Introduction

During the last Olympic Games, there was a media frenzy with photographs of odd-looking marks on the upper backs of some swimmers. Curiouser and curiouser. The large bruises were perfect for speculation about underwater attacks by blood sucking lamprey or vampire squid.

It turned out that these marks were due to an ancient healing technique called ‘cupping’. Swimming coaches had recommended cupping to help heal and optimize the tissues of these elite athletes who had been working out intensively in preparation for the biggest race of their lives.

So technically speaking, the journalists who called these marks ‘ go faster stripes’ were probably close enough to the truth.

Cupping is used outside of elite sports for a wide range of conditions including pain, inflammation, respiratory tract infections and shingles.

Cupping has been around for a very long time and has been passed on from one generation to another. It is also used in diverse cultures.

Proponents of cupping argue that the longevity and widespread use of cupping are indirect proof of its validity as a therapeutic intervention. Let’s look for direct proof of the validity of cupping as a therapeutic intervention by doing our own research.

What Is Cupping Therapy?

Cupping is an age-old form of disease treatment which is done by applying suction to the surface of the skin through the use of a small container in which a vacuum has been created.

It is relatively inexpensive and non-invasive.

Although traditionally associated with Traditional Chinese Medicine, cupping has been used for centuries in Ayurvedic medicine, Arabic medicine( Al-Hijama), Egyptian healing, Ancient Greek and Roman healing practices.

One of the earliest records of cupping is found in Bo Shu which is an ancient book discovered in the tomb of the Han Dynasty. Both Galen and Hippocrates, who are considered the forefathers of western medicine, also used and promoted cupping.

Cupping involves the application of a heated cup to the skin in order to generate a partial vacuum to mobilize blood flow.

Nowadays glass cups are used but in earlier times cups made of bamboo, metal or earth was commonly used. The earliest reports of cupping mention the use of deer antlers as the cupping device.

The vacuum is created by introducing an ignited alcohol-soaked cotton swab (held with a forceps) into a cup and removing it prior to application to the skin. This takes skill and practice.

The cup is applied to the skin (often over the upper back or shoulders) and a vacuum is created as the cup cools. In some ways, the mechanism of action of cupping overlaps with that of acupuncture.

There are a number of different cupping techniques:

  • dry stationary (the cup remains in a single position)
  • wet superficial (incisions are placed in the skin at the site of the congestion to suck out blood into the suction cup)
  • moving running cup (the cup is moved along the skin)
  • moxibustion (dried plants are burned)
  • cupping with acupuncture
  • drug cupping (cupping with creams or ointments)
  • medicinal cupping ( boiling bamboo cups with herbs for use in cupping).

The usual duration of cupping is between 5 and 10 minutes.

In addition, different sizes of cups, different pressure and differences in the length of application of the cup can be used to achieve different effects.

The mark left by cupping varies depending on the temperature, the size of the cup, time that the cup remains on the skin and baseline health of the subject.

Quantitative assessment of the color change of local skin changes from cupping using a hyperspectral camera showed ( not surprisingly) that cupping was associated with statistically significant changes in skin color (1).

There are also attempts underway to develop a numerical scale to interpret the skin color changes generated by cupping and apply some systematic metrics to the ancient art of cupping

Is There Any Research?

There are 5,958 publications on cupping including 638 clinical trials. This compares poorly to research on acupuncture which has 27,781 publications and 4,623 clinical trials.

On closer examination, at least some of these ‘cupping’ studies related to menstrual cups and the optic cup.

A key problem with research on cupping is similar to the problems with research involving any physical intervention and that is the difficulty with having a plausible placebo.

Sham cupping techniques have been developed and involve having a small hole in the cupping device to minimize the negative pressure or suction but this has not been validated.

Is The Philosophy of Cupping Therapy supported by science?

There are two approaches to understanding the mechanism of action of cupping.

  1. From the perspective of Traditional Chinese Medicine, cupping is believed to regulate the flow of chi and balance yin and yang. Hence the similarity with acupuncture.
  2. From the perspective of western medicine, cupping is believed to exert a physical pressure which stimulates neural reflexes and endocrine responses. These effects occur at a local level and systemically.

Both perspectives are valuable but it is easier for me (as a western trained doctor) to evaluate data based on western science. I am just more familiar with p-values than meridians.

I have huge respect for Traditional Chinese Medicine and feel bad trying to analyze cupping from the perspective of the western medical model. On the other hand, I have worked as a doctor for long enough to know that the only way cupping could ever be accepted (and funded by insurers) is to try to translate the language of cupping into modern scientific language.

This allows users and funders to analyze the data to make evidence-based decisions about cupping.

Cupping may be relatively inexpensive, but it has a cost (both in terms of finances and safety) and it also has an opportunity cost.

The birdseye view of the theory behind cupping is as follows – cupping stimulates the skin surface which translates into biological signals which in turn activates the neuroendocrine and immune system which ultimately translates into health and well-being

At the micro level, cupping causes negative pressure which stretches the skin and dilates blood vessels. This increases blood flow which leads to capillary rupture and the formation of a large ecchymosis or bruise. Specialized scavenger blood cells are attracted to the bruise and result in the production of heme-oxygenase 1 and the production of carbon monoxide biliverdin and bilirubin

Limited pre-clinical studies have shown that bilirubin and biliverdin can exert anti-inflammatory, antiproliferative and immune modulatory activity.

Does Cupping Therapy Reduce Pain?

Relief of pain is the leading indication for cupping worldwide.

Saudi investigators evaluated the safety and efficacy of wet-cupping for non- specific lower back pain in 80 study subjects (2).

This was a randomized study of no intervention versus wet cupping (6 sessions within 2 weeks) each of which was done at two bladder meridian (BL) acupuncture points.

The study found significant improvements in pain scores in the cupping arm of the study as compared to the control.

The improvements in the cupping arm lasted for 2 weeks after the cupping session.

Clinically meaningful differences in pain, disability and quality of life for chronic nonspecific neck pain was found in a meta-analysis of 4  randomized trials involving 200 subjects (3).

A systematic review of cupping for lower back pain identified 29 relevant studies (4). The reviewers included non-randomized studies in the analysis in view of the dearth of data. The one randomized study showed a statistically significant reduction in pain and analgesia use in the wet-cupping arm of the study. The non-randomized studies showed an overall improvement in pain.

A systematic review of Traditional Chinese Medicine for neck and lower back pain reviewed data from 75 randomized trials involving 11,077 people (5). Cupping was found to be efficacious in treating the pain and disability associated with neck pain or lower back pain in the immediate term.

A specific area of interest for cupping is the pain associated with herpes zoster or shingles.

A total of eight randomized controlled trials involving 651 patients were included in a meta-analysis of wet cupping for herpes zoster (6). Meta-analyses showed wet cupping was superior to medication in reducing the incidence rate of postherpetic neuralgia.

Bottom Line

The quality of studies on cupping for pain relief is very variable. Cupping appears to offer some benefits in terms of pain relief.

Does It Help The Immune System?

The effect of wet cupping on C reactive protein (CRP) and heat shock protein (HSP) was evaluated in 126 patients with the metabolic syndrome (7).

CRP is a non-specific marker of inflammation that is widely used in clinical practice.

HSP is produced by cells in response to stress and is not commonly used in routine clinical practice.

The intervention group had wet cupping combined with dietary advice while the control group just had dietary advice. No difference in CRP or HSP was noted between the two groups.

Drug cupping (which in this study was cupping with pingchuan ointment) was evaluated in 77 patients with chronic asthma (8). There was a statistically significant increase in CD4 cells, IL-2, interferon, C3, C4,IgA, IgM and IgG and statistically significant decreases in IgE, IL4, IL-8 and CD8 in the treatment versus the control group.

I asked a colleague who is a consultant immunologist what he made of these results and he just shrugged his shoulders. The immune system is really complex and we cannot simplify things by saying that any intervention increases or decreases the immune system. Interventions can have complex effects (like we see in this study) with increases in parts of the immune system and decreases in other parts.

Furthermore, what do we consider a good outcome? For people with immune deficiency, we would want an increase in certain parts of the immune system. For people with allergy or hypersensitivity, we would want decreases in certain parts of the immune system.

Bottom Line

The data on cupping and immunity caused a consultant immunologist to shrug his shoulders. I don’t know either what to make of the limited data that we have either.

Does It Treat High Blood Pressure?

Researchers in Saudi Arabia evaluated the effect of wet cupping (hijama) on BP in patients with baseline hypertension (9).

A total of 86 patients were randomized 1:1 to either conventional treatment for BP control or conventional treatment plus cupping.

The study took place over a period of 8 weeks.

Wet cupping resulted in an immediate reduction in BP which was maintained over four weeks of follow up but was lost at 8 weeks of follow up.

This begs the question- would monthly cupping help with a sustained antihypertensive effect?

This is a study that needs to be done but as of yet has not been undertaken.

Bottom Line

Limited data suggest that cupping may play a short-term role in lowering BP.

Does it Help Dermatological Issues?

A Cochrane review of complimentary alternatives therapies for acne vulgaris in 2015 found no benefit of cupping (10).

A Chinese study evaluated the effect of a combination of bloodletting, cupping, and acupuncture on acute herpes zoster lesions (11). As we will discuss in the safety section, cupping is really not recommended during acute skin eruptions. This treatment was carried out once daily for 3 days and then once daily every other day until day 7 of treatment.

The comparison arm of the study was intravenous aciclovir plus a vitamin B complex. Following treatment, there was a statistically significant reduction in the pain score in both groups. There was an also statistically significant increase in neutrophils in both groups round and a decrease in lymphocytes after treatment (More immunological mumbo-jumbo).

Bottom Line

Cupping is usually avoided in acute skin lesions. The data would want to be overwhelmingly robust to override that safety consideration. We simply don’t have good enough data to override the safety concerns with cupping for skin disorders.

Does it Help Stomach Ulcers or Constipation?

There are a number of-of studies looking at cupping for constipation

Constipation is a problem, especially in children. It is estimated that 3-5% of pediatric doctor visits relate to constipation. No cause of constipation is found in over 90% of these visits and this is known as functional constipation.

One Iranian study looked at 120 children with functional constipation who were randomized to receive dry cupping on the anterior abdominal wall or standard laxatives therapy for 12 weeks (12)

Essentially the two treatments needed a photo-finish to decide between them.

At 2 weeks the laxative was the winner but at 4 weeks the cupping treatment had overtaken the laxative treatment and thereafter there was no difference between the two treatments.

Moving cupping was found to be statistically significantly better than oral laxatives in 64 elderly patients with senile constipation at two months of follow up (13).

There are no clinical studies looking at cupping for peptic ulcer disease.

Bottom Line

Preliminary data suggest that cupping may help with constipation.

Is Cupping Therapy Safe?

There are some common sense precautions that should be taken with cupping.

People with bleeding disorders or people who are taking blood thinning medication should avoid cupping as there is a risk of excessive bleeding. For sure, they really should avoid wet cupping.

Cupping should not be carried out over areas of broken skin or infection.

Best practice in hygiene should be upheld during cupping and especially if the skin is being punctured or scarified.

Cases of spinal abscess have been reported related to poor hygiene practices during cupping.

The Koebner phenomenon occurs in some patients with psoriasis. This refers to the development of a raised weal following a scratch or subcutaneous injection. Not surprisingly the Koebner phenomenon has been reported in some patients with psoriasis who underwent cupping.

Cupping is not recommended in the presence of a deep vein thrombosis

It is also considered unsafe in seizure disorders or edema

Cases of intimal tearing of carotid blood vessels leading to stroke have been reported in some patients who had cupping over their carotid vessels.

One of the most interesting papers I read on cupping came from a Turkish forensic pathologist who recommended that pathologists should be familiar with the physical changes caused by cupping to avoid mistaking the marks of cupping for blunt trauma or livor mortis (14).

Conclusion

Cupping may be useful for pain, BP, and constipation. But what about those Olympic swimmers? I doubt that Olympic coaches do anything without checking the source data. It turns out that they did. An interesting study  published last year included eleven trials with 498 participants from China, the United States, Greece, Iran, and the United

The Arab Emirates who participated in sports including soccer, football, and handball players, swimmers, gymnasts, and track and field athletes of both amateur and professional nature (15). Cupping was reported as beneficial for perceptions of pain and disability, increased range of motion, and reductions in creatine kinase when compared to mostly untreated control groups. So maybe calling cupping marks ‘go faster stripes’  has some merit after all.