Cupping therapy is a form of alternative medicine that originates from traditional Chinese medicine (TCM). Some historical evidence also suggests its use in middle eastern medicine. As with many other systems of traditional Chinese medicine (TCM), including acupuncture, the philosophy behind cupping therapy is the restoration of the individual’s ‘Qi’ (pronounced as ‘chee’). Qi is described traditionally as a fluid, animated life energy source present inside a human. Well-functioning, or well-flowing Qi, is believed to be needed for mental and physical well being; any obstruction in this flow is thought to result in ailments. The principle of cupping therapy lies in the creation of local suction by application of specialised cups or suction devices. While the methods vary across the spectrum, ranging from traditional to modern or ritualistic to medicinal, the practice consists of drawing tissue into a cup, or suction device, placed on the targeted area by creating a partial vacuum – either by the heating and subsequent cooling of the air in the cup, or with a mechanical pump. The skin and tissue underneath the cup is drawn in by the suction force applied and swells resulting in an increased blood flow to the area. Enhanced blood flow and circulation to the area of target draws the toxins and impurities out of the surrounding area to allow elimination through the skin surface. The cups are left in place for five to ten minutes at most. Wet cupping therapy, or hijama, involves controlled medicinal bleeding to occur by making incisions into the skin after removing the cups.

Although initially written off as pseudoscience, cupping therapy has shown promise in the medical arena for the treatment of various conditions. While some such claims are dubious and do not have sufficient data or research backing them, cupping therapy is being used increasingly as an alternative or add-on treatment in certain illnesses. Physiotherapy has provided a strong foothold for cupping therapy use and it is popular amongst professional athletes as well. Cupping therapy can be applied anywhere on the body or specifically over the facial region. The cups used for body cupping therapy are bigger in size whereas the ones used on the face are smaller and exert a smaller suction force.

  1. Types of cupping therapies
  2. Indications for cupping therapy
  3. Procedure of cupping therapy
  4. Contraindications for cupping therapy
  5. Complications of cupping therapy
  6. Facial cupping

Different types of cupping therapy can be categorised on the basis of the technique used (dry, wet, massage or flash), the power of suction applied (light, medium, strong), methods of suction production (fire, manual or electrical cupping therapy), the area of the body being treated (abdominal, facial, etc.) and the materials placed, if any, inside the cup (medicinal herbs, water, magnets, etc). 

While many categorisations exist for cupping therapy, the following are the most widely applied ones in modern medical treatments.

  • Dry cupping therapy: In dry cupping therapy, cups are applied to the target area and with either heat or manual force suction is applied, which draws the skin into the cup.
  • Wet cupping therapy: Wet cupping therapy is also called Hijama and involves the application of suction through special cups as well as induction of controlled medicinal bleeding.

Cupping therapy can be employed in patients suffering from certain ailments that have shown a positive response toward cupping or in healthy patients looking to enhance their overall well-being. Some indications for the use of different types of cupping therapy include, but may not be limited to:

  • Musculoskeletal ailments: cupping therapy has shown positive results in the improvement of orthopaedic conditions within the framework of physiotherapy. Cupping therapy is offered for: 
  • Localised aches and pains:
    • Tension headaches: Acupuncture and cupping therapy can, in fact, help prevent tension headaches. Tension headaches are generally mild, dull, last for up to 30 minutes and are triggered by stress.
    • Migraines: Only modest improvement in symptoms of migraine are noted with cupping therapy but even that can be beneficial for the overall well-being of the patient.
  • Systemic illnesses: Health problems that affect the entire body have also shown modest improvement in the patient’s overall health with cupping therapy. These cupping treatments are add on therapies carried out in addition to allopathic medicine treatment and not in its stead. Cupping therapy is available for use in:
  • Skin conditions: 
  • Sports medicine: Cupping therapy is useful for professional athletes as by increasing the blood circulation in a target area, tissue healing can be promoted and hastened.
  • Healthy facial skin: In facial cupping, smaller specialised cups are applied to the face and the suction pull created increases the blood flow to the skin of the face. Micro tears that are produced elicit an inflammatory response that triggers blood cell movement to the face as well. This helps in healing the facial skin and rejuvenating it by:
    • Increasing oxygen-rich blood circulation
    • Stimulating cells responsible for collagen production and thereby strengthening skin and connective tissues
    • Relaxing muscle tension

Upon choosing to undergo cupping therapy or being advised by a medical practitioner, it is important to find a credible cupping therapist. The therapist must ensure correct technique use apart from taking all necessary safety measures. Safety measures that should be in place include the use of an apron, gloves and protective eye goggles, up to date vaccinations (hepatitis B vaccine in particular) and use of clean, preferably sterilised, equipment by the practitioner. After taking advice from one’s medical doctor, a session can be set up to meet with the cupping therapist. While medical investigations are not necessary, at the very least, a blood haemoglobin level assessment should be done to rule out anaemia. The therapist will take a brief history of the patient’s pre-existing ailments, conditions and complaints. After ruling out any and all contraindications a date is set to begin therapy.

Preparation before the procedure: The patient should take certain measures before the cupping therapy session to reap the maximum benefits and have a pleasant overall experience. Measures to take in preparation include:

  • Avoid shaving the area to be treated four hours before treatment.
  • Hair removal in advance (before four hours) can help limit infection.
  • Ensure adequate hydration to avoid fainting spells.
  • Ensue a normal diet and eat an hour before the session. Wet cupping therapy should not be done on an empty stomach as the chances of experiencing a vasovagal attack increase.
  • Obese patients suffering from polycythemia (a blood condition in which the blood becomes viscous due to increased red blood cell count) may take a hot shower before the session to stimulate peripheral blood flow.

During the procedure: The skin of the area to be treated is cleaned and then a cup is placed on it. With the application of heat (by fire) and subsequent cooling, the air pressure difference formed inside the cup creates a suction force that draws the skin and soft tissue in. The tissue swelling causes blood flow to that area to be increased. Practitioners can also forego the use of fire and use mechanical pumps to create suction instead. The cups are not left in one place for longer than ten minutes. In wet cupping, after the removal of the cup, a small incision is made to draw the blood out for a more pronounced cleansing effect. Antiseptic ointment application and aseptic bandaging are done over the cup discolouration marks to promote quicker healing.

After the procedure: Certain aftercare steps should be taken to avoid side effects and complications. These include:

  • Avoid solid food for at least three hours following a strong, wet or needle cupping session as eating may induce nausea and vomiting.
  • Ensure adequate water intake. Drinking plenty of fluids will prevent dehydration.
  • A bath should be taken 12 hours after the cupping session.
  • Antiseptic cream should be applied on the incision sites made in wet cupping therapy.
  • Exercise and sexual activity should be avoided for at least one day.
  • Discolouration marks from where cups were placed fade within hours or can take upto a few days. Hydration and rest hasten the fading.
  • Avoid sun exposure of the areas treated with cupping therapy.

The presence of certain factors in a patient may need careful assessment and/or remedial measures before proceeding with cupping therapy. Other factors or circumstances make cupping therapy impossible in patients.

Absolute contraindications: The presence of any of the following factors makes it imprudent and unadvisable to go through with cupping therapy.

  • Cancer
  • Organ failure
  • Presence of a cardiac pacemaker
  • Blood disorders like hemophilia or thrombocytopenia
  • Long-term therapy with blood thinning medicines like warfarin
  • Ulcerated skin in the area to be treated 
  • Fractures in the area to be treated
  • Muscle spasm (following fractures) in the area to be treated
  • Dislocations in the area to be treated
  • Wet cupping therapy of female breast

Caution should be taken while considering cupping therapy in the treatment of any of the following groups:

  • Geriatric age group or elderly patients: Special caution and consideration should be given to those over 65 years of age and wet cupping should generally be avoided.
  • Paediatric age group children: Cupping therapy is generally not recommended for use in children but the rough rule of thumb is to avoid dry cupping therapy in children under three years of age and wet cupping therapy in children under eleven years of age.
  • Pregnant woman
  • Women on their menstrual period

Relative contraindications: Some other factors and circumstances need to be addressed before moving ahead with cupping therapy. These include, but are not limited to:

  • Hypercholesterolaemia or raised blood lipid levels are a cause of concern when it comes to cupping as cardiovascular heart problems may arise in these patients later following cupping therapy.
  • Chronic diseases like cardiovascular problems: Cupping therapy should generally be avoided in such patients. 

Lastly, cups should not be directly applied, under any circumstances, to some areas and components of the body. These areas to avoid while conducting cupping therapy are:

  • Open wounds
  • Areas of skin inflammation (allergic, infectious or otherwise)
  • Fractures
  • Muscle spasm following fractures
  • Dislocations of joints
  • Nerves
  • Arteries
  • Veins
  • Varicose veins
  • Deep vein thrombosis 
  • Skin lesions
  • Body orifices
  • Lymph nodes
  • Eyes

Even though modest improvement of signs and symptoms is noted with cupping therapy, it is not entirely risk free. Side effects following cupping therapy are infrequent and generally range from mild to moderate. Certain people with predisposing risk factors should reconsider or avoid cupping therapy. Some adverse events that can arise following cupping therapy include:

Preventable side effects of cupping:

  • Scar formation: More common with wet cupping
  • Burns: Burns can occur on the skin upon which the cups were applied. Burns are even more common when fire cupping, in which the application of heat from the fire produces suction force in cups.
  • Bullae (large and wide blisters) formation
  • Bruising of skin
  • Ecchymoses in skin: Discoloration of the skin resulting from bleeding underneath due to damage to thin blood capillaries in the skin
  • Abscess formation
  • Skin infection
  • Pruritus or itching
  • Anemia
  • Panniculitis (infection of the fat tissue underlying the skin)
  • All varieties of infection are more common with wet cupping therapy

In order to prevent side effects wherever possible, the cupping therapy specialist should ensure they’re wearing an apron, disposable gloves and goggles or other eye protection while carrying out the session. The equipment being used should be clean and the practitioner should have their vaccinations against blood-borne viruses (like hepatitis B vaccine) up to date.

Non-preventable side effects of cupping:

  • Koebner phenomenon: Appearance of new skin lesions on previously unaffected skin secondary to trauma from cups
  • Erythema
  • Vasovagal attacks: Due to unintentional stimulation of the vagus cranial nerve during cupping therapy, a rapid drop in blood pressure and blood flow to the brain occurs, which causes an episode of fainting. Syncope occurs triggered by cupping therapy. Vasovagal attacks are more common with wet cupping therapy.
  • Pain at incision sites
  • Headaches
  • Dizziness
  • Tiredness
  • Nausea
  • Insomnia or sleeplessness
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References

  1. Aboushanab TS, AlSanad S. An Overview from a Modern Medicine Perspective J Acupunct Meridian Stud. 2018 Jun;11(3):83-87. PMID: 29436369.
  2. Al-Bedah AMN, et al. The medical perspective of cupping therapy: Effects and mechanisms of action J Tradit Complement Med. 2018 Apr 30;9(2):90-97. PMID: 30963043.
  3. Lowe DT. Cupping therapy: An analysis of the effects of suction on skin and the possible influence on human health. Complement Ther Clin Pract. 2017 Nov; 29:162-168. PMID: 29122256.
  4. Al Bedah AM, et al. Evaluation of Wet Cupping Therapy: Systematic Review of Randomized Clinical Trials. J Altern Complement Med. 2016 Oct;22(10):768-777. PMID: 27557333.
  5. Zhou X, Ruan JW, Xing BF. Analysis on the adverse events of cupping therapy in the application. Zhongguo Zhen Jiu. 2014 Oct;34(10):1023-5. Chinese PMID: 25543441.
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