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Cupping

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cupping therapy
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Cupping therapy
Cupping application sites
Can cupping therapy relieve fibromyalgia pain?
Cupping methods
Dry Cupping Therapy
Wet Cupping Therapy
Cupping therapy uses
Does cupping therapy work?
Cupping therapy summary
Cupping therapy side effects
Cupping therapy contraindications

Cupping therapy

Cupping also known as cupping therapy, suction cup therapy or Hijama therapy (Hijama Bila shart) in Arabic, can generally be described as a technique that uses a glass, ceramic, bamboo or plastic cups placed over the skin to create negative pressure through suction. Negative pressure is created in the cup either by applying a flame to the cup to remove oxygen before placing it on the skin or by attaching a suction device to the cup after it is placed on the skin. The resulting suction pulls the skin part of the way into the cup. The cup may be left in place for several minutes and then removed, leaving behind a bright red, circular welt. Cupping increases the flow of blood. In traditional Chinese medicine, it is also thought to increase the flow of qi (vital energy). Based on the application of cups, cupping therapies are classified and described as in Figure 1 below. Cupping is a practice used in traditional medicine in several parts of the world, including China and the Middle East. However, the exact origin of cupping therapy is a matter of controversy, its use has been documented in early Egyptian and Chinese medical practices 1. Cupping therapy goes 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 2. In “wet cupping” therapy, the skin is sterilized with alcohol and a very small incision is made with a triangle‐edged needle or a plum‐blossom needle and firmly tapping the point for a short time to cause bleeding 3, then creation of a vacuum by applying suction with a hot cup or jar on the desired points or the specific affected body surface, in order to increase the blood supply to the area under suction.“Dry cupping” doesn’t involve piercing the skin 4. Currently, cupping therapy is used for health promotion, prophylaxis and treatment of a variety of diseases around the world. Moreover, wet-cupping therapy is getting greater attention in the treatment of such various disease states as chronic or acute inflammatory disease, and autoimmune disorders 5. Cupping therapy is also used in daily practices for the rehabilitation of stroke, treatment of hypertension, and as an alternative therapy for chronic pain 6. Dry and wet cupping therapies altogether were proposed to have removed excessive toxins and fluids, activated peripheral neural networks, loosen adhesions and lift connective tissue, and bring blood flow to stagnant skin and muscles and to stimulate the peripheral nervous system 7. Cupping has also been used to improve subcutaneous blood flow and to stimulate the autonomic nervous system 8. In addition, cupping is said to reduce pain and high blood pressure as well as modulate neurohormones and the immune system 9. It has been shown in clinical studies that cupping therapy poses a modulator effect on immune system by releasing beta-endorphin and adrenocortical hormone into circulation with a skin puncture. Furthermore, these hormones may assist in blocking the inflammation during arthritis, thereby exerting beneficial effects on immune system through the central nervous system 10.

There are seven major types of cupping practice in China. Usually, cupping practitioners utilize the flaming heating power to achieve suction (minus pressure) inside the cups to make them apply on the desired part of the body. This basic suction method of cupping therapy is called retained cupping, which is most commonly used in Chinese clinics as the first type of cupping. The second type of cupping is bleeding cupping or wet cupping, which contains two steps: before the suction of the cups, practitioners make some small incisions with a triangle-edged needle or plum-blossom needle firmly tapping the acupoint for a short time to cause bleeding; the third one is moving cupping, which practitioners control the suction by gently moving the cup toward one direction; then is empty cupping, which means the cups are removed after suction without delay; or needle cupping, which apply the acupuncture first, then applying the cups over the needle. Cupping practitioners may also used other methods of suction, such as medicinal (herbal) cupping, which used bamboo cups, usually putting the cups and herbs into a deep pan with water and boiled them together, after 30 minutes apply the cup suction on specific points according to steam instead of fire; or water cupping which is a technique involves filling a glass or bamboo cup one-third full with warm water and pursuing the cupping process in a rather quick fashion. Each kind of cupping therapy may be used for different diseases or different purposes of treatment 11.

Cupping therapy is reported to treat a variety of diseases due to the effects of multiple types of stimulation 12. Cao and associates 13 suggested that cupping therapy appears to be effective for various medical conditions, in particular herpes zoster and associated pain and acne, facial paralysis, and cervical spondylosis. Bloodless cupping is particularly used to treat muscular tension and musculoskeletal pain, such as chronic neck pain 14. Cupping therapy is often used for lowering blood pressure and prevents the development of cardio vascular diseases in healthy people 15. Wet cupping in conjunction with conventional treatment is reported to effectively treat oral and genital ulceration in patient with Behçet’s disease 16. There is growing evidence that wet cupping is effective in musculoskeletal pain 17, nonspecific low back pain 18, neck pain 19, fibromyalgia 20 and other painful conditions 21. Michalsen et al. 22 concluded that cupping therapy may be effective in alleviating the pain and other symptoms of Carpal Tunnel Syndrome. Cupping therapy is also found to be effective in tension headache and migraine 23. Cupping therapy is effective for reducing systolic blood pressure in hypertensive patients for up to 4 weeks without any serious side effects 24. Evidently, cupping therapy is effective in the treatment of cellulitis 25. Cupping therapy has been used with various level of evidence (1 to 5) in many conditions such as cough, asthma, acne, common cold, urticaria, facial paralysis, cervical spondylosis, soft tissue injury, arthritis and neuro-dermatitis 13, 11.

It has been difficult to devise a sham version of cupping that can’t be recognized as a sham by the participants in the study. Proponents believe that cupping therapy can help increase circulation and promote healing. Studies of cupping typically measure the procedure’s effectiveness by comparing it with that of other forms of treatment. However, high-quality research studies usually also include a group of people who receive a placebo — a sugar pill or a fake version of the procedure being studied.

There is more than one theory for explaining the effects of both dry and wet cupping therapy. Cupping therapy stimulates acupuncture points and restores the disruptions in the homeostasis. Tham et al. 26 showed that cupping may be capable of stimulating individual acupuncture points. Removal of toxins, uric acid, lipoprotein, serum glutamic oxalacetic transaminase, iron and heavy metals can be clarified with blood detoxification theory 6. Regarding the anti-inflammatory effect of cupping therapy, immunological modulation and hormonal adjustment can be explained with immune system activation theory. Decreased pain, changes in the biomechanical characteristics of skin, and acceleration of blood circulation can be explained with pain-gate theory, diffuse noxious inhibitory controls and reflex zone theory 6. Relaxation of muscles, specific changes in local tissue structures, and increases in blood circulation can be explained with nitric oxide release theory 27.

Figure 1. Cupping therapy types

Cupping therapy types
[Source 5 ]

Figure 2. Cupping therapy effects

Cupping therapy effects
[Source 28 ]

Cupping application sites

There are many anatomical sites used in cupping therapy. These sites are chosen based on the ailment being treated. Areas where there are abundant muscles are the most common points where cups are placed. Various regions of the body on which cupping is effectively applied under diseases conditions are the back or neck, at the interscapular region, at the right and left carotid, at the lateral side of the neck, at protuberance behind the ear, the middle and crown of the head, at the chin, at the thighs or folds of the thighs, at knee joints, at ankle joints, at the breast, at hips or buttocks, at the anal area, at wrist joints, at ear tragus, and at shoulder joints 29. The back, chest, abdomen, and buttock, areas of abundant muscle are the most common sites on which the cups are applied 5. The cups are typically left in place for 5–10 minutes, or sometimes more.

Anatomical sites avoided are those with abundant hair, those that have little muscle tissue, and those that don’t have enough surface area to place the cups 30.

Can cupping therapy relieve fibromyalgia pain?

Some studies indicate that cupping may reduce fibromyalgia symptoms more effectively than conventional treatments 20, 31, 32. But it doesn’t appear that the procedure works any better than a sham version of cupping. So while some of the available studies do suggest a possible role for cupping in treating fibromyalgia, the definitive answer to its actual role will have to wait for larger and more rigorous studies to be completed.

Cupping methods

There are 10 types of different cupping methods such as weak/light cupping, medium cupping, strong cupping, moving cupping, needle cupping, moxa/hot needle cupping, empty/flash cupping, full/bleeding cupping, herbal cupping, and water cupping 33, however, dry and wet cupping are the two main types 34. Traditionally, cups were made of glass, metals or even bamboo 35. A gourd was explored as the medium for cupping by ancient Greeks 36. Since these traditional cups do not allow the complete cupping of big joints, a modern technology of pulsatile cupping was developed that generates a pulsatile vacuum for complete cupping. Silicone cups allow comprehensive cupping of big joints along with flexibility in therapy 35. Different shapes of cups are available from balls to bells in variable sizes, ranging from 25–75 mm across the opening 37. Across the world, different types of cups are available for cupping which are listed in Table 1 38.

Cupping is a simple application of quick, vigorous, rhythmical strokes to stimulate muscles and is particularly helpful in the treatment of aches and pains associated with various diseases. Thus, cupping carries the potential to enhance the quality of life 21. Each cupping session takes about 20 min and could be conducted in five steps. The first step includes primary suction. In this phase, the therapist allocates specific points or areas for cupping and disinfects the area. A cup with a suitable size is placed on the selected site and the therapist suck the air inside the cup by flame, electrical or manual suction. Then the cup is applied to the skin and left for a period of three to 5 minutes. The second step is about scarification or puncturing. Superficial incisions are made on the skin using surgical scalpel blade No. 15 to 21, or puncturing with a needle, auto-lancing device or a plum-blossom needle 39. The third step is about suction and bloodletting. The cup is placed back on the skin using the similar procedure described above for three to 5 minutes. The fourth step includes the removal of the cup, followed by the fifth step which includes dressing the area after cleaning and disinfecting with FDA approved skin disinfectant. Furthermore, suitable sizes of adhesive strips are then applied to the scarified area, which remain there for 48 hours 40. It is wise to know that the suction and scarification are the two main techniques of wet cupping therapy. Each technique of cupping might be responsible for certain changes at the level of body cells, tissues or organs. Specific interventions could enhance or suppress body hormones, or it might stimulate or modulate immunity, or it may get rid of harmful substances from the body, and eventually it might ease the pain.

In needle cupping, acupuncture is applied initially with subsequent deposition of cups over the needle. Medicinal/herbal cupping makes exclusive use of bamboo cups wherein the herbs are boiled as aqueous dispersions followed by application of suction on specific points 11. The acupuncture method merged with cupping works by the following mechanism – small needles inserted into the skin will contact tension points and thereby relieve the pain. It is widely accepted as a safe therapy, even though the probability of complications such as trauma or infection persists 41. The length of needle retreat in cupping depends on the patient gender and the negative pressure of cupping 42. Water cupping comprised filling a glass or bamboo cup with one third warm water and pursuing the cupping process in a rather quick fashion 11.

Sliding cupping involves three steps: (1) the local area of pain, or the affected channels and points are lubricated; (2) the cup is applied; and (3) the cup is made to slide up and down until the skin becomes hyperemic. This is known to resolve the disturbed functions of Zang-fu via a dual mechanism of cupping as well as massage 43. Zang-fu is a collective term for internal organs; five zang organs encompass the heart, liver, spleen, lungs, and kidneys and the six fu organs contain gallbladder, stomach, small intestine, large intestine, urinary bladder, and sanjiao (the triple energizer) 43. El Sayed et al 44 described cupping therapy in the form of ʻSʼ techniques, as depicted in Figure 2 below.

The pressure and duration factors of cupping therapy are two main factors to change the intensity of cupping therapy and may influence effectiveness of cupping therapy 45. The current principle on adjusting the intensity of cupping therapy is that if the absolute value of negative pressure is too low, cupping therapy may not be effective. On the other hand, if the absolute value of negative pressure is too large, cupping therapy would cause discomfort and pain to the patient. Although different intensities of cupping therapy are believed to cause various effects on treating symptoms 46, there are only few studies in the literature to guide the selection of the pressure and duration of cupping therapy 47.

Although there is no consensus about the potential mechanisms of cupping therapy, a local increase in blood flow is mostly accepted as a critical factor 48. After the removal of cup, cupping therapy causes an increase in local blood flow and lymphatic flow that may be helpful for relieving myofascial pain and improving soft tissue healing 45. The study of the response of skin blood flow to various intensities of cupping therapy could be used to assess the efficacy of various intensities of cupping therapy 45. In this study, the efficacy refers to the ability of cupping therapy to achieve the desired effect of increasing blood flow. Tian 49 showed that skin blood flow significantly increased after cupping therapy at three negative pressures [i.e., −225 mmHg (−0.03 MPa), −300 mmHg (−0.04 MPa), and −375 mmHg (−0.05 MPa)] for 5 minutes. The author indicated that the absolute value of negative pressure should not exceed −375 mmHg (−0.05 MPa), which may be harmful to the tissues. For example, negative pressure at −450 mmHg (−0.06 MPa) is considered too large and may harm the soft tissue within the cupping cup. The author also indicated that the absolute value of negative pressure should be above −225 mmHg (−0.03 MPa) for increasing skin blood flow after cupping therapy. For example, negative pressure at −150 mmHg (−0.02 MPa) is too small and may not benefit the treated area 49.

Researchers recommend that cups should be on the skin for no more than 5-10 minutes to avoid the blister 50. Liu et al. 51 demonstrated that skin blood flow increased after the application of negative pressure at −300 mmHg (−0.04 MPa) for 10 minutes in healthy volunteers. Tian et al. 49 also showed that skin blood flow significantly increased after negative pressure at −225 mmHg (−0.03 MPa) for 5 minutes. Based on these studies, the duration between 5 and 10 minutes has been recommended in cupping therapy. However, there is no specific guideline on choosing a duration between 5 and 10 minutes. Overall, it remains largely unknown about the interactions between different pressures and durations of cupping therapy on skin blood flow responses.

The residual marks left from cupping disappear in 1-10 days 50. Recovery time shows a trend with longer recovery time when the absolute value of negative pressure was larger and duration was longer. The recovery time is also related to degree of ischemia of soft issue; a larger ischemic stress needs a longer time for ischemic tissues to remove metabolic wastes and restore skin blood flow 52.

Table 1. Types of cups explored for cupping therapy and their origin

CupsRegion
Round glass cups or bell shape cupsJapan
Buffalo horn shape cupsNorth America
Hollow animal horn shape cupsEurope, Asia, Africa, and North America
Mouth or buffalo horn shape cupsIraq to the Mediterranean (Assyrian Empire period)
Shell shape cupsNorth America (specifically near Vancouver Island)

Figure 2. Cupping therapy and ‘S’ techniques

Cupping therapy techniques
[Source 44 ]

Dry Cupping Therapy

Dry cupping is a technique of bruising the skin painlessly, in which the bottom of a glass cup is rinsed with methylated spirits, set alight, and planted over the skin. The flame exhausts the supply of oxygen, causing a partial vacuum and the skin is sucked into the mouth of the glass. Retained cupping is utilized to stimulate mammary glands for improving milk ejection. Dry cupping also assists in healing of wounds via quick pus discharge 53. It contains two steps: (1) prior to the application of suction, small incisions are made with a triangle-edged or plum-blossom needle to the cups; and (2) an acupoint is firmly tapped for a short time to cause bleeding.

Wet Cupping Therapy

Wet cupping involves two different application methodologies, such as cupping, puncturing and cupping method. Wet cupping commonly use in Arabic nations to treat the various disease conditions involves six steps with skin demarcation, sterilization, cupping, puncturing, cupping, and sterilization 54. In Al-hijamah wet cupping, honey is used to fix the cups and for the scarification, which aids in healing 5. Al-hijamah is a 6 step process including demarcation, sterilization, cupping, scarification, cupping, and sterilization.

Traditional wet cupping is a 5 step process that includes demarcation, sterilization, scarification, cupping, and sterilization 5. The puncturing and cupping method followed five steps of skin demarcation, sterilization, puncturing, cupping, and sterilization. The puncturing and cupping method is common in China, Korea, and Germany 29. In this method, practitioners need to control the suction by gently moving the cup in one direction 11. On comparing the cupping across the meridian running direction and that against the running direction, similar local effects were observed. Dual-directional moving cupping is applicable for the treatment of local disorders. The abscopal effect is better with moving the cup against the meridian running direction 55. When cups are removed after suction without delay, then it is called empty cupping 11.

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 56. 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 57. The authors attributed the result to the gravitational pull of the moon and its possible effect on cardiovascular function in humans 57.

Cupping therapy uses

Cupping therapy is indicated for both healthy patients and those suffering from ailments 30. Localized ailments that benefit from cupping therapy include a headache, lower back pain, neck pain, and knee pain 47. Systemic illnesses that have seen benefits with cupping therapy include hypertension, rheumatoid arthritis, diabetes mellitus, mental disorders, heart disease, hypertension, infections, and skin disorders 47.

Does cupping therapy work?

Cupping therapy is an ancient method and had been used by various culture and societies and currently used in the treatment of a broad range of medical conditions. Nonetheless the mechanism of action of cupping is not fully understood 58. The postulated modes of actions of cupping therapy include the interruption of blood circulation and congestion as well as stopping the inflammatory extravasations (escaping of bodily fluids such as blood) from the tissues 59, 60. Others have postulated that cupping could affect the autonomic nervous system and help to reduce pain 59, 60. None of these theories are have been established in a scientific sense.

Recently, interest in cupping has re-emerged and subsequently, several studies have begun to investigate the mechanisms underpinning cupping therapy 61. For the mainstream doctors trained in western medical sciences, the focus is largely on the biomedical causes of disease, while traditional medicine practitioners take a holistic approach 62. Notably, cupping therapy possibly produces numerous effects through a plethora of mechanisms 63. Research scientists tend to explain a particular phenomenon or effect of a drug or device or cupping therapy by describing its underlying mechanism(s). In practice, description of a mechanism is never complete because details of related processes are not fully identified.

Fønnebø et al. 64 stated that a common strategy in traditional medicine is to use a reverse research strategy, because traditional therapies -including cupping therapy-have been in clinical use for thousands of years. Accordingly, researchers need to understand what the treatment procedure is, how many variations it has, and what theoretical foundations underline it, the ideas about health and disease, its contextual framework and key treatment components. One of the controversial views concerning cupping therapy is that it has only a placebo effect 23. This placebo theory about cupping therapy will remain alive until a reliable and valid mechanism is found out 65. Detailed studies regarding cupping therapy mechanisms, supported by well-designed scientific researches, would help in the safe and effective application of the cupping therapies 5.

There is converging evidence that cupping can induce comfort and relaxation on a systemic level and the resulting increase in endogenous opioid production in the brain leads to improved pain control 61. Other researchers proposed that the main action of cupping therapy is to enhance the circulation of blood and to remove toxins and waste from the body 60. That could be achieved through improving microcirculation, promoting capillary endothelial cell repair, accelerating granulation and angiogenesis in the regional tissues, thus helping normalize the patient’s functional state and progressive muscle relaxation 66. Cupping also removes noxious materials from skin microcirculation and interstitial compartment which benefit the patient 67. Cupping may be an effective method of reducing low density lipoprotein (LDL or “bad” cholesterol) in men and consequently may have a preventive effect against atherosclerosis and cardiovascular diseases 68. Cupping is known to significantly decrease in total cholesterol, low density lipoprotein (LDL)/high density lipoprotein (HDL or “good” cholesterol) ratio 69. Cupping therapy can significantly lower the number of lymphocytes in the local blood related to the affected area with an increase in the number of neutrophils, which is one of the antiviral mechanisms that reduces the pain scores 70. Loss of blood along with vasodilation tends to increase the parasympathetic activity and relaxes the body muscles which benefit the patient and could also be associated with the after effects of cupping. Furthermore, the loss of blood is thought to increase the quality of the remaining blood that improves pain symptoms 71. It has also been found that cupping increases red blood cells 72. It has been claimed that cupping therapy tends to drain excess fluids and toxins, loosen adhesions and revitalize connective tissue, increase blood flow to skin and muscles, stimulate the peripheral nervous system, reduce pain, controls high blood pressure and modulates the immune system 73, 60. Some researchers believe that the build-up of toxins is the main reason for illness development. In the cupped region, blood vessels are dilated by the action of certain vasodilators such as adenosine, noradrenaline and histamine. Consequently, there is an increase in the circulation of blood to the ill area. This allows the immediate elimination of trapped toxins in the tissues, and, hence, the patient feels better 74. Cupping has been found to improve subcutaneous blood flow and to stimulate the autonomic nervous system 75. Like injuries to the skin due to the incisions, stimulation of the skin causes several autonomic, hormonal, and immune reactions attributed to the sympathetic and parasympathetic efferent nerves to the somato-visceral reflexes related to the organs 76. Cupping is reported to restore sympathovagal balance and might be cardio-protective by stimulating the peripheral sympathetic and parasympathetic nervous system 77. Cupping seems to play a role in the activation of complement system as well as modulation of cellular part of immune system 78. There is also a significant reduction in blood sugar in diabetic patients after cupping 79. Chen and colleagues 80 concluded that there are some improvements in the research concerning the mechanisms of cupping therapy. Overall, cupping is reported to effect changes in the biomechanical properties of the skin 81, increase immediate pain thresholds in patients with neck pain and in a healthy subject as well 12, reduce significantly peripheral and local P substance 82 and reduce the inflammation 83.

Many theories have been suggested to explain numerous effects of cupping therapy and its mechanisms of action 84. Several researchers proposed biological and mechanical processes associated with the cupping session. For instance, reduction of pain may result from changes in biomechanical properties of the skin as explained by the “Pain-Gate Theory” 85, “Diffuse Noxious Inhibitory Controls” 86 and “Reflex Zone Theory” 87. Muscle relaxation, specific changes in local tissue structures and increase in blood circulation could be explained by the “Nitric Oxide Theory” 88. The immunomodulatory effects of cupping therapy could be attributed to the “Activation of Immune System Theory” 78. Releasing of toxins and removal of wastes and heavy metals might be attributed to the “Blood Detoxification Theory” 89. These theories may have been interacting harmoniously to produce the beneficial effects of cupping in treating patients with various diseases and promoting wellbeing in healthy people.

No single theory could explain the mechanisms of action underpinning cupping therapy along with its multiple effects. Cupping is performed by several individual techniques according to cupping type 63. Each technique might be responsible for certain changes in the cells, tissues and organs 73. Reviewing the literature on cupping and its mechanism of action has revealed insufficient information about the physiological, biological and mechanical changes of the body during cupping therapy 28. The beneficial effects of cupping therapy need to be substantiated by large randomized clinical trials, systematic reviews and meta-analyses in the future. Basic scientific innovative research is also needed to verify the discussed theories about cupping along with inventing new theories.

The number of randomized controlled trials on treatment using cupping therapy is scarce in terms of a specific disease. Existing trials are of small size and low methodological quality. Further high quality studies of larger sample size are needed to assess the effectiveness of cupping therapy. It might be worthwhile to examine the effectiveness of cupping therapy or combination of cupping therapy with other non-pharmacological or pharmacological treatments for pain conditions, herpes zoster, symptoms of cough and asthma, acne, common cold, or other common diseases which were most treated by cupping therapy according to this review 11. In addition, the methodological quality should be improved, and the study design and report should also be standardized.

This review suggests that there is insufficient high-quality evidence to support the use of cupping therapy on relevant diseases 11. Although quite a number of clinical studies reported that cupping therapy may have effect on pain conditions, herpes zoster, symptoms of cough and asthma, acne, common cold, or other common diseases. The current evidence is not sufficient to allow recommendation for clinical use of cupping therapy for the treatment of above diseases in people of any age group. The long-term effect of cupping therapy is not known, but use of cupping is generally safe based on long term clinical use and reports from the reviewed clinical studies.

Table 2. Applications of cupping therapy in various conditions

Cupping therapy
ApplicationReferences
Wet cupping therapy.In treatment of chronic idiopathic urticaria and acne vulgaris.
(Improving the immune system)		90
Alleviate current pain in persistent, nonspecific low back pain.91
Nonspecific low back pain.92
Used in carpal tunnel syndrome but suffers from minor adverse effects like local hematoma.93
An effective method of reducing low density lipoprotein cholesterol in men.
(Preventive effect against atherosclerosis)		94
Effective in treatment of herpes zoster.95
Treatment of migraine- and stress-associated headaches and postherpetic pain.96
An effective role in improving pain, quality of life, and hyperalgesia in chronic nonspecific neck pain.97
Remedy for cellulitis (induced by honey bee sting).98
Adjuvant treatment for iron overload in treating thalassemia, hemochromatosis, and sideroblastic anemia.99
Wet cupping therapy with conventional treatments.Treatment of oral and genital ulceration in patients with Behcet disease.100
Dry cupping therapy.In chronic asthmatic bronchitis therapy.
(Better curative effects than that of common cupping)		101
A series of five dry cupping therapies.Relieving chronic nonspecific neck pain.
(Influence on functional pain process)		102
Dry cupping therapy with a pulsatile cupping device.Relieved symptoms of knee osteoarthritis.103
Dry or/and wet cupping therapy.Chest pain alleviation.104
Electroacupuncture (EA) with cupping therapy.Relieve fatigue of poststroke patients.105
Used in vertebroarterial type, nerve root type of cervical spondylopathy and sympathetic type of cervical spondylopathy.106
EA plus flash cupping therapy.Synergistic action is obtained in peripheral facial paralysis.107
EA plus bloodletting puncture and cupping therapy.Acute gouty arthritis.108
EA combined with bloodletting and cupping therapy.A better therapy for herpes zoster.109
EA combined with moving cupping therapy.Control target symptoms and improve bad emotion of somatoform disorders.110
Acupuncture and cupping therapy.Relieve moderate insomnia.111
A rapid relief of hiccup with no toxic side-effects, especially for hiccup due to cerebrovascular accident.112
Better therapeutic effect on ankylosing spondylitis than simple acupuncture.113
Better than conventional medications for reducing pain and for improving depression scores related to fibromyalgia.114
Acupuncture, cupping along with acupoint catgut embedding therapy.Increase therapeutic effect on simple obesity of stomach.115
Acupuncture, moving cupping, bloodletting puncture.Treatment of chloasma.116
Acupuncture-moxibustion combined with cupping therapy.Treating primary dysmenorrhea.117
Laser acupuncture plus soft cupping.Effective on lower back pain.118
Medicinal cupping therapy followed by acupuncture with cupping therapy.Reduction in fibromyalgia symptoms.119
Bloodletting cupping therapy (BLC) with herbal medicine.Treatment of acute gouty arthritis.120
Bloodletting puncture (BLP) with plum-blossom needle and cupping therapy.Alleviated acute articular soft tissue injury.121
BLP, BLC, and external application of Chinese-drug facemask.Effective in treating acne.122
BLP and cupping therapy.Treat neck type of cervical spondylosis.123
Bloodletting with cupping therapy.Show effective treatment in asthmatic conditions.124
Bleeding and cupping therapy.Postherpetic neuralgia as it can significantly reduce peripheral and local serum P substance.125
BLC.Improve clinical condition of rheumatoid arthritis patient and show modulatory effects on natural killer cells and adaptive cellular soluble interleukin-2 receptor.126
Red-hot needle therapy with BLP and BLC.Therapeutic effect on neurodermatitis.127
Clustered needling, massage, and cupping therapy.Relieve myofascitis of the back.128
Deep puncture by elongated needle combined with spike-hooked needle and cupping therapy.Treatment of shoulder periarthritis.129
Warm needling treatment combined with cupping therapy.Used in intractable systremmaa and found more effective when needle inserted on to sciatic nerve.130
Coiling dragon needling and moving cupping therapy.Chronic fatigue syndrome treated.131
Needling and cupping therapy.Treatment of erysipelas, infection of lower limbs.132
Pricking blood therapy with three-edged-needle plus cupping.Good therapeutic effect on Bi-syndrome of wind-dampness type in Yemenia, with more convenience than Arabic Heigama.133
Warm needling plus cupping therapy.Treatment of facial paralysis.134
Pricking, bloodletting and cupping therapy with a three-edge needle.A definite therapeutic effect on acute eczema.135
Fire needles at bones combined with cupping therapy and Tuina.bKnee osteoarthritis.136
Coiling dragon needling and cupping therapy on back.Positive effect on chronic fatigue syndrome.137
Plum-blossom needle tapping plus cupping therapy.Improving periauricular pain, facial, and muscular functions for the treatment of acute facial paralysis.138
Flash-fire cupping, movable cupping, and fixed cupping in combination.Improve the pulmonary functions in asthmatic children, especially for those with mild asthma.139
Fire insertion cupping therapy.Antipyretic effect in the treatment of fever. (High fever caused by the upper respiratory tract)140
Flash and wet cupping therapy with acupuncture.Facial paralysis therapy.141
A moving flash-fire cupping therapy.In treatment of urticaria.142
Cupping therapy with physical exercise.Effective in reducing pain and improving neck function in musculoskeletal diseases.143
Herbal cupping therapy.Postherpetic neuralgia treatment.144
Pneumatic pulsation therapy.Chronic neck pain.145
Combined pricking and cupping therapy.As remedy to herpes zoster, postherpetic neuralgia.146
Multiple cupping therapies.Relieving chronic fatigue syndrome.147
Mild moxibustion combined with cupping therapy.Eliminating athletic fatigue.148
Ear point bloodletting combined with cupping.In treatment of acne vulgaris.149
Moving cupping at the Hechelu combined with Shenque Bazhenxue moxibustion.An effective remedy for senile habitual constipation.150
Cupping therapy with ultrasonography.A valuable tool in assessing knee effusions. (Especially subclinical levels)151
Duhuojisheng Tangc alone or combined with cupping therapy.Effectively improve pain and other clinical symptoms of patients with prolapse of lumbar intervertebral disc.152
Chinese cupping therapy.Reduction of symptoms associated with subacute and chronic low back pain.153
Raktamokshana (Ghati yantra avacharana)Remove the poison after snake.154

Footnotes:

a Systremma is a cramp in the muscle of the leg calf.
b Tuina is a manual technique aimed at enhancing health and treating various clinical conditions.
c Duhuojisheng Tang (DHJST) is a traditional Chinese herbal medicine used to treat osteoarthritis.

Cupping therapy summary

The strongest evidence for cupping therapy’s therapeutic benefit is for the treatment of pain, but the evidence for this isn’t very strong 155, 156. There’s not enough high-quality research to allow conclusions to be reached about whether cupping is helpful for other conditions.

In one study, there was a 66% reduction in mean headache severity following wet cupping treatment 23. The number of headaches per month for these patients also decreased an equivalent of 12.6 days 23. Cupping therapy has been shown to provide pain relief in lumbar sprain, scapulohumeral periarthritis, brachialgia paraesthetica nocturna, arthritis, and neuralgia pain 30.

Dry cupping is commonly used for musculoskeletal pain and muscular tension 5. 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 50. For chronic back pain treatment, results indicated on average, 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 50.

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

There have been studies done that have shown the benefits of cupping therapy beyond pain management. In a German study 56, traditional wet cupping was shown to be effective in treating carpal tunnel syndrome. Wet cupping was also shown to treat thalassemia and autoimmune diseases effectively 56. Cupping therapy demonstrated to be effective against a cough, dyspnea, and acne 30.

Cupping therapy side effects

The after effects of cupping often include redness, swelling, and bruising as blood is drawn to the surface of the skin in a characteristic circular arrangement. Most of the local skin changes subside within a few weeks 37. Reports of side effects with cupping were scarce and those that were reported were mild. Cupping is generally safe when performed by trained professionals, but it can cause bruises, soreness, persistent skin discoloration, scars, burns and, rarely, skin infections and may worsen eczema or psoriasis. Rare cases of severe side effects have been reported, such as bleeding inside the skull (after cupping on the scalp) and anemia from blood loss (after repeated wet cupping). Other adverse effects of cupping are Koebner’s phenomenon, fainting (vaso-vagal syncope), headache, dizziness, and nausea 157. Cupping leaves temporary marks on the skin. The origin of these marks should be explained to health care providers so that they won’t be mistaken for signs of physical abuse. Because cupping equipment can become contaminated with blood (intentionally in wet cupping or inadvertently in dry cupping), using the same equipment on more than one person, without sterilization between patients, can spread bloodborne diseases such as hepatitis B and C.

The application of cupping therapy is contraindicated in special patient groups such as pediatrics, geriatrics, pregnant, and menstruating women 38.

In a study related to cupping therapy, Jiang and Liang 158 suggested that the principle, indications, and contraindications associated with the cupping therapy depend on the type of cup, application, and frequency of cupping. When psoriasis was treated by cupping therapy, subsequent development of the Koebner phenomenon at the cupped sites was observed. Cupping can induce both epidermal cell injury and dermal vascular damage in terms of abrasions, ecchymosis, and purpura 159. High serum cholesterol is an important risk factor for cardiovascular ailments during wet cupping 160.

During the cupping of the cervical area, the tensile radial stresses generated by cupping may potentially facilitate the development of a dissection in the presence of an intimal tear. This may cause hemorrhagic stroke with an acute rise in blood pressure 161. Moreover, the possible presence of microinclusions can intensify the local stress concentration for a thin cup 161. When applying cupping and acupuncture together, a rare complication of epidural abscess appears 162. Cupping is particularly not advised over excoriated, oozing or infected areas 163 as it may enhance D-dimer (a fibrin degradation product) levels 164. Appropriate precautions and guidelines as well as hygiene throughout the cupping therapy aid in preventing related side effects. Panniculitis (inflammation of panniculus adipose, especially of the abdomen) is one of the serious side effects of cupping therapy 165. As cupping encourages blood flow to the cupped region (hyperemia), one may therefore feel warm as a result of vasodilatation and slight sweating may occur. Cupping therapy is contraindicated in deep vein thrombosis 33. Wet cupping therapy carries a risk of skin infections 166. Development of lipoma following a single cupping massage 14. Specific procedures should be adopted for bloodletting therapy to avoid anemia as a result of blood loss 167. Application of dry, wet, and other types of cupping therapies may cause bleeding, skin bruises, keloid (an area of irregular fibrous tissue formed at the site of a scar or injury) scarring and burns owing to deep long scarification, excessive suction pressure, dermal capillary rupture, and suction with use of cotton or alcohol ignition, respectively 168. Weng et al 169 reported hemophilia A in one of the patient undergoing traditional Chinese wet cupping therapy. One of the major limitations of cupping therapy is that it is not applicable in the treatment of internal organ disorders.

Cupping therapy contraindications

Absolute contraindications to cupping therapy include cancer patients, those suffering from any organ failure and those using a pacemaker or suffering from hemophilia or a similar blood disorder 47. Cupping therapy is not recommended for geriatric patients, pediatric patients, and pregnant and menstruating women 5. Those with high serum cholesterol are at higher risk of developing cardiovascular ailments with cupping 5.

Anatomical contraindications include sites with deep vein thrombosis, open wounds, and bone fractures 47. Cupping should not be done directly on nerves, arteries, veins, varicose veins, skin lesions, body orifices, lymph nodes, eyes or areas with skin inflammation 47. Cupping done over excoriated, oozing or infected areas may cause an increase in D-dimer levels 5.

Those suffering from chronic diseases (like cardiovascular diseases), using anticoagulants or have an acute infection should generally avoid cupping therapy 47.

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