March 2017 Issue

Focus on Fitness: The Cupping Phenomenon
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 19, No. 3, P. 50

What's behind this trend, and is it evidence-based?

Cupping dominated news headlines this past summer when US Olympic swimmer Michael Phelps won his events sporting strange round bruiselike marks on his torso. And he wasn't the only Olympic athlete competing with those marks; several swimmers and gymnasts from the United States and various other countries had cupping marks as well. Over the past 10 years, cupping has intermittently popped up in news media when celebrities like Gwyneth Paltrow were caught in photographs with cupping marks on their shoulders. It was written off as an alternative medicine fad until the 2016 Rio Olympics, when athletes touted its benefits for athletic recovery and muscle soreness.

What Is Cupping?
Cupping is thousands of years old and is considered one of the oldest therapeutic practices. Earliest historical reports indicate cupping originated and was first practiced in China, Egypt, and Arabic countries; its use has been documented in ancient Greek medical accounts, as well as Ayurvedic (Indian) and medieval European medical literature.1 Currently, cupping is labeled as a traditional Chinese medicine (TCM) and complementary and alternative medicine (CAM) modality, much like acupuncture.

Cupping involves the placement of round cups (usually glass) at various points on the body. Suction is created by the application of a flame to the glass before and after placement. The vacuum inside the cup causes the skin to "bubble" up inside the cup, often resulting in a round bruiselike mark, described by an integrative medicine physician at the 2016 Olympics as basically like a "hickey," which, though somewhat crass, communicates the basic process to laypeople.2 According to TCM, cupping restores the flow of qi (also called chi, translated as "life energy") and the balance of yin and yang in the body. TCM practitioners believe that the darker the mark left by the cup, the poorer the blood circulation or the more toxins have accumulated in that part of the body; however, this relationship hasn't been proven. From a biomechanical and physiologic perspective, cupping increases local blood circulation, relieves muscle tension, increases anaerobic metabolism, and may promote capillary endothelial cell repair and angiogenesis in tissues. Much like certain massage techniques, cupping pulls at tight muscles and stretches fascia. Though cups generally are applied and left in place for several minutes, they may be moved in rhythmic strokes for a cupping massage.1,2 In TCM cupping, cups usually are positioned along the body meridians and acupressure points (as in acupuncture).

Historically, gourds, animal horns, shells, bamboo, pottery, glass, and metal all have been used as cups to generate suction.1 Today, glass and silicone in various shapes and sizes are used. Glass cups require the use of a flame for heat to generate suction. Heated glass does carry the risk of skin burns, and having a flame/heat source at competitive athletic events is inconvenient. As a result, silicone cups with small, attached air pumps are now available and the type most commonly used by Olympic athletes and consumers.

The cupping method just described is referred to as dry cupping. In Asian, Middle Eastern, Arabic, and African countries, wet cupping is still a common therapeutic practice. In wet cupping, small punctures or incisions are made in the skin and the cup is placed over the area to draw out blood. Wet cupping practitioners believe bloodletting in conjunction with cupping can further release toxins from the body. Wet cupping carries the same risk of skin burns as dry cupping with heat, but adds the risk of bloodborne infections, anemia, nonhealing skin wounds, and pain due to the incision.1

Is Cupping Supported by Scientific Evidence?
Most news media reporting on cupping during the 2016 Olympics labeled it as quackery, superstition, placebo effect, or unsupported by science. However, there are hundreds of published studies in the National Institutes of Health's PubMed database, including some systematic reviews and controlled studies. The majority of studies report on wet cupping and were published by Asian and Arabic researchers. I won't discuss these, since dry cupping is of greater interest here in the United States and is considered a safer CAM modality. Fewer studies report on dry cupping, and none report specifically on its ability to improve athletic performance and recovery or relieve muscle knots and tension. A 2014 study conducted by Boston researchers found that dry cupping significantly reduced low back pain and improved range of motion in a small group of patients with at least eight weeks of lower back pain.3 A 2013 German study found that home-based cupping massage worked as well as home-based progressive muscle relaxation exercises in relieving chronic neck pain; patients reported significantly better well-being scores and decreased pressure pain sensitivity after cupping.4 Though evidence is scant, anecdotal reports on the benefits of cupping for musculoskeletal pain relief and postathletic recovery are numerous, driving interest in cupping.

The Olympic-related news stories dismissing cupping as quackery reflect a poor understanding of its long history and range of therapeutic applications. Though unproven by good published scientific evidence, dry cupping—especially that performed with the self-suctioning silicone cups—seems to be relatively safe compared with some CAM modalities. For example, many chiropractic applications also aren't supported by much scientific evidence yet are accepted and widely available to consumers. Olympic athletes reported using cupping for easing aches and pains associated with rigorous training. Many other athletic recovery methods, such as ice baths, compression garments, kinesio taping, and sports massage, haven't been extensively researched nor proven to be effective for their intended use.

If you have clients curious about cupping, keep an open mind, but encourage them to put safety first. Only a trained and appropriately accredited massage therapist, acupuncturist, sports medicine professional, or integrative medicine practitioner with experience in dry cupping and/or cupping massage should perform cupping. Skill and experience is especially required for dry cupping used with heat/flame sources for suction. Using heat/flame without training risks severe burns. Clients can easily purchase home cupping kits online, but they shouldn't use them unless they're willing to attend training sessions on their appropriate use. Cupping risks are minimal when knowledgably applied to the large muscles of the shoulders, back, hips, and legs for relief of musculoskeletal pain and knots. However, applying cupping suction without anatomical knowledge and cupping training to these and other areas (eg, face, neck, and abdomen) could result in circulatory and organ injury from the suction force.

Based on PubMed search results, it appears that cupping methods are under research for a variety of medical indications, and the future clinical value of this ancient technique will be determined by study findings.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area.

1. Mehta P, Dhapte V. Cupping therapy: a prudent remedy for a plethora of medical ailments. J Tradit Complement Med. 2015;5(3):127-134.

2. Marcus MB. Why is "cupping" attracting Olympic athletes like Michael Phelps? CBS News website. Updated August 9, 2016.

3. Markowski A, Sanford S, Pikowski J, Fauvell D, Cimino D, Caplan S. A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. J Altern Complement Med. 2014;20(2):113-117.

4. Lauche R, Materdey S, Cramer H, et al. Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain — a randomized controlled trial. PLoS One. 2013;8(6):e65378.