Continuing Education Activity

Cupping therapy can generally be described as a technique that uses cups placed over the skin to create negative pressure through suction. Cupping therapy dates back to ancient times and was used around the world. In 400 BC, Herodotus listed wet and dry cupping as a treatment for many ailments, including maldigestion, lack of appetite, and headaches. This activity describes the technique, indications, and contraindications of cupping therapy.

Objectives:

• Identify the technique of cupping therapy.
• Describe the indications for cupping therapy.
• Review the clinical relevance of cupping therapy
• Outline the importance of improving care coordination among interprofessional team members to improve outcomes for patients undergoing cupping therapy.

Introduction

Cupping therapy can generally be described as a technique that uses cups placed over the skin to create negative pressure through suction.

Cupping therapy dates back to ancient times and was used around the world. In 400 BC, Herodotus listed wet and dry cupping as a treatment for many ailments, including maldigestion, lack of appetite, and headaches.[1] Hippocrates advocated cupping for gynecological complaints, back and extremity illnesses, pharyngitis, lung diseases, and ear ailments.[1] Cupping therapy was mentioned in the famous Papyrus Ebers in Ancient Egypt (1550 BC).[1] In the Middle East, cupping was advocated for by prominent physicians like Abu Bakr Al-Razi (AD 854-925), Ibn Sina (AD 980-1037), and Al-Zahrawi (AD 936-1036).[2] In China, cupping was recorded as a medical treatment in the Mawangdui Silk texts (sealed in 168 BC).[3] Cupping therapy was used in ancient Europe as well. In the first century AD, Celsus advised cupping therapy for extracting poison from bites and for abscesses.[1] In the 2nd century AD, Aretaeus treated prolapse of the uterus, cholera, epilepsy, and ileus with wet cupping.[1] Galen was an advocate for cupping therapy and detailed a variety of materials that could be used for cups like horns, glass, and brass.[1]

There are two types of cupping methods, dry and wet. Dry cupping is noninvasive with no bloodletting. Wet cupping is invasive and includes bloodletting. It is further subdivided into traditional wet cupping and Al-hijamah. Al-hijamah comes from the Arabic word hajm, which means sucking, expansion, and bloodletting.[4] Traditional wet cupping is commonly used in China, Korea, and Germany.[1] Al-hijamah is more common in the Middle East and North Africa.[1][5]

The specific mechanism in which cupping exerts its therapeutic effect has not been identified. However, a number of theories have been proposed. One method, called Taibah, suggests wet cupping mimics an artificial kidney.[4] 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.[4] Filtered fluid collected contains disease-related and disease-causing substances as well as prostaglandins and inflammatory mediators. The scratches made with the scalpel increase innate and acquired immunity by stimulating inflammatory cell migration and endogenous opioid release.[4] This action leads to improved blood flow, removal of toxins, restored neuroendocrine balance, improved oxygen supply, and tissue perfusion.[4]

Cupping therapy has been used for centuries to treat a wide variety of health disorders. However, to improve patient outcomes, clinicians should understand that cupping therapy is not a substitute treatment for conventional therapies but a complementary therapy. Health professionals should also be aware evidence to support its use for treating most medical disorders is lacking and that some health professionals may mistake cupping bruises as evidence of abuse.

Anatomy and Physiology

There are numerous anatomical sites that can be used in cupping therapy and are chosen based on the ailment being treated. Areas where muscle tissue is abundant are the most common location for cup placement, including the back, chest, abdomen, and buttocks.[1]

Anatomical sites avoided are those with abundant hair, those that have little muscle tissue, and those that do not have enough surface area to place the cups.[6]

Indications

Cupping therapy is indicated for both healthy patients and those suffering from ailments.[6] Localized ailments that benefit from cupping therapy include headache, low back pain, neck pain, and knee pain.[2][6] Systemic illnesses that have seen benefits with cupping therapy include hypertension, rheumatoid arthritis, diabetes mellitus, psychiatric disorders, systemic infection, and skin disorders.[2][6]

Contraindications

Absolute contraindications to cupping therapy include cancer, organ failure, hemophilia or a similar blood disorder, and having a pacemaker.[2] Cupping therapy is not recommended for geriatric patients, pediatric patients, or women who are pregnant or are currently menstruating.[1] Those with high serum cholesterol are at higher risk of developing cardiovascular ailments with cupping.[1]

Contraindications include sites with deep vein thrombosis, an open wound, or a bone fracture.[2] Cupping should not be done directly over nerves, arteries, veins, varicose veins, skin lesions, body orifices, lymph nodes, eyes, or areas with skin inflammation.[2] Cupping done over excoriated, oozing, or infected areas may cause an increase in D-dimer levels.[1]

Those suffering from certain chronic diseases, like cardiovascular disease, those being treated with anticoagulants, or those experiencing an acute infection should generally avoid cupping therapy.[2]

Equipment

Cups can be fabricated from a variety of different materials, including bamboo, glass, and clay.[7] However, disposable cups are preferred, as non-disposable cups require advanced sterilization and disinfection procedures before they are reusable.[8] The size of the cup used depends on the location where it is being used.[8]

A sharp surgical blade is commonly used to create superficial lacerations in Al-hijamah wet cupping.[4] An auto-lancet needle is more commonly used in the two-step traditional wet cupping method.[9]

Technique or Treatment

Dry cupping is a one-step technique. Traditional wet cupping is a two-step technique: superficial skin scarification followed by cupping. Al-hijamah is a three-step wet cupping technique: cupping, superficial scarification, cupping.[1]

In Islamic medicine, it is recommended to perform Al-hijamah in the third quarter of the lunar month, particularly the 17th, 19th, and 21st days.[10] A study on the effects of lunar phases on blood pressure showed that mean arterial blood pressure was higher in the third quarter of the lunar month in those with a decreased physical fitness index.[11] The authors attributed the result to the gravitational pull of the moon and its possible effect on cardiovascular function in humans.[11]

Researchers recommend that cups should be on the skin for no more than 5-10 minutes.[8] The residual marks left from cupping disappear in 1-10 days.[8]

Suctioning

To create the necessary negative pressure in the cups, there is manual pumping, automatic pumping, and the fire method. For dry cupping, using fire to create a suction is the most popular choice and the primary method used in China.[8] In the fire method, a glass cup is rinsed with methylated spirits before being lit and then placed over the appropriate anatomical site on the skin.[1]

In Al-hijamah wet cupping, honey is used to fix the cups and for the scarification, which aids in healing.[1]

Complications

Cupping therapy is generally safe, with adverse events being infrequent.[2] Those that are reported range from mild to moderate in severity.[2] Preventable adverse events include scar formation, burns, bullae formation, abscess, skin infection, pruritus, anemia, and panniculitis.[2]

Nonpreventable adverse events include Koebner phenomenon, headache, dizziness, tiredness, vasovagal syncope, nausea, and insomnia.[2] Infection, vasovagal syncope, and scarring are seen more often in wet cupping.[8] Normal results of dry cupping include local erythema and ecchymosis.[8] Understandably, there is an increased risk of burns if fire is used for suctioning.[8]

Clinical Significance

The strongest evidence for cupping therapy’s benefit is for the treatment of pain, particularly musculoskeletal pain, migraine, or tension headache.[7] In one study, there was a 66% reduction in mean headache severity following wet cupping treatment.[12] The number of headaches per month for these patients also decreased by 12.6 days.[12] Cupping therapy has been shown to provide pain relief in lumbar sprain, scapulohumeral periarthritis, brachialgia paraesthetica nocturna, arthritis, and neuralgia pain.[6]

Dry cupping is commonly used for musculoskeletal pain and muscular tension.[1] Dry cupping has shown benefit to patients suffering from chronic back pain in both behavioral variables of pain and physiological parameters when applied to the lumbar or cervical regions.[8] For chronic back pain treatment, five sessions of cupping therapy, with 3-4 day intervals between sessions, and with cups applied to the skin for around 8 minutes achieved significant effects in reducing overall pain.[8]

Overall, dry cupping showed the most benefit in generalized pain conditions, while wet cupping showed the most benefit in inflammatory-related pain conditions, such as herpes zoster infection (shingles).

There have been studies done that have shown the benefits of cupping therapy beyond pain management. In a German study, traditional wet cupping was shown to be effective in treating carpal tunnel syndrome.[10] Wet cupping was also shown to treat thalassemia and autoimmune diseases effectively.[10] Cupping therapy was demonstrated to be effective against cough, dyspnea, and acne.[6]

As mentioned in the Introduction, to improve patient outcomes, clinicians should understand that cupping therapy is not a substitute treatment for conventional therapies but a complementary therapy. Health professionals should also be aware evidence to support its use for treating most medical disorders is lacking and that some health professionals may mistake cupping bruises as evidence of abuse.

Enhancing Healthcare Team Outcomes

Detailed measures for infection control are vital for preventing infections from cupping therapy. Hand washing and wearing the appropriate protective equipment (gloves, mask, protective eyewear, gown) are essential in preventing the spread of infection. Disinfecting beds or chairs used during treatment ensure a sterile environment. Using disposable equipment for cups, surgical blades, and vacuum pumps is preferable to disinfecting.

To minimize complications and adverse effects of cupping, a detailed medical history is recommended. Compiling a checklist that includes known contraindications to cupping therapy is a simple and effective method of automating the initial encounter. A physical exam should also be performed to evaluate whether or not the patient has any other abnormalities that would hinder or contraindicate treatment.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Mehta P, Dhapte V. Cupping therapy: A prudent remedy for a plethora of medical ailments. J Tradit Complement Med. 2015 Jul;5(3):127-34. [PMC free article: PMC4488563] [PubMed: 26151023]

2.

Aboushanab TS, AlSanad S. Cupping Therapy: An Overview from a Modern Medicine Perspective. J Acupunct Meridian Stud. 2018 Jun;11(3):83-87. [PubMed: 29436369]

3.

Cao H, Han M, Li X, Dong S, Shang Y, Wang Q, Xu S, Liu J. Clinical research evidence of cupping therapy in China: a systematic literature review. BMC Complement Altern Med. 2010 Nov 16;10:70. [PMC free article: PMC3000376] [PubMed: 21078197]

4.

Ghods R, Sayfouri N, Ayati MH. Anatomical Features of the Interscapular Area Where Wet Cupping Therapy Is Done and Its Possible Relation to Acupuncture Meridians. J Acupunct Meridian Stud. 2016 Dec;9(6):290-296. [PubMed: 28010830]

5.

Kim S, Lee SH, Kim MR, Kim EJ, Hwang DS, Lee J, Shin JS, Ha IH, Lee YJ. Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis. BMJ Open. 2018 Nov 05;8(11):e021070. [PMC free article: PMC6231582] [PubMed: 30397006]

6.

Nimrouzi M, Mahbodi A, Jaladat AM, Sadeghfard A, Zarshenas MM. Hijamat in traditional Persian medicine: risks and benefits. J Evid Based Complementary Altern Med. 2014 Apr;19(2):128-36. [PubMed: 24647093]

7.

Mazhar Uddin SM, Haq A, Sheikh H. The Use of Hijama (Wet Cupping) in Alternative and Complementary Medicine: Efficacious or Perilous? J Acupunct Meridian Stud. 2016 Dec;9(6):285-286. [PubMed: 28010828]

8.

Moura CC, Chaves ÉCL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM. Cupping therapy and chronic back pain: systematic review and meta-analysis. Rev Lat Am Enfermagem. 2018 Nov 14;26:e3094. [PMC free article: PMC6248735] [PubMed: 30462793]

9.

Khalil MKM, Al-Eidi S, Al-Qaed M, AlSanad S. Cupping therapy in Saudi Arabia: from control to integration. Integr Med Res. 2018 Sep;7(3):214-218. [PMC free article: PMC6160619] [PubMed: 30271709]

10.

El-Shanshory M, Hablas NM, Shebl Y, Fakhreldin AR, Attia M, Almaramhy HH, Baghdadi H, Ayat M, Albeihany A, El-Dardear A, Ibrahim HA, Mahmoud HS, Nabo MMH, El Sayed SM. Al-hijamah (wet cupping therapy of prophetic medicine) significantly and safely reduces iron overload and oxidative stress in thalassemic children: a novel pilot study. J Blood Med. 2018;9:241-251. [PMC free article: PMC6300367] [PubMed: 30588142]

11.

Chakraborty U, Ghosh T. A study on the physical fitness index, heart rate and blood pressure in different phases of lunar month on male human subjects. Int J Biometeorol. 2013 Sep;57(5):769-74. [PubMed: 23161271]

12.

Ahmadi A, Schwebel DC, Rezaei M. The efficacy of wet-cupping in the treatment of tension and migraine headache. Am J Chin Med. 2008;36(1):37-44. [PubMed: 18306448]

Disclosure: Shabi Furhad declares no relevant financial relationships with ineligible companies.

Disclosure: Abdullah Bokhari declares no relevant financial relationships with ineligible companies.