Cupping Therapy - How it Works & Safety

I’ll never forget my first clinical shadow shift as a 1st year Naturopathic Medical student. I walked into a treatment room and saw cupping being done on a patient’s back. I had never seen anything like it and I was so repulsed! In that moment - and remember, I came from a conventional pre-med undergrad education - I seriously questioned the career path that I had chosen.

Fast forward to present day, and here I am, having sought out additional cupping training (two 21 hr workshops) in addition to the my basic curriculum because I absolutely love the therapeutic benefits of cupping and want to keep learning new techniques.

Here’s the issue with cupping - it isn’t regulated. Meaning, various practitioners can offer this as a service with very minimal understanding of tissue response, technique, and lymphatic physiology. This can actually cause bruising and harm to patients so I want to shed light on the safety considerations, in addition to the physiological tissue responses.

Time to get nerdy…

Physiological Responses:

1. Releases myofascial adhesions: Negative pressure created by the suction creates separation and lift of underlying fascia from the muscle to release existing adhesions.

Fascia is connective tissue that surround muscles, but is a separate, independent layer. I think of it like skin on a grape. Normally, muscles should freely move underneath it. When the two layers get stuck together, adhesions can form, which can cause pain and restricted mobility. There are fascial networks in our body that connect over great distances, and sometimes a restriction in one area, creates pain/discomfort in another. When an adhesion forms, it can prevent blood flow from adequately hydrating the tissue, and when soft tissue is dehydrated, it tightens - further affecting contractility and range of motion.

Adhesions can form from: repetitive use of muscles (sport or job), bad posture, sedentary lifestyle, hard pressure (siting on hard chair), and poor hydration.

2. Improves circulation: Cups bring blood and lymph to an area, improving the fluid status of the muscle and fascia. Also, by addressing tight musculature and/or removing myofascial adhesions, peripheral blood flow to the extremities (like hands and feet) can improve.

3. Pain Gate Theory: It’s been proposed that cupping actives pain receptors in the skin (nociceptors) which alters pain response by decreasing signals travelling from the spinal cord to the brain. Cupping also creates micro-trauma via increased pressure on underlying capillaries. Basically, through those two mechanisms, cupping out-competes other pain signals. This can help address ‘central sensitization’ – an over-activation of pain circuitry in the brain in absence of injury, thought to be an underlying mechanism of chronic pain.

Note - the body is responding to cupping via pain signalling mechanisms, but cupping isn't painful. In reality, it feels like a unique massage where you're left with a sensation like more space has been created, as odd as that sounds. My patients know that if it ever feels too tight - they need to let me know ASAP so I can lessen the suction.

4. Release of Humoral/Immune Mediators: Cupping increases nitric oxide release from blood vessels which lowers vascular resistance (decreases blood pressure) and prevents platelet aggregation – so blood is less ‘sticky’. It also affects the immune system by boosting our natural defences (ex. complement proteins like C3) and decreasing inflammatory cytokines (IL-2.)

5. Clears Cellular Waste: This is the basis of a cupping mark. The suction action pulls trapped material to the surface of the skin, which has been trapped in soft tissue and hasn’t been resorbed or cleared by our immune system. These are things like: old red blood cells, cell fragments, lactic acid, and even cigarette smoke!

Lactic acid, a natural by-product of muscle activity, in particular can be irritating to local tissue (and nearby nerves) and can become ‘stuck’ and inadequately cleared without proper hydration, stretching, or with the presence of large, tight muscles. Here’s a common reality for many: work-out hard at the gym, improper cool-down/stretch routine followed by watching Netflix all evening or returning to sedentary desk job.

Indications:

1. Athlete performance and injury prevention

2. Pain relief – fibromyalgia, tension headaches, unspecified low back pain, poor muscle recovery, stiffness, etc.

3. Stress support – slow, sliding cupping upwards along back = pure bliss

4. Constipation – gentle, sliding cupping clockwise along abdomen

5. Improving mobility and maintaining healthy range of motion

Technique:

Most of my cupping treatments involve a variety of the following techniques. A light lift-and-release technique to begin treatment is essential to warm up tissue to prevent tissue damage.

1. Sliding – Cups are moved along muscle group/body region. I always end in the direction of closest lymph nodes.

2. Stationary – Cups left in place and tissue response is carefully monitored. I will leave stationary cups when I meet resistance during sliding cupping (suggesting fascial restriction) or when I encounter an adhesion (muscle knot.)

3. Active Range of Motion (AROM) – Cups are left in place and I have patient activate muscle for increased, more intense stretch.

4. Combo with acupuncture – For certain indications, such as low back pain and sciatica, I prefer to start with cupping and finish with acupuncture.

Safety & Concerns:

1. Bruising – Should not occur when done correctly. However, it can happen if stationary cups are left in place for too long, if sliding cupping is too vigorous, if skin is too fragile or thin, or soft tissue isn't ‘warmed up’ first. This is actual rupture of underlying capillaries and is an injury to soft tissue.

The difference:

Bruises = tender to touch and they turn colour over time

Cupping marks = non-tender and colour fades over a few days

2. Patients on blood thinners – Stationary cupping should be avoided or reduced. I like to ensure that someone is meeting their INR target before proceeding.

3. Lymph congestion - The ending direction of cup movement is very important. If fluid is moved in the opposite direction of lymph flow and away from draining nodes, then cupping is actually creating more work on the body. If congestion is already present, it's making the issue worse - hence, the importance of understanding lymphatic physiology.

4. Hairy areas – The cupping seal is compromised over hairy areas and sliding cupping will pull on hair and create pain. Shaving is always an option - depending on level of dedication!

Contraindications to Cupping Therapy:

Pregnancy

Cancer

Uncontrolled diabetes

Over disc herniation

Recent injury (within last 72hr)

Active, contagious skin infection

Surgery or joint replacement in the last 4-6 weeks

Surgically implanted abdominal mesh

Over injection sites

Lymph node removal or re-mapping

Thin skin

If you have any more questions about principles of cupping therapy, my training, or unsure if it’d be safe for you, you can book a free 15min consult or email me at drjackson@kawarthatherapeutic.com.

Resources:

Al-Bedah AM, Elsubai IS, Qureshi NA, Aboushanab TS, Ali GI, El-Olemy AT, Khalil AA, Khalil MK, Alqaed MS. The medical perspective of cupping therapy: Effects and mechanisms of action. Journal of Traditional and Complementary Medicine. 2018 Apr 30.

Nevuelus, S. Modern Cupping Therapy for Sports and Athletic Performance. Asian Integrative Medicine Learning. 2018