ASTERS & GOLD

Cupping Therapy

 

I aim to provide detailed information about cupping therapy, including: who can benefit, potential contraindications, the traditional/biomedical mechanisms of action, and historical context. This will hopefully inform and excite people looking for affordable bodywork.

Cupping Practices in Different Cultures Throughout Time

 

Its exact origins are unknown, but various cultures around the world have uncovered and utilized the principles of cupping. Cupping has been documented in early Egypt (~1300 BC), China (~200 Ad) as well as Greece, southeast asia, Africa, and the Arab world. The oldest documentation is attributed to an Egyptian ‘Ebers papyrus’. Greek, Chinese and Arab medical traditions all extensively utilize(d) cupping.

 

Egypt

 

The Ebers papyrus retains a special recognition in the history of conventional western medicine. It is seen as representing a transition to a scientific mindset rather than a ‘superstitious’ mindset about the nature of disease.

 

Edwin Smith, an American who fled to Luxor, Egypt around ~1850, became a well known collector and forger of ancient Egyptian artifacts. He sold the paper to Georg Ebers in the winter of 1872. Standard medical history considers the ebers papyrus as genuine and an essential marking point in the development of systematic medical science.

 

You can find an online translation of the papyrus at (https://papyrusebers.de/en/) , however out of the hundreds of wellness websites and scholarly articles written about cupping, I could not find a single one that actually cites the Ebers papyrus directly, and I have been unable to find the exact quotation in the available translations.

 

Greece

 

Greek medicine, as well as other sciences and philosophy, were presumably built with significant Egyptian foundations. They used cups for a variety of situations including: uterine prolapse, menstruation control, ear aches, infections of the legs, bilious people, arthritis, swelling, infection from bad water, sciatica, swollen uvula (tonsillitis), erysipelas of the lungs (a type of infection), as well as eye diseases.

 

In the case of sciatica, famous Greek physician Hippocrates recommended patients drink warming fluids in order to prepare the body for a cupping treatment. From their prospective, sciatica could occur when fluids in the body were blocked and had “nowhere else to go” thus following the path of least resistance which would be the joints (Christopoulou-Aletra et al). The hippocratic texts make an interesting comparison of cups to other structures found in the body that need to retain substances, such as the skull, bladder and womb.

 

“Again, cupping instruments, which are broad and tapering, are so constructed on purpose to draw and attract blood from the flesh. There are many other instruments of a similar nature. Of the parts within the human frame, the bladder, the head, and the womb are of this structure.” (Hippocrates. Ancient medicine. Vol. 1.)

 

The famous Roman physician Galen was a big proponent of cupping and discussed it extensively. The practice could be found throughout Europe until the end of the 19th century.

 

Cupping remains popular in Greek folk culture. Bruce Bently, a practitioner of Chinese medicine did informal field research in 1998, to learn about how Greeks use cupping today. He recounts several interviews and experiences with people very enthusiastic about the subject. One person he came across was Dr. Manazas, who trained and graduated at the university of Athens from 1952-59, from him ( with confirmation from others he met) Bently learned that they use cupping primarily to treat respiratory illnesses, colds, chills and fever. This contrasts with how cupping was used in the Hippocratic era as noted above.

 

Dr. Manazas strongly maintained that the patient must stay warm and at home for at least 12 hours after treatment. Cupping opens up the pores of the body, leaving them vulnerable to climatic cold. Much like the Chinese, the people of Greece identify the climate as a source of illnesses. Every household generally had someone who could perform cupping, so while he does not use cupping in his practice he often recommends people to go home for treatment.

 

Arab and Islamic Cupping Practices

 

Cupping in the islamic world often went under the name hijama. Hijama deserves special consideration because of its unique position in the Koran. It is said to be the only medical treatment mentioned by the Prophet Mohhammad. Author and hijama practitioner M.I Mugal (1) cites several quotes from the Koran about cupping including:
 

Narrated Abu-hurayrah: “The Prophet (May peace_be_upon_him) said: The best medical treatment you apply is “Cupping”. (Book #28, Hadith #3848)

 

To Mughals knowledge there are no other medical treatments mentioned in the Koran. I believe studying the islamic beliefs around hijama therapy is quite valuable for any practitioner that uses cupping. Hijama is used as a primary treatment for ailments and general wellbeing, as well as the faith practice of islam.

 

Mugal also describes two broad treatment categories “hijama in strength” which refers to treatments when someone is in relatively good health, and is looking for a general boost in wellbeing. This treatment uses standard location that will be used more or less the same on everyone. The other category referred to as “special hijama”, which involves treating specific ailments, here the “prophetic points” would be used, perhaps in conjunction with the standard hijama points, in order to treat the ailment. Mugal describes Hijama as:

 

“Faith based and Sunnah Therapy; it is practiced at specific timings and cupping is carried out following skin incisions on selected points of the body. Whereas Dry-Cupping can be carried out at any time, and on any safely selected points of the body that can either be, specific i.e correspond to hijama points OR Nonspecific i.e. those that do not correspond to hijama points such as; those in accordance to Traditional Chinese medicine- (T.C.M) i.e. T.C.M Meridian Points.”

 

An intense concentration of energy is put into the practice and observation of hijama, rather than many other cultures where cupping can be seen as an ‘adjunctive’ treatment such as TEAM and modern western bodywork. This also leads to a clearer understanding about potential adverse effects.

 

An important shared understanding between Traditional East Asian Medicine and islamic hijama includes a contraindication in patients with general deficiency. This would be most commonly felt at the pulse or abdomen, meaning a weak or deep radial pulse, or strong palpitations and laxity at the abdomen.

 

Arabic letters for hijama

 

حجامة

 

Chinese Characters and pinyin for cupping

拔罐療法 bá guàn liáo fǎ

 

Ancient Greek word for cupping (according to Dr. Manazan)

Sikia

 

The more common Greek word used today

vendouses

 

Cupping in Chinese Medicine

 

Cupping is perhaps most widely identified with Chinese Medicine. Cups are used in a variety of clinical situations, including but not limited to digestive, gynecological, emotional, respiratory, musculoskeletal, and nervous system complaints. Even without specific issues, cupping can help the body feel more relaxed, nourished and move smoother.

 

Before I can explain how Chinese Medicine understands the therapeutic mechanisms of cupping, we need to explore some of the foundational teachings. Personally, the TCM perspective guides my intellectual approaches to inform the healing work.

 

A note on terminology, I will use ‘Chinese Medicine’ and ‘Traditional East Asian Medicine’ fairly interchangeably. There is a wide variety of practices in Asia; putting the Chinese at an elite position neglects the independent and unique perspectives that exist throughout east asia. The histories of these places are largely a mystery. The more we learn from archaeology, the more we are realizing that the reality of human history may be very different than taught in academics. Knowing the true origin of concepts is difficult to summarize.

 

Returning to medicine, when we talk about ‘organs’ (zang-fu) in Chinese medicine we are generally including the anatomically defined organ, as well as a larger set of processes or transformations the organ performs in close relation to one another. Additionally each organ directly associates with meridians that flow throughout the body and take an active role in physiology. Acupuncture points are specific (with variation person to person) locations where the meridian opens to the surface of the body. Thousands of years of treatments, observation and contemplation have led to knowledge about the significance and influence of the points.

 

The philosophy of Yin in Yang also plays a major role in China, and serves as a primary conceptual framework for understanding the transformations of the body as it exists within nature. Observations of each organ's nature and relationships within the body led to classifications of them as yin or yang. This is a painfully brief primer, but hopefully will alleviate confusion when I use terms such as organ or meridian.The dynamics of the meridian networks also deserve much more focused attention than I will be able to give in this essay, but is especially relevant to cupping therapy.

 

Two other foundational concepts include the inseparable Qi and Blood. Blood includes what western medicine calls blood, but is also a broader concept. It is a yin substance, it nourishes, has a fluid nature, but is also inseparable from Qi which is more Yang. Qi, while less physical than blood, provides the vital force that keeps blood in movement. Giovanni Machoccai, the late TCM scholar and practitioner, describes the relationship between Qi and Blood “Qi is the commander of Blood; when Qi moves, Blood moves. Blood is the mother of Qi; where Blood goes, Qi goes”.

 

Without the smooth flow and proper supply of qi, yin substances such as blood can become imbalanced, stagnant and vulnerable to pathogenic environmental Qi. Qi ultimately provides the force for the movement of blood and fluids, but they move together, Qi does not separate blood, so it follows it as well as directs it.

 

The Spleens functions and description differ significantly with western medicine (The Chinese concept includes the pancreas). It also enables the generation of blood by raising the pure essence from food (Gu Qi) to the chest. There it combines with lung Qi, and Source Qi (yuan Qi) and it's fully formed by the heart. This nexus at the chest generates all the Qis of the body, including the Qi that flows through the meridians.

 

Organs such as the pericardium, liver, spleen, heart play specific roles in the production, maitaniess and organizing of blood. For instance, the spleen is said to “hold the blood” while the liver stores and dredges the blood. The ancient Chinese authors also made constant comparisons to positions of government to describe the role of each organ. The heart is the emperor, the liver the general, lungs the prime minister and so on.

 

So how does cupping affect Qi and Blood? The vacuum held within the cups provides the energy to pull blood and fluids. Blood and Qi are inseparable so Qi comes with the blood. This also moves stagnant Qi/Blood while simultaneously encouraging the new flow into the area. Prolific author and TCM practitioner Ilkay Zihni Chirali describes his understanding of how cupping works in his book Traditional Chinese Medicine Cupping Therapy:

 

 The negative power inside the cup forces almost every molecule, cell, and tissue into a movement, i.e. towards the source of the power, which is the suction cup on top of the skin. When the pressure is released from the cup at the end of a treatment, the skin and each physical parts and particles directly under the cup returns to their original state. As a direct result of this forced activity, Qi (life force / energy) is created. With this newly found Qi, Heat is also generated. Heat in turn accelerates the metabolic rate, hence triggering the chain of activity and communication between the cells, tissues, channels and finally the organs!

 

It helps to draw out and eliminate pathogenic factors such as Wind, Cold, Damp and Heat. Cupping also moves Qi and Blood and opens the pores of the skin, thus precipitating the removal of pathogens through the skin itself. In my opinion, nothing moves Qi and Blood faster than cupping.

 

…cupping is particularly effective when the external pathogen still resides in the superficial energetic area of the body, the defensive / protective level (Wei Qi). Whatever the vessel used, the objective of the treatment remains the same: to remove the external pathogens from the deeper layers of the body and restore the circulation of Qi, Blood and the Body Fluids

 

Restoring circulation of Qi Blood and fluids, while simultaneously removing any external pathogenic Qi summarizes the Chinese Medicine perspective on cupping. Sections below review the biomedical research around how cupping affects the body.

 

Cupping moves Qi and Blood extremely well. This ability serves as their primary therapeutic action, treating stagnant Qi and Blood. A famous Chinese saying goes:

 

Where there is pain, there is no movement, and where there is movement there is no pain.

-Bu Tong Ze Tong, Tong Ze Bu Tong

 

Contraindications

 

While generally safe for most people and ages, there are various situations where cupping is not an appropriate treatment. Oftentimes the practitioner modulates the strength of the cupping and length of treatment when a patient is more vulnerable.

 

Acupuncture and Cupping

 

While the same medical principles guide how acupuncturists use cups and needles, the natures of the tools differ. In my opinion, the two approaches highlight an example of the interplay between yin and yang. A needle symbolizes the yang force through its rigidity, forward moving, and piercing nature. Needles, by their nature, require greater precision to maximize efficacy; cups target a much broader area of tissue and perform a broader immediate physical action. 

 

Vessels historically represent femininity and cups offer an energy that holds, draws inward, and works on a wider area, directly affecting the fluids of the body. In The Tao De Ching, the first two lines of chapter four read: 

“The Tao is like an empty bowl,
Which in being used can never be filled up.”

 

The third and fourth lines of chapter one contextualize the Tao as feminine:
 

“As the origin of heaven-and-earth it is nameless:
As “the mother” of all things it is nameable.”

In western mystical traditions, for example in the tarot, cups are also seen as symbols of the water element and divine feminine. More colloquially, vessels of all sorts such as ships, homes, and even countries are often referred to with feminine pronouns.

However, rather than separating, the beauty of taking a yin-yang perspective exists in recognizing that yin and yang live within each other. Cupping shows yang characteristics by leaving visible, dramatic marks as well as a much more intense physical experience to receive. Meanwhile the effect of needling is less visibly obvious and the experience to receive much less intense. Also, cups are usually kept on for only 5-15 mins, while needles are commonly retained for at least a half hour.

 

 

Fascia

 

As one of the hotter topics in “alternative” medicine, fascia encompasses a wide variety of connective tissues. Fascia more or less interpenetrates the entire body, from our bones, to our muscles, skin, organs, vascular and nervous system.

 

Exact definitions of fascia and its function remain somewhat controversial, yet anatomical research over the last few decades has dramatically changed our understanding of this type of connective tissue. Previously fascia was described as ‘packaging material’ around the muscles, organs, ect, and seen as serving little other purpose. However, today we know that fascia plays an extensive role in the entire body, from gross musculoskeletal movement, to neural, vascular and organ structure . Here and excerpt from Bordoni B et al. describes the extent of the system

 

Researchers do not agree on one comprehensive "fascia" definition. Despite the scientific uncertainty, there is an agreement with medical text that the fascia covers every structure of the body, creating a structural continuity that gives form and function to every tissue and organ. The fascial tissue has a ubiquitous distribution in the body system; it is able to wrap, interpenetrate, support, and form the bloodstream, bone tissue, meningeal tissue, organs, and skeletal muscles. The fascia creates different interdependent layers with several depths, from the skin to the periosteum, forming a three-dimensional mechano-metabolic structure

 

The all encompassing and integrative nature of this tissue complex provides an almost spiritual catalyst to practitioners of western “alternative” medicine. In the west, or at least the United States, the focus on the facial system for therapy originates from the founder of osteopathy Andrew Still, with elucidation from Ida Rolf who founded a popular approach to bodywork called “rolfing”. Thomas Myers, former teacher at the Ida Rolf institute, popularized an idea called myofascial meridians, which he describes as chains of 12 fascial chains organized in the body akin to the meridians of Asian medicine. The exact anatomical existence of these specific myofascial meridians is disputed, but at least some of them have strong evidence. A 2018 systemic review found “strong evidence” for 3 of the lines, and moderate-strong evidence for 2 more (Wilke, J et al.). Due to the difficulty of dissecting this tissue, anatomical variability, inadequate understanding of the communication methods within the fascial web, an exact mapping of fascia in the traditional anatomical sense remains elusive (to the best of my knowledge). However besides these uncertainties, some relationship to the meridian system described in TEAM appears evident.

 

However, other authors have pointed out that the main meridian system is not the best comparison for the myofascial system. Rather, they point out that another system called the ‘sinew channels’ are better suited. They follow the same path as their meridian channels i.e. the bladder sinew channel strongly resembles the bladder channel, however unlike the meridian channels, they are not considered to have a direct effect on their respective zang-fu (organ). Additionally they are depicted as wide bands, with various areas of convergence, called ‘binding points’.

 

A striking similarity exists between the ‘superficial back line’ and the bladder sinew channel. The utmost importance in both western and eastern therapies is placed on the back, so it may be helpful to actually see the similarities here.

hile less apparent in these images, the superficial backline ends around the same area as the bladder sinew channel, past the front of the forehead. The bladder sinew encircles the eyes, and the first point of the bladder meridian channel is right at the inner canthus of the eye. The fact that each stretches from the foot to the front of the forehead, following an extremely similar path (with some subtle variations), is quite remarkable to me.

 

While several interpretations exist, several authoritative sources describe the sinew channels as physical lines of musculotendinous tissue rather than nonphysical channels (Legge, David 2011). Legge also makes a brief argument that the Mang Wa Dui, a text predating the first mention of the sinew meridian system (in the Huang Di Nei Jing), describes channels starting from the hands and feet moving towards the trunk, without any mention of connection to the internal organs. This early system is believed to be the predecessor to the meridian system. Meaning that the sinew channel system may actually predate the meridians, and the modern emphasis on the myofascial system connects to this deeper heritage.

 

In practice of course this differentiation is less meaningful because the meridian and the sinew channel overlap. However, drawing a comparison of the myofascial system to the sinew channels rather than the meridians themselves appears more appropriate. The sinew channels and the myofascial system represent a promising interface for TEAM and biomedical practitioners.

 

The next section details western biomedical studies/theories regarding the physiological mechanisms and of cupping.

 

 

Biomedical Perspective

Therapists use cupping for a variety of conditions and situations. Cupping for athletes is a popular recent trend, and it is common to see top athletes sporting cupping marks these days.  One of the most common reasons to use cups remains treating general and chronic back/shoulder pain. While pain is one of the main indications for cupping, it is certainly used to treat other areas such as immunity, gynecology, and digestion.

 

Blood Analysis

A large segment of the clinical research around cupping involves the comparison of blood samples before, during and after cupping treatment. Different studies target different biological metrics, ranging from chemical composition to mechanical properties of the blood. Information from the blood gives insight to various functional aspects of the body such as immunity, vascular flow, and digestion.

In an excellent paper on sinew channel theory, published by Pablo Nava Jaimes et al, they describe the detoxifying effects of cupping by citing studies which have analyzed blood samples of wet cupping vs non-cupped venous blood:
 

In comparison to the traditional idea that cupping is able to expel pathogens and detoxify the body [30], there is some evidence in favor of it. When analyzing wet cupping blood samples, much higher concentrations of metabolites, such as uric acid and triglycerides, have been identified compared to venous blood samples [45,46].

Metabolites are the products left over from metabolism in the body. These are generally excreted somewhere like the kidneys, but high levels in the blood can occur and generally indicate pathologies.  For example, high levels of uric acid can lead to gout, and high triglycerides can indicate type two diabetes.

Another study found that wet cupping decreased overall cholesterol levels. However the majority of the reduction was found in LDL cholesterol and there was a slight increase in HDL. LDL cholesterol is considered a main culprit in cardiovascular disease and HDL is colloquially considered “good” cholesterol because it helps transport fat buildup in the arteries back to the liver (Niasari M, 2007).
 

Li et al used near infrared spectroscopy to analyze the effect of dry cupping on the oxygenation of hemoglobin (blood) at the infraspinatus muscle (shoulder blade). They found a rise in oxygenated blood and a decrease in deoxygenated blood during and post cupping (Li 2016).

 

Microcirculation

One study measured the circulation at the tips of the fingers after cupping treatment on the forearm. They utilized a digital thermal monitoring unit which measures the temperature at the fingertip before and after 5 mins of occlusion above the elbow. Occluding the arms drops the temperature at the fingers due to lack of blood flow, and after the occlusion is released temperature returns to the finger. The rate of temperature return is considered to give a reliable measure of what's called “Vascular Reactivity Index”, which is viewed as a significant predictor of cardiovascular disease (Naghavi M et al). 

 

The study only included 11 college age people, but they found an average 36% increase in the Vascular Reactivity Index, after a 10 min dry cupping treatment on the forearm and 20 min rest period. Temperature, so blood flow, returned faster to the fingertips after the cupping treatment. Blood flow at the hands depends on blood flow throughout the arms, so it makes sense how cups could have this non local effect (Arturo A, 2017).

The Chinese produce much research about cupping in an integrative medical context. However, the scientists in China still highlight several limitations in the published research, including lack of double blinded placebo controlled studies, lack of understanding of the therapeutic mechanisms of cupping, negative results remain unpublished, adverse events due to risky cup placement, or complications from wet cupping. One Chinese meta-review authored by Hui-juan Cao and Jian-ping Liu, analyzed 725 studies between 1958-2011.
 

Although the number of RCTs on treatment using cupping therapy is small in terms of any specific disease, and existing trials are of small size and low methodological quality, meta-analysis of a combination of cupping therapy with other treatments (such as acupuncture or medications) has nevertheless demonstrated significant benefit compared with other treatments alone in curing patients with herpes zoster, acne, facial paralysis, cervical spondylosis and prolapse of lumbar intervertebral disc. However, we evaluated almost all the included trials as having a high risk of bias, so consider it to be worthwhile (and, indeed, necessary) to conduct further high-quality RCTs of larger sample size in order to assess fully the effectiveness of cupping therapy for those common conditions that most benefited from cupping therapy according to this review’s findings. ("A Systematic Literature Review of Clinical Evidence-Based Research" by Hui-juan Cao, Jian-ping Liu. Found in Chirali "Traditional chinese medicine: Cupping therapy")

They highlight that combination with other modalities appeared to confer better results than any treatment by itself. The researchers mixed cupping with acupuncture, moxibustion, or herbal medicine (Chirali, I. Z, 2014). I believe there is much unexplored territory, especially in the west, with mixing cupping and these other modalities.
 

 

Cited

Mughal. , M.I. A Complete Manual of "The Arabic Cupping Points" and Practical Guide to Hijama Therapy-(A Compiled Manual For Students; Professionals & Practitioners of Hijama/Cupping Therapy). (p. 6). Nabawi Academy of Hijama Therapy-(N.A.H.T).. Kindle Edition.

 

Greek cupping folk

(2)https://healthtraditions.com.au/essays/explorations-of-cupping-in-greece/#:~:text=I%20believe%20it%20has%20to,instead%20of%20the%20Latin%20based

 

 

Colin Halverson, Ph.D., and Jane Hartsock, J.D., M.A. John Shaw Billings Lecture (March 1, 2023) https://media.dlib.indiana.edu/media_objects/5d86pn87w

 

https://sae.saw-leipzig.de/en/documents/papyrus-ebers

 

https://papyrusebers.de/en/

 

Christopoulou-Aletra, H., & Papavramidou, N. (2008). Cupping: An alternative surgical procedure used by Hippocratic Physicians. The Journal of Alternative and Complementary Medicine, 14(8), 899–902. https://doi.org/10.1089/acm.2008.0238

 

Hippocrates. Ancient medicine. Vol. 1. Cambridge Mass., Harvard University press, 1995;59, 179-81
 

Wilke, J., Schleip, R., Yucesoy, C. A., & Banzer, W. (2018). Not merely a protective packing organ? A review of fascia and its force transmission capacity. Journal of Applied Physiology, 124(1), 234–244. https://doi.org/10.1152/japplphysiol.00565.2017

 

Bordoni B, Mahabadi N, Varacallo M. Anatomy, Fascia. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493232/

 

Legge, David. "The jingjin--a 21st century reappraisal." The Journal of Chinese Medicine, no. 95, Feb. 2011, pp. 5+. Gale Academic OneFile, link.gale.com/apps/doc/A303010882/AONE?u=vol_oweb&sid=googleScholar&xid=beb5ef2a. Accessed 30 Dec. 2023.

 

Deadmen et al ,“A Manual of Acupuncture” published 1998.

 

Anatomy Trains by Thomas Meyers

 

https://healthtraditions.com.au/essays/explorations-of-cupping-in-greece/#:~:text=I%20believe%20it%20has%20to,instead%20of%20the%20Latin%20based

 

Effect of Dry Cupping on Vascular Function among Young Individuals Arturo A. Arce-Esquivel , Brandon J. Warner , Diana M. Gallegos & S. Andrew Cage
2017 http://ijhsnet.com/journals/ijhs/Vol_5_No_3_September_2017/2.pdf

Naghavi M, Yen AA, Lin AW, Tanaka H, Kleis S. New Indices of Endothelial Function Measured by Digital Thermal Monitoring of Vascular Reactivity: Data from 6084 Patients Registry. Int J Vasc Med. 2016;2016:1348028. doi: 10.1155/2016/1348028. Epub 2016 Oct 18. PMID: 27830091; PMCID: PMC5088311.

Li T, Li Y, Lin Y, Li K. Significant and sustaining elevation of blood oxygen induced by Chinese cupping therapy as assessed by near-infrared spectroscopy. Biomed Opt Exp 2016;8:223-229.

Niasari M, Kosari F, Ahmadi A. The effect of wet cupping on serum lipid concentrations of clinically healthy young men: a randomized controlled trial. J Altern Complement Med 2007;13:79-82

https://www.journal-jams.org/journal/view.html?uid=1094&vmd=Full (chinese lit review)

Iranian study https://ppj.phypha.ir/article-1-500-en.pdf


Chirali, I. Z., Bentley, B., & McIntyre, M. (2014). Traditional chinese medicine: Cupping therapy. Church Livingstone/Elsevier.