What is cupping therapy?
Cupping therapy is one of the old traditional or cultural alternative medicine, this method of treatment is used for thousands of years in diverse cultures under several names such as horn suction therapy, or Al-hijama.
In the cupping therapy, the practitioner puts special cups on the patient’s skin on specific sites on chest, back, or legs. The placed cup causes suction pressure on this specific site. This suction pressure leads to increase blood flow to the skin and the surrounding area. The increase in blood flow is claimed to purify the blood from specific toxins and treating multiple conditions such as: chronic back pain, menstrual disturbance, gut problems, high blood pressure, and headache.
History of cupping therapy
Cupping therapy is a modern treatment trend nowadays, but it is not a new hype, this technique is an ancient method of treatment that was practiced from old times in diverse cultures. In these old practices of cupping therapy, the techniques were like similar with different equipment from the nearby environment.
A) Ancient Egyptians
The first mention of cupping therapy in history returned to 1550 BC, when it was mentioned in one of the oldest medical books “the Eber’s papyrus”. In the ancient Egypt, multiple drawings of cupping therapy technique were found on one of the oldest temples in Egypt. They used cupping therapy for treating multiple diseases and conditions such as:
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- Decrease in appetite
- Cupping therapy was used frequently in treatment of pain
- Menstrual disturbances
B) Old and traditional Chinese medicine
Cupping therapy is used extensively in traditional Chinese practices along with other methods such as acupuncture. These traditional techniques could be followed back to Han dynasty from 202 BC to 220 AD. One of the early persons who uses this traditional way of treatment was Ge Hang, one of the best herbal therapists, who believed in the power of healing of cupping therapy and acupuncture.
C) The Greeks
In old Greece, one of the most famous known physician “Hippocrates” used cupping therapy for treating multiple disorders such as:
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- Gynecological diseases
- Treating accumulating fluids in the body
- Inflammations and infections in body such as ear infections
He also gave a detailed description of his cupping technique, which consisted of two different methods, one for treating superficial conditions such as in skin diseases. The other method was used for treating of more deep conditions.
D) Islamic culture
Cupping therapy is widely used in Arabic and Islamic countries, it is also known as Al-Hijama. The prophet of Islam “Muhammed” PBUH, was treated with Al-Hijama, and even recommends its use to fellow Muslims.
A few Muslim physicians with great repetitions as Ibn Sina, Al-Razi, and Alzahrawy have used cupping therapy in treating their patients. There are multiple illustrations available to describe the technique, and the recommended sites of cupping therapy for every disease.
E) Old western culture
In old western cultures, the use of holistic and traditional medicine including cupping therapy was widely used between the fourteenth-14th century, and the seventeen-17th century. In Europe, the use of cupping therapy was common for treatment of flu and chest infections. The popularity of cupping therapy has diminished since the rise of modern medicine.
Types of cupping therapy
The use of cupping therapy differs from time to time, and from culture to culture with tendency to use the available tools and materials in the surrounding culture. This is the main reason the cup material is changing through the years. Examples of cup material include:
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- Bamboo cups
- Ceramic cups
- Pottery and clay cups
- Glass cups
- Disposable plastic cups
There are multiple types of cupping therapy, but the most common types are wet and dry cupping.
Dry cupping
One of the most popular types of cupping therapy, in which a hot cup is applied to patient’s skin on specific sites, then the skin is suctioned inside the cup, and the cup stay in place from five to ten minutes. This technique increases the blood flow and circulation in the cupped location.
Wet cupping
It is a common type of cupping therapy, especially in Arabic and Islamic countries and known as Al-Hijama. In wet cupping, the therapist makes a small skin incision in the patient’s skin before applying the hot cup, later the blood would be drained from the skin incision into the cup.
In a pilot study by Umar et al. to evaluate the effects of wet cupping therapy in treatment of heavy metal toxicity. The results showed that, wet cupping could reduce the heavy metal toxicity of the blood, and even the levels of the heavy metals did not increase after the treatment. They founded also that treatment of wet cupping therapy could induce the excretion of these heavy metals outside the body.
Fire cupping
In fire cupping therapy, the therapist allows a small flame of fire inside the cup, this fire heats the cup up and then the cup is placed quickly on the patient’s skin.
This type of cupping therapy is recommended for treating musculoskeletal pains. This type can cause a skin burn to the patient. In a study by Sagi et al., they founded an increased risk of burns in patients undergoing fire cupping technique.
Massage cupping
In this technique, a skin oil is applied, then a cup is placed on the skin, and moved very quickly in a planned spots to relief muscle tension and enhance relaxation.
Flash cupping
In this type of cupping therapy, there are a quick movement of the cups on and off the patient’s skin in a repetitive movement. This technique increases the blood flow over large area of the patient’s skin.
Miscellaneous
There are other techniques of cupping therapy includes:
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- Deep cupping
- Liquid cupping
- Acupuncture cupping
- Hot needle cupping
- Facial cupping
Equipment of cupping therapy
Cups used in cupping therapy comes in different material such as:
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- Glass cups: it is commonly used in fire cupping therapy
- Plastic cups: it is used in cupping therapy especially Al-Hijama
- Silicon cups: it is preferred in some conditions as facial cupping
- Other cups: other materials include horn suction cups, bamboo, or wooden cups
Due to the hazardous of infection, the use of disposable cups is preferred over the multi-use materials. When using non-disposable materials, disinfection is important to avoid infection. In cases of wet cupping, a sharp blade is used to causes superficial laceration to the skin. There are several types of blades, but auto lancet blades are preferred by therapists of cupping therapy.
Technique of cupping therapy
There are multiple techniques of cupping therapy. in dry cupping technique, the method consists of one step technique, while in wet cupping the method consists of two steps. First, skin incisions then the therapist puts the hot cup on the patient’s skin.
In the Arabic culture, Al-Hijama, which is a wet cupping therapy, it consists of three steps technique. First a hot cup is applied to patient’s skin, then the therapist makes small incisions in the skin, and finally, the therapist returns the hot cup again. After wet cupping session, some therapists apply honey to the treated area of skin to enhance healing.
The optimum time for the cupping therapy session ranges from five to ten minutes, and skin marks following the session usually fades in ten days. In a study by Moura CC et al., they founded that post cupping residual marks disappear after one week of cupping therapy.
The negative pressure in the cup is usually achieved by heating the cup to create a suction power. Other methods include manual and automatic pumping techniques. In China, the most common method used is by fire.
In some cultures, the timing of cupping therapy may affect the results. Therapists who do wet cupping therapy, or Al-Hijama prefers specific days on the lunar months to perform the procedure. El-Shanshory M et al. reported in their study that therapists prefer to perform Al-Hijama on specific days of the lunar month, especially days 17, 18, 19, and 20 of the lunar months.
Those days are preferred due to the possible effects of the moon phases on the cardiovascular functions of the human body. a study by Chakvaborty U et al. founded that, the gravitational pull of the moon on earth is changing throughout the phases of the lunar months. This gravitational power may pose specific effects on the fluid dynamics in the human body. these effects reach its peak on the third quarter of the lunar months.
Needle cupping is a type of cupping therapy, in which a needle is inserted in a stress site on patient’s skin first, followed by placing the cup over the inserted needle.
Application sites
Cupping therapy can be done on various spots of the body. Most common used sites are back, chest, and abdomen of the patients. Other sites include:
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- The back of patient’s neck
- At the interscapular region
- Around carotid bones
- Behind the ears
- Middle of the head
- At the thigh and knee joints
- Ankle, shoulder, and wrist joints
Precautions before the cupping therapy
Cupping therapy is quite easy procedure, and do not require any specific arrangement or preparations. Before starting sessions of cupping therapy, the area that will be treated should be cleaned very well, and thoroughly disinfected.
A new disposable cups should be used for every patient, and in case of multi-use cups it is preferred to encourage every patient to have his own set, and not to share it with other patients.
A good inspection of the patient skin before the cupping therapy session is crucial to notice if there is any inflammation, bruises, or infections.
After the session of cupping therapy
It is recommended to apply local antibiotic to the area of cupping therapy to prevent skin infection.
In cases of wet cupping, the lacerated area should be disinfected, and dressings should be applied. Post cupping bruises and wounds usually heals within one week to ten days after the procedure.
Who can perform cupping therapy?
Cupping therapy is a safe procedure, which are done for thousands of years without many complications. so, theoretically any body can perform cupping therapy, but to perform the cupping therapy in a legal way, and with less side effects, the practitioner should be a physician or at least from a paramedical field, with good knowledge of human anatomy and physiology. Examples of individuals who can perform cupping therapy includes:
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- Medical physicians
- Physical therapists
- Chiropractors’ therapists
Indication of cupping therapy
Cupping therapy is not indicated only for therapeutic purposes, healthy individuals can benefit from cupping therapy too. In a study by Kordafshari et al. to evaluate the effect of cupping therapy on healthy individuals. The researchers founded that, after one month of cupping therapy sessions, 88% of participants reported improving in their quality of life, 11.7% of participants reported no change in their life quality, while 89.9% of participants reported no side effects after cupping therapy.
In a study by Abushanab et al., the authors founded that cupping therapy has a promising results in treatment of pain related conditions.
Cupping therapy is indicated for treatment of localized conditions such as:
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- Migraines and headache
- Torticollis
- Low back pain
- Knee pain
Patients of certain diseases can benefits from cupping therapy too such as:
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- Hypertension
- Rheumatoid arthritis and fibromyalgia
- Diabetes mellitus
- Skin conditions such as eczema
- Some digestive diseases as irritable bowel diseases
- Some psychiatric conditions
A study by Nimrouzi et al. to evaluate wet cupping or Al-Hijama in the old-fashioned Persian medicine. They founded that, wet cupping has a significant effect in treatment of multiple diseases and helps in removing toxic substances from the body.
Contraindication of cupping therapy
Although cupping therapy is a safe procedure, but there are some conditions that prevents patients from undergoing cupping therapy such as:
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- Patients with cancer
- Patients with kidney, liver, or any organ failure
- Patients with hemophilia or any other blood diseases that may cause coagulation dysfunction
- Cardiac patients with implanted pacemaker
- Patients with active psoriasis
- Patients on anticoagulation treatments
- Immunocompromised patients
- Patients with epilepsy
- Geriatric age group
- Pregnant and breastfeeding females
Cupping therapy can be done on many spots of the body except:
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- Areas with deep venous thrombosis
- Recent or active wounded skin
- Inflamed skin or areas with eczema or active infection
- Cupping therapy is contraindicated to be done over arteries, veins, lymph nodes, varicose veins
The effects and benefits of cupping therapy
The most effective result of cupping therapy is relieving pain, and pain associated conditions such as musculoskeletal pain, neurological pain, migraine, and headache. According to Mazharuddin SM, Al-Hijama or wet cupping shows a good result in treatments of pain especially headache and tension headache.
In another study by Ahmadi et al. to assess the effectiveness of wet cupping in patients with tension and migraine headaches. They founded the severity of headaches decreased in 66% of patients after treatment with wet cupping therapy.
According to Nimrouzi M et al., treatment with cupping therapy leads to decrease pain in some of musculoskeletal conditions such as lumbar injuries, low back pain, arthralgia, and neuropathic pain.
In a systemic review and meta-analysis by Moura CC et al. to assess the evidences about the role of cupping therapy in treatment of low back pain. After treatment with different protocols of cupping therapy, the patients showed decrease in pain intensity, with improvement of their life quality. These results were achieved after five sessions of cupping therapy.
On the other hand, wet cupping therapy shows promising results in treatment of inflammatory-induced painful diseases such as rheumatoid arthritis, and neuralgia of herpes zoster.
A study by El-Shanshory et al. to evaluate wet cupping therapy in treating pediatric patients with thalassemia. they founded that, wet cupping was highly effective and safe therapy to induce iron excretion with minimum blood loss. Wet cupping was more safe than other conventional methods used to chelate iron in pediatric age group.
According to a study by Nimrouzi et al., cupping therapy causes effective treatment in patients with respiratory symptoms such as cough and dyspnea.
Other benefits of cupping therapy may include:
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- Regional enhancement of blood flow
- Deep massage and relaxation of tensed muscle
- Has cosmetic effects
- facial cupping causes skin revive and treat multiple skin problems
- Can be used as a supportive treatment to help musculoskeletal healing after injury or trauma
- Increase lymphatic drainage
- Can help in treatment of some gastrointestinal diseases such as irritable bowel syndrome as it enhances GIT peristalsis and decrease patient’s anxiety
Complications of cupping therapy
Cupping therapy do not cause major side effects or complications, and no long-term side effects are associated with cupping therapy. The reported side effects of the procedure were mild to moderate side effects and occurred immediately after the cupping therapy session.
According to Kim et al. systematic review about side effects of cupping therapy in researches done in Korea, they concluded that, side effects of cupping therapy in the involved studies were rare.
Side effects of cupping therapy can be classified into preventable, and non-preventable complication. From the possible complications of cupping therapy that could be preventable:
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- Formation of scar after cupping therapy
- Skin burns and bullae formation
- One of the common side effects is skin infection
- Abscess formation
- Hematoma formation at the site of cupping therapy
- Panniculitis which is inflammation of adipose tissue especially in the abdomen.it is a serious side effect of cupping therapy
Non-preventable complications include:
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- Headache, tiredness, and even fainting due to Vaso-vagal attack after the session
- Koebner phenomenon can occur in patients with psoriasis
- Scar formation after session of wet cupping therapy
In a study by Jiang et al., they concluded that, cupping therapy side effects depends on the cup type, application method, and the frequency of cupping sessions. One rare side effect was reported in Weng et al. case study. They reported a case of fifty-eight-year-old woman, who acquired type A hemophilia after extensive bleeding following a cupping therapy session.
How do cupping therapy works?
Cupping therapy is an old technique used for long time and in diverse cultures, with patients’ improvements from pain and other conditions. Multiple researches were conducted to understand how cupping therapy works, and a lot of researches are yet needed for full understanding of cupping therapy mechanism of action. There is multiple hypothesis that tried to propose a mechanism of action of cupping therapy.
A) Pain-gate theory
in this theory, cupping therapy can decrease the pain intensity and perception by affecting the pain pathway which starts from the area of pain perception at the skin, and to the brain.
B) Diffuse noxious inhibitory control (DNICS)
It is also known as conditioned pain modulation, which is a pain modulatory pathway. When one painful stimulus can inhibit or decrease the feeling of another painful stimuli. In this proposed mechanism of action, the cupping therapy causes counter-irritation, thus these stimuli can decrease the perception of the chronic pain. This means cupping pain can mask the original pain of the patient.
C) Reflex-zone theory
There are areas in the body that is related to specific regions or organs in the body. applying pressure to these areas is suggested to cause relief of pain in this specific region.
D) Release of nitric-oxide theory
Nitric oxide is a gaseous molecule that causes vasodilatation and improves the area blood flow. Nitric oxide can regulate blood pressure and aids the human body’s immune functions. Cupping therapy can increase the production of nitric oxide through stimulating the endothelial cells of the skin. In a study by Tagil et al., they founded a higher levels of nitric oxide in the extracted cupping blood in comparison to nitric oxide levels in venous blood.
According to Moncada et al., nitric oxide which originates from endothelial cells after cupping therapy causes multiple effects:
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- Decrease vascular resistance
- Decrease blood pressure
- Decrease platelets adhesions
- Decrease smooth muscle proliferation
All these changes can decrease and even prevent the formation of atherosclerosis.
E) Immune system activation theory
Cupping therapy induce the activation of the complement system and the cellular part of immune response. In this case, increasing immunity can protect the body from various diseases. In a study by Sahbaa et al. to assess the immunomodulatory effects of cupping therapy in patients with rheumatoid arthritis. They reported significant decrease in the activity of rheumatoid arthritis and decrease in activity laboratory markers.