapies received significant relief from neck pain with few adverse side effects, compared with those who received no treatment or had other non-pharma pain relief interventions (Kim S, et al. BMJ Open. 2018)

Summing up their findings, Kim and colleagues write: “When compared with inactive controls, cupping significantly reduced pain, and improved function and quality of life.” They acknowledge however, that there was a high degree of heterogeneity in the trials they analyzed, in terms of specific cupping techniques, numbers of treatments, patient characteristics, pain assessment methods, and patient responses.

A similar sort of systematic review by Brazilian researchers looked at 16 cupping studies of patients with chronic low back pain—another common complaint for which cupping is sometimes recommended.

While the authors admitted there is more work to do on these types of studies, overall they found that patients who had the treatment experienced a reduction in pain intensity and improvement in quality of life (de Castro Moura C, et al. Rev Lat Am Enfermagem. 2018)

A team at the Charite University Medical Center, Berlin, randomized 40 patients with radiologically-confirmed osteoarthritis of the knee, and pain intensity scores greater than 40 to either 8 sessions of dry cupping over a four-week period, or no treatment at all.

At the close of four weeks, average global scores on the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scale were far lower in the cupping group versus the controls (27.7 vs 42.2). And at the 12-week point—two months after cessation of therapy—the patients treated with cupping still showed lower scores (31 versus 40.8). The treatment appeared to lower pain intensity, though the investigators did not see significant long-term changes for joint stiffness (Teut M, et al. BMC Complem Altern Med. 2012).

Qualifications & Contraindications

Cupping has a long and venerable history as a cheap, readily accessible home remedy. It is ingrained in many cultures, and seen as a normal part of self-care. But when it comes to severe musculoskeletal pain, or any other serious medical conditions, the treatment should only be done by licensed, trained, and skilled practitioners.

There is no specific licensure for cupping therapy. It is a technique that medical doctors, chiropractors, licensed acupuncturists, licensed massage therapists, and licensed (or license-eligible) naturopaths are all well-qualified to learn, and to incorporate into their practices.

Cupping can be an excellent complement to allopathic treatments, as well as to other holistic or naturopathic therapies. But it is not a substitute. People should be wary of any practitioners who claim it to be a “one true cure-all” for every ailment, and anyone who is practicing outside his or her licensed scope of practice.

As with any modality, there are contraindications for cupping. Cups should never be used on open wounds or broken bones. Nor should they be applied to the eyes, any orifice, varicose veins, or areas with deep vein thrombosis (DVT). In general, those with cardiac issues—especially those taking blood thinners–should not receive cupping.

Pregnant clients require a practitioner with skill. While not an absolute contraindication, pregnant patients need to be treated very carefully: the cupping should be gentle and the cups applied above the diaphragm only.

Cupping on children should be gentle and brief. In my experience, it is useful for children experiencing mucus buildup in their chests as well as digestive issues. 

Complications can occur, though are generally rare. According to the Furhad & Bokhari review paper, “Non-preventable adverse events include Koebner phenomenon, headache, dizziness, tiredness, vasovagal syncope, nausea, and insomnia. Infection, vasovagal syncope, and scarring are seen more often in wet cupping.”

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Stacy Collier is an independent practice management and billing consultant based in Anchorage, AK. She is also a certified personal trainer with a special focus on Corrective Exercise Therapy, helping people living with low back, shoulder, hip, and knee pain. Stacy recently launched Attainable Fitness, LLC, her personal training and fitness coaching practice.

 
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