Contraindications to cupping therapy (adapted from Ahmedi
Cupping therapy is an ancient method which has been used for centuries for various painful conditions. It is performed by applying cups to selected skin points most commonly in the back aiming to create areas of sub-atmospheric pressure. It has been classified as either dry or wet type of therapy. Its mechanism of action is not well understood but several proposed mechanisms are described in the literature. It is relatively safe with a few reported side effects which include scar formation and skin infection. In this paper, a review of the literature will be presented to determine its potential benefits in pain management particularly in musculo-skeletal conditions such as low back and neck pain.
- cupping therapy
- chronic pain
- complimentary therapies
- low back pain
- pain management
Cupping therapy is one of the oldest methods of complimentary therapies which has been used in early human civilization. Evidence shows that it was first practiced by the Ancient Egyptians more than 5500 years ago and then it was introduced to the Greek, the Romans, and the rest of the world . The main postulated aim of this therapy is the extraction of harmful substances or toxins from the body by creating negative pressure in a cup . Cupping was described by Razi as a process in which blood from superficial small vessels located in muscles is released . It has been traditionally used for the treatment of painful conditions but has also been used to treat chronic diseases such as cardiovascular disorders, skin diseases, inflammatory disorders, and metabolic diseases [4, 5]. Its exact mechanism of action is not well-understood but several theories have been proposed .
2. Description of cupping therapy
Cupping therapy is done by applying small round cups which are made of glass, bamboo, ceramic or plastic to the area of pain. The cup has a rolled rim to ensure tight contact with skin to preserve the negative pressure created . The mouth of the cup is placed firmly over the preferred location against the skin. The negative pressure is generated by heat or by other vacuums like manual pumps. This negative pressure fixes the cup onto the skin and creates suction effect which pulls the skin upwards into the cup. Sometimes, the therapist uses lubricants to facilitate the movement of the cups to cover a wider area . The common application sites are the back, chest, abdomen, buttock, and areas of abundant muscle. Traditionally, the cupping therapy is done in sets of four, six or ten . The cups are usually kept in place for 5 to 20 minutes . The common side-effects of cupping therapy are erythema, edema, and ecchymosis in the area where the cup rim was placed. These effects may take several days to weeks to disappear [4, 10]. The cupping therapy process usually consists of the following five main steps:
The therapist assigns and disinfects the designated area for cupping therapy.
A suitable sized cup is positioned on the selected area and the therapist uses a method of suction to suck the air inside the cup. The cup will be left on the skin for 3–5 minutes. If it is wet cupping, then superficial incisions are performed on the skin by a scalpel blade (No. 15 to 21) or by puncturing the skin with a needle, or an auto-lancing device or a plum-blossom needle .
The cup is placed again on the skin for 3–5 minutes.
The cup is removed.
The treated area is cleaned, disinfected, and a dressing is applied. The dressing is usually kept for 48 hours following the session of therapy .
3. Mechanism of action
While the exact mechanism of action of cupping therapy is not well-understood, multiple theories have been proposed. Six mechanisms of action have been suggested to describe the various effects of cupping therapy. Three of these theories are addressing the biological and mechanical basis of pain relief which results from cupping therapy. These theories are as follows: the pain-gate, the conditioned pain modulation, and the reflex zone. The remaining three proposed mechanisms of action are meant to explain the beneficial effects of cupping therapy which include an increase in blood circulation, immunomodulatory effects, and the removal of toxins and wastes . The former three theories which are related to pain relief will only be discussed here.
3.1 Pain-gate theory
This theory proposes that cupping therapy could reduce pain intensity by influencing the communication routes of pain transmission from a stimulated area to the brain and backward . Following a painful stimulus, pain signals are carried by both the small-diameter (A-delta and C) and the large-diameter (A-beta) nociceptive nerve fibers to synapse into a transmission cell in the dorsal horn of the spinal cord . In this area pain modulation takes place through a network of interneurons and presynaptic pain gates . The small fibers have an obstructive effect on the inhibitory cells thus allowing the flow of the transmission signals to the spino-thalamo-cortical pain pathway and then to the brain. While the large fibers stimulate the inhibitory cells and tend to inhibit transmission of pain signals. Thus, pain intensity is expected to be reduced when large nerve fibers are stimulated by touch or pressure or vibration. Based on this theory, both small and large nerve fibers are stimulated during cupping therapy . During the initial stage of cupping therapy, the afferent large nerve fibers will partially close the presynaptic gate as a result of the application of pressure to the skin . As the stimulus intensity is increased, the number of activated units of nerve fiber increases. The subsequent positive and negative effects of the small and large nerve fibers responses tend to counteract each other. However, prolonged stimulation will lead to adaptation of the large fibers which will eventually result in opening of the presynaptic pain gates . This adaptation can be modulated by employing additional stimuli during cupping therapy such as vibration and scratching to stimulate the large fibers again . This increased activity will lead to the closure of the pain gates and experiencing further pain relief . More research is needed to validate the application of this theory in cupping therapy.
3.2 Conditioned pain modulation
This theory has been also known by the term “Diffuse Noxious Inhibitory Controls (DNICs).” It is based on the assumption that “pain inhibits pain,” or one type of pain masks another . DNIC comprises a spinal-medullary-spinal pathway that is activated when two concomitant painful stimuli are applied at the same time . The activation of this pain pathway, which is triggered by a distant noxious stimulus, causes inhibition of the primary pain at the level of the nociceptive spinal neurons . This pain inhibitory system has been successfully demonstrated in animal studies . Furthermore, findings from clinical studies on the idiopathic pain syndromes such as irritable bowel syndrome, temporomandibular disorders, fibromyalgia, and tension-type headache had confirmed the relevance of this theory to chronic pain in humans . According to this theory, local vibration or scratching done during cupping therapy causes a nociceptive stimulus that triggers the activation of DNICs which eventually lead to the relief of the primary pain .
3.3 Reflex zone theory
Reflex Zone Theory proposes that there is an existing link between one organ of the body and another one. This link is mediated by interaction between nerves, chemicals, and muscles . Thus, a disturbance in one organ causes external manifestations which can be detected at a site distal to the disturbed organ. The external manifestations are dependent on the organ manifesting them. For example, skin can become cold and pale due to vasoconstriction or it can become warm and red due to vasodilatation. The organ functions are affected due to a reduction in the circulating blood and tissue fluids . Animal studies showed that somatic stimulation of the skin or the peripheral joints could lead to significant effects on the cardiovascular, urinary, and gastrointestinal functions . These reflexes can be either excitatory or inhibitory in terms of organ function. Their main action is attained through spinal pathways, supra-spinal and cortical centers . Therefore, it is hypothesized that the application of the cupping therapy cups over the skin result in the stimulation of the skin receptors which will eventually lead to an improvement in the blood circulation through the neural connections to the affected organ .
4. Classification of cupping therapy
Cupping was broadly classified into dry and wet cupping, but in 2016 Al-Bedah
4.1 Technical types
This category of cupping is classified according to the cupping technique which is used. It includes four types; dry cupping, flash cupping, wet cupping and massage cupping .
4.1.1 Dry cupping
4.1.2 Flash cupping
4.1.3 Wet cupping
4.1.4 Massage cupping
4.2 Power of suction
This category of cupping is classified according to the negative pressure level created inside the cups. The pressure levels used are light, medium, strong or pulsatile pressure .
4.2.1 Light cupping pressure
4.2.2 Medium cupping pressure
4.2.3 Strong cupping pressure
4.2.4 Pulsatile cupping
4.3 Methods of suction
The classification here is based on the method used to create the negative pressure inside the cups. These are as follows:
4.3.1 Fire cupping
4.3.2 Manual vacuum cupping
4.3.3 Electrical vacuum cupping
4.4 Added therapy types:
4.4.1 Needle cupping
4.4.2 Hot cupping or Moxa cupping
4.4.3 Herbal cupping
4.4.4 Laser cupping
4.4.5 Electric stimulation cupping
4.4.6 Water cupping
5. Common clinical indications for cupping therapy
5.1 Low back pain
Low back pain (LBP) is a common clinical problem which has an estimated one-year prevalence of 38% in the general population . The current management options include bed rest during the acute phase, analgesia, physiotherapy, traction, alternative treatments, and health education on prevention of future episodes . Cupping therapy has been used for a long time for both acute and chronic low back pain. Studies have shown significant reduction in pain intensity scores and improvement in functional outcome tools with cupping compared to other modalities of treatment like usual care or medications [34, 35]. Wang
5.2 Neck pain
The lifelong prevalence of neck pain varies from 14.2% to 71% and it is more dominant in the high activity age groups, mainly individuals aged 35 to 49 years . It was found to be associated with increased medical costs and adverse effects on personal productivity . The commonly used therapies for neck pain include the use of analgesics and physiotherapy. In addition, surgery might be of help in some specific situations. However, these options are not always effective, and sometimes are associated with serious side-effects. Therefore, people have been always looking for other alternative options which include traditional medicine . Cupping is one of the methods used commonly by people to relieve neck pain especially for the non-specific types. Studies conducted in patients with this condition investigated the effectiveness of cupping by measuring the following outcomes: pain intensity, disability scores, and quality of life . The current available evidence indicates that cupping is effective for patients with chronic non-specific neck pain in terms of reduction in pain scores, improvement in disability scores, and quality of life indices compared to no treatment or active controls (physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), heat pack therapy, and acupuncture) . Kim
Arthritis is a commonly seen clinical problem in medical practice. It is a manifestation of many joint disorders like osteoarthritis, gout, rheumatoid arthritis and others. Cupping therapy has been used to reduce the joint pain associated with osteoarthritis (OA), gout and ankylosing spondylitis. OA is a common chronic degenerative joint disease. The commonly affected joints are knees, hips and shoulders. It may present with pain, stiffness, and decreased mobility due to the effects on joint function and stability . Li J
Gout is an inflammatory arthritis which results from deposition of monosodium urate crystals in the joint space. It typically presents with painful joint inflammation, mainly in the first metatarsophalangeal joint . A single study which was conducted in China investigated the combined effects of cupping and herbal medicine in comparison to the use of NSAIDs in acute gouty arthritis. The investigators reported that the therapeutic effects of both cupping and herbal medicine were comparable to NSAIDs but the differences were not statistically significant .
Ankylosing spondylitis (AS) is a chronic inflammatory disorder which causes chronic back pain. The common presenting symptoms are back pain and stiffness due to spinal fusion and ankylosis . Ma
In conclusion, there is a weak evidence which supports the use of cupping therapy for pain management in different types of arthritis. Further research is required with better designed clinical trials to overcome the methodological problems, and the risk of bias with the present studies.
5.4 Post-herpetic neuralgia
Post-Herpetic Neuralgia (PHN) is a persistent neuropathic type of pain which develops as a complication of herpes zoster infection. It may occur in 20% of herpes zoster patients and it can persist for 90 days after the acute phase of the rash . The aim of the treatment of PHN is to control the pain by using topical and systemic drugs like topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic anti-depressants . Cao
5.5 Carpel tunnel syndrome
Carpal tunnel syndrome (CTS) is a peripheral nerve entrapment due to the compression of the median nerve in the carpal tunnel of the wrist joint. It usually manifests as numbness and burning pain in the palm and the first three fingers (sensory involvement), and reduction in the grip strength (motor involvement) . The beneficial effects of cupping therapy were observed when used in combination with physiotherapy or alone. Mohammadi
Fibromyalgia is a disorder characterized by chronic generalized pain, fatigue, cognitive disturbances, sleep disorder, and pronounced somatic and psychological distress . The main aim of treatment for fibromyalgia patients is to relieve pain and to improve the patients’ quality of life . Few studies were conducted to investigate the effects of cupping in fibromyalgia. Lauche
Cupping therapy is a process where suction with or without scarification is done as a treatment for different types of pain and medical problems. Direct application of cupping on specific sites of the body is contraindicated as the negative pressure created during cupping therapy might be harmful . These sites are veins, arteries, nerves, inflamed and injured skin, body orifices, eyes, lymph nodes, varicose veins, bone fractures, and sites of deep vein thrombosis . Ahmedi et
|Absolute contraindication||Relative contraindication||Caution|
|Cancer||Acute infection||Active psoriasis|
|Organ failure (heart, renal, hepatic)||Severe chronic disease (e.g. heart disease)||Keloid scars|
|Patients using pacemaker||Pregnancy, puerperium||Children|
|Bleeding disorders like hemophilia||Anti-coagulant therapy||Anti-platelet therapy|
|Active cellulitis/erysipelas/abscess||Recent wet cupping session or recent blood donation||Peripheral vascular disease|
|Ulcer||Recent wet cupping session or recent blood donation|
|Deep vein thrombosis|
|Stroke — unstable or evolving|
|Suspected osteomyelitis or septic arthritis|
|Life threatening asthma|
7. Infection control measures
Prevention of infection by following strict infection control measures is an essential aspect of clinical care. In cupping therapy, such measures are of paramount importance since the therapy necessitates direct contact with the skin and body fluids. Several infection control measures should be considered. These measures include hand hygiene and washing, and wearing personal protective equipment like gloves, masks, protective eyewear and gowns. Disinfection of the patient’s skin with approved disinfectants is required before starting the procedure. Also, disinfection of the patient’s bed or use of disposable bed covers is needed. It is recommended to use disposable cups, vacuum pumps, and surgical blades to avoid cross-transmission of infection. Lastly, adhering to proper medical waste segregation system is crucial [63, 64].
8. Complications of cupping
Cupping therapy is generally considered as a safe treatment with minor side-effects and complications [23, 65]. However, the safety of cupping therapy is under-reported. Most of the studies which were conducted primarily addressed its efficacy but only a few studies reported its complications. Generally, the complications can be divided into preventable and non-preventable . The commonly recognized side-effects are erythema, edema, and ecchymosis which are directly caused by cupping. Skin burns have also been reported . They may occur because of the following reasons: excessive use of alcohol, prolonged exposure to cupping therapy, sensitive skin especially in elderly people, and the use of fire [23, 65]. Separation of the epidermal layer from the dermal base of the skin may occur due to prolonged exposure of more than 20 minutes to high vacuum pressure during cupping therapy. This complication was specifically reported with pumping cupping therapy . In one case report, application of cupping therapy for about 40 minutes over the lower back resulted in severe pain immediately after removal of the cups and the patient developed bullae and crusting over the application site later . Change in atmospheric pressure has been reported as a risk factor for skin injury as seen in a patient who was traveling in an airplane. This resulted in multiple blisters and shades of redness, petechiae, and ecchymosis . Exposure to blood-borne infections may occur if infection control measures are not followed strictly. For example, cases of factitial panniculitis and herpes simplex virus infection have been reported after cupping therapy [68, 69]. Possible complications of cupping therapy are summarized in Figure 2.
9. Future directions
Cupping therapy is a complimentary type of therapy which is widely used all over the world for the treatment of chronic medical problems, especially for pain-related conditions. Although, there are several proposed theories which attempt to explain its mechanism of action in the management of chronic pain, the exact mechanism is still not clearly understood. Future research could focus on trying to find clear answers for the most likely mechanism of action and to validate the current theories in clinical trials. There is an emerging evidence of the promising benefits of cupping therapy in patients with common chronic painful conditions. However, despite the large number of clinical trials which were conducted, the evidence is still inconclusive due to major limitations. Future clinical trials of good quality are required. Such trials should ideally have a large sample size, better methodology and design, standardized treatment and reporting protocols, standardized assessment tools, and long follow-up periods.
Cupping therapy is an ancient complementary medicine practice which has been used for thousands of years for a variety of common medical problems. The current evidence is suggesting that cupping therapy may be effective in treating common chronic painful conditions for a short period. Yet, most of available studies have major limitations like small sample size, and different outcome assessment tools, duration of treatment, and treatment regimens. Publication bias is another important drawback, as most of the available studies were conducted in a single country. Future good quality, multicenter clinical trials utilizing standardized protocols are needed.