The Use of Cupping Massage in Musculoskeletal Medicine

The Use of Cupping Massage in Musculoskeletal Medicine

 Bronze cupping vessel, Egypt, 300 BCE-300 CE Credit: Science Museum London

Bronze cupping vessel, Egypt, 300 BCE-300 CE Credit: Science Museum London

Cupping has been practiced in most cultures in one form or another throughout history but the true origin of cupping therapy remains uncertain (Qureshi et al 2017). The practice of cupping is a technique where a vacuum is created in a cup, drawing the skin up and decompressing the layers of the epidermis and subcutaneous superficial fascia. 

Cupping massage is a modern version of a traditional therapy, frequently carried out using plastic cups and a manual hand-pump to create the vacuum. The vacuum draws the soft tissue perpendicular to the skin, providing a tensile force, which can be left in one site or moved along the tissue. The practitioner can control the intensity of the desired suction from 80 mmHg to 250 mmHg.

The most common sites of application are the back, chest, abdomen and hips. The cups are typically left in place for 5-15 minutes depending on the client’s reaction and sensitivity. To cover a wider area, cupping massage can also be used with varying amounts of suction.

Why Does Cupping Work?

The responses to cupping are multifactorial - physiological and psychological factors interplay in a complex manner. The biopsychosocial provides a practical framework for investigating the complex interplay between cupping therapy and clinical outcomes.

Based off the biopsychosocial model, investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation. An observed favorable outcome may be explained by a number of overlapping mechanism in the periphery, spinal cord, and brain including, but not limited to:

 A manual hand-pump version of cupping

A manual hand-pump version of cupping

  1. Affective Touch - Therapeutic stimulation of somatosensory nerves (C-tactile afferent) mediates the release of oxytocin. Which can result in reduced reactivity to stressors and improved mood/affect.

  2. Neuromodulation - The skin, subcutaneous tissue and fascia are all embedded with mechanosensitive nerve fibers, so the application of cupping invokes a number of neurophysiological responses. One being, input from low-threshold Aβ fibers inhibits nociceptive processing and contributes to the activation of endogenous pain inhibitory mechanisms.

  3. Contextual Factors - A positive therapeutic encounter is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning.

  4. Mechanical Factors - Gentle stretching of neurovascular structures and muscles induces a molecular response that helps blunt edema and expedite clearance of noxious biochemical by-products of inflammation (cytokines, prostaglandins, and creatine kinase).

Is Cupping Safe?

Cupping is generally considered a safe therapy with minor side effects such as erythema, edema, and ecchymosis in a characteristic circular arrangement. The longer a cup is left on the skin and the higher tensile stress inside of the cup, the more of a circular mark is created this is due to capillary dilation. Cupping encourages blood flow to the cupped region (hyperemia), often the patient may feel warmer and/or hotter as a result of vasodilatation taking place, slight sweating may occur.

Summary

Cupping is a technique where a vacuum is created in a cup, drawing the skin and subcutaneous superficial fascia up into the cup. The use of cupping originated as early as 3000 B.C.E in a pre-scientific era and much of the reasoning once used to explain the effects do not make sense in the light of what we know today. Anecdotally cupping is used to alleviate pain, whether cupping works via a placebo effect, counter irritation or mechanotransduction are all up for discussion.


More to Explore

Aboushanab & AlSanad (2018). Cupping Therapy: An Overview From A Modern Medicine Perspective. J Acupunct Meridian Stud. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/29436369/

Bialosky et al. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther.
https://www.ncbi.nlm.nih.gov/pubmed/29034802

Chen & Michalsen (2017). Management of chronic pain using complementary and integrative medicine. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28438745

Kim et al. (2018). Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis. BMJ Open.
https://www.ncbi.nlm.nih.gov/pubmed/30397006

Ge et al. (2017). Dry cupping for plantar fasciitis: a randomized controlled trial. J Phys Ther Sci. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/28603360

Leggit, J.C. (2018). Musculoskeletal Therapies: Acupuncture, Dry Needling, Cupping. FP Essent.
https://www.ncbi.nlm.nih.gov/pubmed/29963846

Lowe, D.T. (2017). Cupping therapy: An analysis of the effects of suction on skin and the possible influence on human health. Complement Ther Clin Pract.
https://www.ncbi.nlm.nih.gov/pubmed/29122256

Qureshi et al. (2017). History of cupping (Hijama): a narrative review of literature. J Integr Med.
https://www.ncbi.nlm.nih.gov/pubmed/28494847

Rossettini et al. (2018). Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/29357856

Rozenfeld & Kalichman (2016). New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. Journal of Bodywork and Movement Therapies.
https://www.ncbi.nlm.nih.gov/pubmed/26891653 

Thompson et al. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/26637643 

Wang et al. (2017). The effect of cupping therapy for low back pain: A meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil. 
https://www.ncbi.nlm.nih.gov/pubmed/28946531