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Cupping therapy: An analysis of the effects of suction on skin and the possible influence on human health

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Abstract

Background: Cupping therapy is a traditional therapy that has been employed worldwide for thousands of years. Despite a lack of quality clinical studies evaluating the efficacy of cupping therapy, its long history and widespread use throughout the world suggests the commonly claimed health benefits should not be completely discounted as without merit. Purpose: The goal of this paper is to present the research detailing what is known concerning the effects of suction on skin and underlying tissue, and the reaction of the body to that stimulus. Understanding the literature on the physiological effects of this mechanical force may help elaborate an explanation for the advertised local and systemic effects of cupping therapy. Findings: Negative pressure causes stretching of the skin and underlying tissue and dilation of the capillaries. This stimulates an increase in tissue blood flow, eventually leading to capillary rupture and ecchymosis. Macrophages phagocytize the erythrocytes in the extravascular space which stimulates the production of Heme Oxygenase-1 (HO-1) to metabolize the heme. Heme catalysis results in the production of carbon monoxide (CO), biliverdin(BV)/bilirubin(BR) and iron. HO-1, BV, BR, and CO has been shown to have antioxidant, anti-inflammatory, antiproliferative, and neuromodulatory effects in animal and human systems. These substances also stimulate a shift of macrophages to the anti-inflammatory M2 phenotype. There is evidence that the effects are both local and systemic. Conclusion: Besides the mechanical effect of cupping increasing the local blood flow and stretching underlying tissue, activation of the HO-1 system could account for many of cupping therapy's claimed local and systemic health benefits.
UNCORRECTED PROOF
Complementary Therapies in Clinical Practice xxx (2017) xxx-xxx
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice
journal homepage: www.elsevier.com
Cupping therapy: An analysis of the effects of suction on skin and the possible
influence on human health
Duane T. Lowe
Interdisciplinary Pain Management Clinic, Department of Pain Management, Madigan Army Medical Center, Joint Base Lewis-McChord, 9040 Jackson Avenue, Tacoma, WA
98431, USA
ARTICLE INFO
Article history:
Received 5 September 2017
Accepted 12 September 2017
Available online xxx
Keywords:
Cupping therapy
Negative pressure
Heme oxygenase-1
Ecchymosis
Bilirubin
Carbon monoxide
ABSTRACT
Background
Cupping therapy is a traditional therapy that has been employed worldwide for thousands of years. Despite
a lack of quality clinical studies evaluating the efficacy of cupping therapy, its long history and widespread
use throughout the world suggests the commonly claimed health benefits should not be completely discounted
as without merit.
Purpose
The goal of this paper is to present the research detailing what is known concerning the effects of suction
on skin and underlying tissue, and the reaction of the body to that stimulus. Understanding the literature on
the physiological effects of this mechanical force may help elaborate an explanation for the advertised local
and systemic effects of cupping therapy.
Findings
Negative pressure causes stretching of the skin and underlying tissue and dilation of the capillaries.
This stimulates an increase in tissue blood flow, eventually leading to capillary rupture and ecchymosis.
Macrophages phagocytize the erythrocytes in the extravascular space which stimulates the production of
Heme Oxygenase-1 (HO-1) to metabolize the heme. Heme catalysis results in the production of carbon
monoxide (CO), biliverdin(BV)/bilirubin(BR) and iron. HO-1, BV, BR, and CO has been shown to have an-
tioxidant, anti-inflammatory, antiproliferative, and neuromodulatory effects in animal and human systems.
These substances also stimulate a shift of macrophages to the anti-inflammatory M2 phenotype. There is evi-
dence that the effects are both local and systemic.
Conclusion
Besides the mechanical effect of cupping increasing the local blood flow and stretching underlying tis-
sue, activation of the HO-1 system could account for many of cupping therapy's claimed local and systemic
health benefits.
© 2017.
1. Introduction
At the 2016 Summer Olympics, U.S. Athletes in swimming, gym-
nastics and track and field sports competed with multiple circular
marks on their backs and shoulders. These marks were produced by
a therapy known as “Cupping”. In interviews, these athletes claimed
that this therapy provided effective relief from the muscle and joint
soreness that is associated with their respective sports and speedier re-
covery from injuries. This has led to increased awareness and curios-
ity about of this therapy. It has also provoked questions concerning the
authenticity of this therapy and the claims that are made concerning
the benefits.
Corresponding author.
Email address: duane.t.lowe.civ@mail.mil (D.T. Lowe)
2. Cupping therapy
Cupping therapy is an ancient traditional therapy that has been
used throughout the world for thousands of years [1]. The oldest men-
tion of this treatment is in an ancient Egyptian papyrus. It is a tech-
nique found in many traditional Asian medicinal systems [2]. It was
promoted by ancient physicians, such as Hippocrates, for a variety of
conditions [3]. Various forms of cupping were used in western med-
icine until the early 1900's. In the early twentieth century, August
Bier, who developed procedures that are still used in anesthesiology
today, was a proponent of cupping in his “Passive Hyperemia Ther-
apy.” [4–6].
Cupping therapy, employed by various folk medicine providers, is
a traditional treatment that may be dismissed as ineffective or even
harmful because of some of the visually unpleasant marks this ther-
apy leaves on patients and the unconventional explanations presented
for this therapy's mechanism of action [7]. Skepticism of cupping
therapy, as well as the proposed mechanisms, can be found as far
back as 1835 when Charles Alexandre Louis wrote, “and how then
https://doi.org/10.1016/j.ctcp.2017.09.008
1744-3881/© 2017.
UNCORRECTED PROOF
2 Complementary Therapies in Clinical Practice xxx (2017) xxx-xxx
can we believe that the effect of a blister is to check an inflamma-
tion, when this blister is one inflammation superadded to another?” [8]
With the advent of antibiotics and other modern therapies, cupping fell
out of fashion with western medicine, but has continued to be popular
by traditional practitioners throughout the world.
3. Techniques
There are several methods of traditional cupping [9]. Wet cupping
involves piercing the skin with needles or small blades before apply-
ing the cups. Because it involves piercing the skin and removal of
body fluids, the physiological response to wet cupping would be ex-
pected to be different than its “dry” counterpart, and is not evaluated in
this paper. Moving cupping is a technique in which a lubricant is used
and after the cups are applied, they are slid along the skin [10]. This
does not normally lead to the hallmark ecchymosis of the underlying
skin that is the goal in stationary cupping. Dry Cupping involves the
application of a hollow container on the skin with suction. The suc-
tion is traditionally created by placing a flame within the cup for a few
seconds to heat the air, then removing the flame, and quickly applying
the opening of the cup to the skin. Skin is drawn up into the container
due to the negative pressure that is created as the air cools. Glass cups
are used for the technique where fire is employed to create the suction,
though other materials have been used by traditional cultures such as
brass, bamboo, and animal horn [2]. Today the suction can be applied
with hand pumps and electric pumps or even with soft silicon cups the
suction can be applied by hand [2,11].
4. Traditional indications
Though dry cupping in modern times is most often used for con-
ditions involving pain, such as back pain or arthritis, it has been tra-
ditionally recommended for systemic inflammatory conditions and to
address organs of the body far removed from the area of applica-
tion [1,12,13]. In ancient writings there was almost no condition for
which cupping was not considered appropriate treatment [14]. Sandler
and Haynes point out that the 1923 edition of Abt's Pediatrics lists
indications for dry cupping in its chapter on Therapeutic Technique
as “acute congestion of pneumonias, bronchitis, or pulmonary edema
with marked dyspnea and cyanosis… mastoid disease and nephritis.”
[15,16].
5. Traditional explanations
The traditional explanations given of how cupping benefits a pa-
tient's health vary significantly. Anciently, the concept of removing
“evil spirits” was a common theme. From Hippocrates time and even
until the late 1800's, the redistribution and balance of the four cardinal
“humors” was the explanation being promoted by western physicians
[14]. In the early 20th century, it was proposed that cupping stimulated
the production of antitoxins within the tissue [17]. Traditional Asian
medicine describes the benefits of cupping via the movement of “Qi”
(pronounced “chee”) energy between 12 basic meridians throughout
the body [2]. Even with such vague explanations of how it works, the
significant worldwide use by multiple cultures for over 3 thousand
years would suggest that this therapy may elicit a beneficial effect on
human physiology. There has been some clinical research on the ben-
efits of cupping for various health conditions [9,12]. While there is
some evidence for efficacy, higher quality studies still need to be done
to objectively evaluate clinical benefit.
6. Superficial suction in healthcare
Doctors in the 19th century used suction to produce hyperemia to
improve healing [6]. Suction has also been used as a mechanism for
studying capillary fragility in patients [6,18–20]. Negative pressure is
still commonly used in modern medicine for more effective wound
care and healing [21]. Each medical use of suction is based on the spe-
cific physiologic response to the negative pressure.
The concept of dry cupping is simple; locally applied negative
pressure is applied over an area of skin. It is retained from 5 to 10 min,
or more, eliciting an area of petechiae, purpura or ecchymosis [22].
The ecchymosis resolves the same way a bruise would over approxi-
mately 7–14 days, with the colors slowly changing over time. There
has been research showing the physiological sequelae of negative
pressure on skin and the body's reaction to blood external to its vas-
cular containment in living tissues. Based on this research, it might be
possible to evaluate the physical and biochemical changes that would
be expected from dry cupping therapy.
7. The effects of localized negative pressure on skin
When the cup is applied, centrally localized negative pressure pro-
duces compression of the skin at the rim of the cup and distraction of
the skin and underlying tissue within the interior of the cup. The depth
of distraction of the skin, underlying fat and muscle is dependent on
the amount of negative pressure employed and the diameter of the cup
that is used [22]. The lowered pressure within the interior of the device
causes a pressure differential between the skin surface and underlying
blood vessels, eliciting an almost immediate visible vasodilation of the
superficial capillaries producing a localized hyperemia. In one study
there was a five-fold increase in vascular perfusion within the area of
vacuum. Wider diameter cups or greater suction was associated with
increasing perfusion [23]. Increased blood flow in the patients muscles
may be one of the mechanism cupping affects localized pain symp-
toms [24].
Over time the increased vascular pressure in the vessels can cause
rupture of capillaries with resultant petechiae, purpura or ecchymosis
developing within the area of the cup. Cutter in 1935 hypothesized
that some of the differences in appearance of the marks in individual
patients may be due to variations in capillary rupture versus capillary
leakage by diapedesis, but there is no follow up research to determine
if this was ever verified [19].
The result of the prolonged suction is extravascular blood within
the subcutaneous tissue which is similar to a bruise, but without the ac-
companying non-vascular tissue damage due to trauma [25]. In 1924
Valmyre claimed that the depth of the ecchymosis from cupping was
from 1 to 4 cm [26]. In his follow up letter in the British Medical Jour-
nal he states that this had been determined by autopsies on patients
who had cupping performed prior to their death [27].
As mentioned previously, like bruises, the resultant ecchymosis
from cupping therapy resolves slowly over many days. Insight into the
physiological cascade that is stimulated by the presence of superficial
extravascular blood in bruises may illuminate possible influences of
cupping therapy.
8. The healing bruise
The human body removes hemoglobin from the tissue by
macrophages and the production of the inducible enzyme heme oxy-
genase-1 (HO-1) which was identified in the 1960's [28]. This en-
zyme catalyzes the hemoglobin heme into biliverdin(BV), carbon
UNCORRECTED PROOF
Complementary Therapies in Clinical Practice xxx (2017) xxx-xxx 3
monoxide (CO) and iron. The BV is further reduced to bilirubin (BR)
by biliverdin reductase.
The initial dark color of a bruise is caused by the release of ery-
throcytes into the extravascular tissue. Extravasation of blood into the
tissue elicits an inflammatory reaction [29]. Within 3–6 h, neutrophils
are the first reactant cells to arrive in the area, but neutrophils, for the
most part do not contain nor produce HO-1 [31]. Background expres-
sion of HO-1, and the weaker constitutive form heme oxygenase-2, is
found in only small amounts within the dermal and subdermal tissues
[30]. At approximately 6 h, there is an increase in HO-1 concentration
which is directly correlated to the arrival and increasing concentration
of macrophages.
The levels of HO-1 peaks in 1–3 days, then slowly starts to dimin-
ish. HO-1 levels are still increased above basal levels even 7 days af-
ter initiation of the bruise [30]. BV from heme gives a bruise a green-
ish color and the conversion of BV to BR is the source for the yellow
color in a bruise as it ages [31]. The free iron, which is highly reactive,
is controlled by being rapidly bound by ferritin which is found in most
tissues and increased in the presence of heme [32].
9. Heme Oxygenase-1 system
Activation of the HO-1enzyme system has been shown to have po-
tent antioxidant, anti-inflammatory, anti-apoptotic, antiproliferative,
and immunomodulatory effects throughout the body either directly or
via the biological activity of its products [33–35]. HO-1 is a stress
protein that responds to adverse environmental conditions and di-
rectly contributes toward preventing or limiting tissue damage. The in-
creased synthesis of HO-1 protein is stimulated by a broad number of
chemical and physical agents beyond heme, such as inflammation, re-
active oxygen and nitrogen species, cytotoxic chemicals, and hypoxia
[36].
HO-1 increases production of IL-10, an anti-inflammatory cy-
tokine that stimulates resolution of inflammation [37]. In an autocrine
fashion HO-1production is upregulated by increased levels of IL-10
[38–40]. While HO-1increases IL-10, it simultaneously down reg-
ulates the production of pro-inflammatory cytokines such as tumor
necrosis factor (TNF) alpha and interleukin-6 (IL-6) and inhibits the
effects IL-1b [41–43]. Antioxidant enzymes such as Catalase and Su-
peroxide Dismutase are significantly increased by the activity of HO-1
[44–46].
Besides the anti-inflammatory and antioxidant mechanisms, HO-1
increases tissue levels of vascular endothelial growth factor (VEGF)
and simultaneously stimulates mitochondrial biogenesis [47–49,53].
All of these effects would have significant benefit in wound healing.
Consistent with this, increased HO-1 activity has been found to be a
necessary factor in the healing of wounds. Stimulating this enzyme
accelerates healing, while inhibiting the enzyme delays the process
[50–53]. In 1978 Myer found that pre-treatment of a wound site with
autogenous injections of blood elicited significantly stronger wound
tensile strength [54]. He hypothesized that this was due to the stim-
ulation of inflammation by the blood. However, they found that the
optimum timing between injection and wounding to maximize the ef-
fect was 2 days. This would closely approximate the time when HO-1
was at maximum concentration and activity, suggesting that the HO-1
system was a more likely candidate improving the healing. Evidence
of a systemic effect of HO-1 system activation is shown by improved
wound healing in mice by intraperitoneal injection of hemin, the fer-
ric protoporphyrin-IX group from hemoglobin used to stimulate HO-1
production [55].
10. Products of HO-1: biliverdin/bilirubin
While toxic in higher concentrations, both BV and BR have been
ascribed potent antioxidant affects against both reactive oxygen and
nitrogen species [56,57]. Mildly elevated levels of bilirubin have been
shown to be associated with significant prevention of conditions such
as atherosclerosis, diabetes and cancer [58–62]. Besides the antioxi-
dant effect of BV/BR, elevated levels are also correlated with lower
levels of systemic inflammation as well [63,64]. In mice and rats
injections of BV or BR has significant anti-inflammatory effects
[65,66]. BR has also been found to be and effective stimulator of
wound healing in a model of diabetes [67].
11. Products of HO-1: carbon monoxide
Like its cousin, nitric oxide (NO), CO in the environment and at
higher concentrations it is considered a pollutant. CO has about 200
times the affinity for hemoglobin than oxygen. By strongly binding
hemoglobin, and forming carboxyhemoglobin, CO can lead to tissue
hypoxia and eventually death. While it is true that CO is toxic in
higher amounts, this product of HO-1 activity in small amounts has
been shown to have anti-inflammatory, anti-apoptotic, and antiprolif-
erative activity, as well as being a vasodilator and neuromodulator
which includes antinociception [36,68].
CO stimulates the production of cyclic guanosine monophosphate
(cGMP) that leads to the vasodilation of blood vessels, though the ef-
fect is slightly weaker than NO. CO inhibits inflammation by down
regulating inflammatory cytokines, such as IL-1b and tnf-alpha
[69,70]. CO inhibits depolarization of nociceptors, possibly via acti-
vation of ATP-sensitive K+channels, inhibiting pain [71].
The physiologic effects of CO depend significantly on the concen-
tration and the specific tissue involved [72]. The minute amounts gen-
erated by the normal physiology of the human body may not elicit
these biological functions in an appreciable amount, but with a larger
pool of substrate, such as in a bruise or produced by cupping, the
increase in CO concentration due to HO-1 activation may be high
enough to stimulate the physiologic effects, without toxic levels.
12. The local effect
The immediate direct effects of suction on the area would increase
local blood flow and lymphatic flow [24,73]. Local increase in blood
flow and lymphatic flow would be beneficial for local myofascial
pain [74]. Considering the effects of activating the HO/BR/CO sys-
tem, it could be presumed that the localized result of the ecchymo-
sis from cupping therapy would have an anti-inflammatory, antioxi-
dant and antinociceptive effect in the local tissue, resulting in an even-
tual decrease in any local inflammation, and an increase in angiogen-
esis and mitochondrial biogenesis as well as a decrease in local pain.
This could lead to shorter healing times for sprains, strains, or wounds
depending on the locale and timing of the cupping. This may be the
mechanism behind a diminished perception of pain, which has been
seen in clinical research of cupping therapy's effects on musculoskele-
tal pain [75,76].
An injection of autologous blood into areas of tendon pain is a ther-
apy for various tendinopathies, such as lateral epicondylitis, used in
sports medicine [77,78]. In a similar way, the localized effects of cup-
ping therapy could be considered a non-invasive perfusion of the tis-
sue with autologous blood.
UNCORRECTED PROOF
4 Complementary Therapies in Clinical Practice xxx (2017) xxx-xxx
13. The systemic effect
Cupping is claimed to have a systemic influence on the body, not
just a localized benefit. Evidence of systemic influence, far removed
from the local biochemical tissue reaction is described in a 1953 Ohio
University study by Hamdy et al. on the healing of bruises in animals
[79]. In their studies they found that the rate of the appearance of
bilirubin in a bruise and the time to heal of standardized bruises in dif-
ferent species of animals, such as cattle, hogs, sheep and rabbits, was
approximately the same regardless of the species studied. In their third
published article on bruised tissue they note that whenever a previ-
ously bruised animal later received a second bruise, the second bruise
would heal faster than the initial bruise. In testing this phenomenon
they inflicted standardized bruises on 120 rabbits. 3 days later they in-
flicted a second standardized bruise in 80 of the animals. 2 days after
this they elicited a third bruise in 40 of those rabbits that already had
2 bruises. They measured the time for the appearance of BR and the
time of visual disappearance of the bruise. The following was the re-
sult:
There was an earlier appearance of BR and a shorter healing time
in the second bruises, and even shorter times observed in the third
bruise. This suggests that whatever process was stimulated to initi-
ate the catabolism of hemoglobin in the first bruise elicits more effi-
cient resolution of the subsequent bruises. It also would suggest that
the larger the initial source of the “healing factor” (more bruises), the
larger the impact on subsequent bruises.
With these results in mind, they elected to evaluate whether this
“healing factor” could be passively transferred from one animal to an-
other. They bruised a group of rabbits. 5 days later they transfused
20 ml of blood with 3 ml of anticoagulant from the bruised rabbits into
5 other rabbits. They also had control rabbits (no treatment), some rab-
bits they transfused with 20 ml blood from non-bruised rabbits plus
3 ml of anticoagulant, and a few animals that they injected with 3 ml
of anticoagulant. 24 h after these infusions, they inflicted a standard-
ized bruise in all of the animals. Again, they measured the appearance
of bilirubin and the mean healing time. The synopsis of their results is
as follows:
This would suggest that a bruise stimulates not only a localized
chemical breakdown of hemoglobin in response to blood within the
tissue, but that these factors are increased within the general circula-
tion as well.
In animal models, injections of hemin are often used to stimu-
late HO-1 system activation. While intraperitoneal injection is a more
common method to stimulate systemic HO-1 production, subcuta-
neous injections of hemin have been used successfully to stimulate the
HO-1 system for inflammatory conditions within organs such as the
kidney and lungs [80–82]. An increase in systemic levels of BV/BR
or CO may stimulate some anti-inflammatory effects, but they would
not have been expected to increase the resolution of bruises since that
requires degradation of hemoglobin. This would suggest that there is
either a direct increase in concentration of circulating HO-1, or possi-
bly an increase in the circulation of the macrophages that have been
primed to increase production of HO-1.
14. HO-1 and macrophage phenotype
Macrophage activation can be broadly divided into two pheno-
types, M1 and M2, which can be further subclassified. M1
macrophages express high levels of pro-inflammatory cytokines, high
production of reactive oxygen and nitrogen species, have antimicro-
bial activity and reflect a Th1 helper T-cell response [83]. M2
macrophages produce substances that promote resolution of inflam-
mation and cell proliferation manifesting a Th2 response. HO-1 stim-
ulates the shift of macrophages to the M2 phenotypes [84–87]. This
includes subtypes of M2 macrophages that overexpress HO-1. For
example, a study in mice used intraperitoneal injections of hemin
to stimulate HO-1 induction. This stimulated increased levels of M2
macrophages that overexpress HO-1. These mice were fed a choline
deficient diet that induces pancreatitis. In the group injected with
hemin there were no deaths due to induced pancreatitis, whereas 7 of
16 of the control mice died [88].
Higher levels of M2 macrophages that already overexpress HO-1,
with production anti-inflammatory substances such as IL-10, which
also stimulates shift to M2 phenotype, may be part of the reason
that the “healing factor” was transferrable in Hamdy's experiments on
bruises. It may also be a significant reason why cupping therapy has a
systemic influence on conditions that are hallmarked by inflammation.
More recently a study was performed exposing mice to influenza
virus and injected with hemin to stimulate HO-1 production [89]. The
hemin elicited significantly less lung damage and 50% of the mice
survived verses none of the mice without the hemin injection. These
author's in vitro results also showed HO-1 inhibited viral replication,
though this was not seen in vivo. There have been other studies that
suggest HO-1 has antiviral activities against some important human
pathogens [90]. These studies would support the effects of stimulation
of the HO-1 system being beneficial in patients with illnesses, such as
flu and pneumonia, which is consistent with traditional indications for
the use of cupping therapy.
15. Similar therapies; stimulate same physiologic cascade; similar
results
Gua Sha is a traditional technique where lubricated skin is repeti-
tively rubbed with a smooth edged instrument which breaks superfi-
cial capillaries [91]. This causes large areas of petechiae and ecchy-
mosis. The result is the same as dry cupping; blood in the extravas-
cular space. This elicits the same stimulation of the HO-1 system as
cupping therapy as evidenced by the slow color change as the marks
resolve. A 2009 study by Kwong et al. at Harvard Medical School
showed that Gua Sha applied to the backs of transgenic mice elicited
a significant upregulation of HO-1, not just in the skin, but in organs
of the gastrointestinal tract, the genital tract, the liver, kidneys and
Mean Time for appearance of
bilirubin (hours)
MeanHealing Time
(Days)
First bruise 70 7.9
Second bruise 56 5.6
Third bruise 46 4.9
Number of Rab-
bits Source of Infusion
Mean Time for ap-
pearance of biliru-
bin (hours)
MeanHealing
Time (Days)
5 Bruised Rabbits 43 6.1
14 Control (none) 70 7.9
4 Non-Bruised Rab-
bits
72 7.8
3 Only Anticoagulant 71 8.0
UNCORRECTED PROOF
Complementary Therapies in Clinical Practice xxx (2017) xxx-xxx 5
others [92]. In this study levels of HO-1 peaked at 36 h, and were still
increased above the baseline even 120 h later. Like dry cupping, this
therapy has also been claimed to be effective for systemic inflamma-
tory conditions.
Autohemotherapy, is another unconventional medical therapy in
which venous blood is withdrawn and then injected into the tissues
of the same patient [93]. This would also elicit the reaction of
macrophages and the production of HO-1, BV/BR, and CO very sim-
ilar to the injection of hemin. While there are few studies on Autohe-
motherapy, there are a small number of published reports of success-
ful treatment of conditions such as Herpes Zoster and chronic urticaria
[94–96].
The application of each of these therapies is significantly differ-
ent, but the result is the same. Cupping therapy, Gua Sha and Auto-
hemotherapy all lead to endogenous extravascular blood, and would
stimulate the same physiologic reaction; attraction of macrophages
and the stimulation of the HO-1 system with resulting anti-inflam-
matory/antioxidant products and shift to M2 macrophages. It is not
surprising that the beneficial health effects claimed for Cupping, Gua
Sha, and Autohemotherapy are very similar.
16. Pharmacokinetic aspects of cupping therapy
While both heme and lysed erythrocytes both have been shown
to stimulate HO-1 production/activity, erythrocytes are metabolized
about 10 times slower than free hemoglobin [97]. This is consistent
with HO-1 activity peaking in 1–3 days and being sustained over a
week's time. Hemin, which has been used effectively to study the ben-
efits of HO-1 activation, has a short half-life of only a few hours. It
is possible that the extended activity of this enzyme system caused
by slower degradation of erythrocytes may be advantageous by pro-
longing the therapeutic effects of HO-1 over many days.
17. Summary
The following are well supported and accepted statements sup-
ported by the current literature:
1. Negative pressure on skin can elicit ecchymosis.
2. Ecchymosis attracts macrophages which phagocytize the erythro-
cytes and stimulates them to produce HO-1 to metabolize the heme
they contain.
3. HO-1 breaks down heme into BV/BR, CO and iron. The iron is se-
questered by ferritin
4. HO-1, BV/BR, CO, directly and indirectly have significant antioxi-
dant, anti-inflammatory, antiproliferative, and neuromodulatory ac-
tivities.
5. HO-1 system activation can have both local and systemic effects.
Scientists are researching ways to activate and modulate the HO-1
system to address conditions such as cardiovascular disease, kidney
disease, asthma, sepsis, lung injury and other inflammatory diseases
and conditions [98–101]. They are attempting to use both natural and
pharmacological substances to stimulate these endogenous anti-in-
flammatory, anti-oxidant and anti-proliferative substances to benefit
human health [102–106].
Cupping therapy activating the HO-1 enzyme system is visibly
demonstrated in cupping patients by the slow changing colors and res-
olution of the ecchymosis. It is reasonable to assume that the larger
the surface area involved, the more macrophages would be attracted to
the area and the larger the activation of the HO-1 system and higher
concentration of resultant CO/BV/BR as well as M2 macrophages.
There are many questions that still need to be an
swered. Would a larger involved surface area improve the effect of
the cupping? A set of eight 7 cm diameter cups would elicit 8 ecchy-
motic marks on a patient, with a total surface area of approximately
307 cm2. Would that have a different effect than 4 or 6 cupping marks
at 153 cm2or 230 cm2? Because of the delay of production of HO-1,
would cupping every other day for three treatments be more effective
for some illnesses than one treatment with more cups?
Cupping therapy has evidently been endogenously stimulating the
activity of the HO-1 system for thousands of years. So it is not a ques-
tion as to “if” HO-1 is upregulated, but is there enough activation of
the HO-1 system in these patients to stimulate the local or systemic
health benefits claimed for this therapy?
Conflicts of interest
None.
Acknowledgements
I would like to thank Diane Flynn, M.D., Tyler Snow, D.P.T.,
Michael Clay, D.C., and Aaron Harris, D.C. for their invaluable input
and suggested edits.
The views expressed are those of the author(s) and do not reflect
the official policy of the Department of the Army, the Department of
Defense or the U.S. Government.
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... 9 When exposed to this pressure differential, blood vessels undergo vasodilation, which causes localized increased blood flow at the treatment site. 9 This increase in blood flow may result in pain reduction demonstrated in previous studies. 10 Aside from increasing blood flow, cupping therapy may reduce pain through other mechanisms. ...
... Lowe reported that while the body is healing from the circular marks left by cupping therapy treatment, macrophages are attracted to the site of treatment and the enzyme heme oxygenase-1 (HO-1) is produced. 9 As HO-1 is broken down, the bi-products include: heme, biliverdin, bilirubin, carbon monoxide, and iron. 9 During this process, the iron bi-product is sequestered by ferritin and the other biproducts have direct and indirect antioxidant, anti-inflammatory, and neuromodulary effects that may create a better environment for healing at the treatment site. ...
... 9 As HO-1 is broken down, the bi-products include: heme, biliverdin, bilirubin, carbon monoxide, and iron. 9 During this process, the iron bi-product is sequestered by ferritin and the other biproducts have direct and indirect antioxidant, anti-inflammatory, and neuromodulary effects that may create a better environment for healing at the treatment site. 9 Another theory that has been put forth is that cupping therapy decrease pain through the principle of counterirritation. ...
... There is evidence that the effects are both local and systemic. Besides the mechanical effect of cupping, increasing the local blood flow and stretching the underlying tissue, and the activation of the HO-1 system could account for many cupping therapies that have local and systemic health benefits [1]. Figure 1 shows a comparison between bubble growth in a normal blood vessel as an example of the body soft tissues and another one which undergoing suction process. ...
... To the authors' knowledge, the study by Adubato, & Miller [2] is the only study available on the effects of dry cupping therapy on lower extremity [20]. Arce et al. [5] investigated the effects of dry cupping therapy on vascular function and found out that by applying dry cupping therapy, the number of microvasculature in the tissues increases which is responsible for increased blood flow to the concerned area. ...
Background There is limited evidence available on the effects of dry cupping therapy on outcomes of pain, dynamic balance and functional performance in young female recreational runners chronic plantar fasciitis. Purpose To investigate the effectiveness of dry cupping therapy on pain, dynamic balance and functional performance parameters in young female recreational runners with chronic plantar fasciitis. Method Thirty female recreational runners with plantar fasciitis were recruited from outpatient department of SGT hospital. They were randomly divided into two equal groups: Dry cupping therapy (Experimental group n = 15) and Conventional therapy (Control group n = 15). The experimental group received dry cupping therapy along with the conventional treatment whereas the control group received conventional treatment alone for 4 weeks (3 days/week). Outcome variables such as pain (Numeric pain rating scale), dynamic balance (Star excursion balance test) and functional performance (Figure of eight hop test) were evaluated at baseline and after 4 weeks of study period. Appropriate statistical tests were performed to test hypothesis the study hypothesis. Results Findings suggested a significant improvement in parameters of pain, dynamic balance and functional performance (p < 0.05). However, these improvements were found to be significantly greater (p< 0.05) with the addition of dry cupping therapy to the conventional treatment. Conclusion Findings of the present study suggests that dry cupping therapy may be considered as an adjunct treatment method in addition to the conventional treatment in young female runners with chronic plantar fasciitis.
... According to some reports, sensitization of epithelial cells lining the airways can also trigger these responses and induce the production and release of IL-25, IL-33 [33]. Our findings unraveled that the sensitiza- shift of macrophages to an anti-inflammatory M2 phenotype [36]. One of the major roles of IL-5 is to recruit eosinophils and increase their trafficking and survival in different tissues [37]. ...
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As an inflammatory disease of the lung, asthma is characterized by bronchoconstriction, mucus hypersecretion, inflammatory mediator release, and eosinophil recruitment. Cupping therapy is an ancient method of treatment for a vast range of ailments. This study aimed to evaluate the anti-asthmatic effects of wet cupping therapy (WCT) in a mouse model. A total number of 35 Balb/c mice were randomly divided into five groups (n = 7): Negative and positive control groups were administered Phosphate Buffered Saline (PBS) and ovalbumin (OVA), respectively. The remaining three OVA-challenged groups were treated with budesonide, one session, and two sessions of WCT. Finally, eosinophil counts, the gene expressions, and the protein levels of interleukins IL-5,-13, and-33 were measured in bronchoalveolar lavage fluid (BALF) of mice. Lung tissues were removed and kept for histopathological evaluations. Both eosinophil counts and interleukin levels in BALFs were significantly diminished following WCT. Moreover, WCT prevented hyperplastic growth of TRADITIONAL AND INTEGRATIVE MEDICINE Wet cupping therapy against asthma A. Joushan et al. goblet cells, overproduction of mucus, and inflammation of peribronchial and perivascular areas of lung tissue of mice compared to positive control group. Interestingly, the anti-in-flammatory effects of WCT against asthma were comparable to budesonide. Our data suggested that the anti-asthmatic effects of WCT were mediated by reducing eosinophil trafficking and modulating Th2 inflammatory cytokines, leading to the histological changes of the lung. This may propose WCT as an efficient therapeutic approach to mitigate inflammatory complications of asthma.
... DC was applied one time on each subject [7]. The criterion for correct DC was that the skin should be pulled up about 1-2 cm into the cup and the skin of the site should be purple [8]. After each intervention, muscle strength of back and leg using a dynamometer (SIHAN, Seoul, Korea) [9,10], anaerobic power using the 30-second Wingate Test [11,12], mood status using Profile of Mood States (POMS) questionnaire [13,14], and cognitive function using Tower of London (TOL) test [15,16] were measured. ...
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... Furthermore, the next process makes an injury to the cupped skin to pull out CPS contained in the blood. After the cupping is done, it is showed that the CPS is significantly reduced 13,14 . ...
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Background: Lateral epicondylitis is a common painful elbow disorder. Several approaches to treatment have been proposed, with a local injection of corticosteroids being the most frequently used. Recent insights into the pathophysiology encouraged the introduction of autologous blood injections as an alternative treatment method. Aim: The aim of this meta-analysis is to summarize quantitatively the evidence regarding the efficacy of corticosteroids and autologous blood injections for treatment of pain in lateral epicondylitis. Design: Meta-analysis. Setting: Outpatient treatment. Population: Studies were considered eligible based on the following inclusion criteria: adult human, diagnosis of lateral epicondylitis, randomized controlled trials comparing corticosteroids versus autologous blood injections, pain assessment. Exclusion criteria were previous surgery for lateral epicondylitis or for other elbow disorders, concurrent treatment with drugs or physiotherapy, diagnosis of musculoskeletal systemic disorder. Methods: A systematic search of literature was performed according to PRISMA statement. Effect size of each included study was calculated and analyzed in a random-effects model. Results: Four studies, enrolling total of 218 patients (139 females and 79 males), were included in quantitative analysis. At 2 weeks there was a trend towards a reduction of VAS score in the corticosteroid group (WMD = 2.12 [95% CI: 4.38 to 0.14], P=0.07). No significant differences were recorded in the medium-term (4-12 weeks; WMD = 0.85 [95% CI: -0.44 to 2.15], P= 0.19) and long-term (24 weeks; WMD = 0.63 [95% CI: -2.40 to 3.66], P= 0.68) follow-up. Conclusions: Few high-quality trials compare the efficacy of corticosteroid and autologous blood injections in the control of pain related to lateral epicondylitis. Available data indicate that corticosteroids tend to reduce VAS score in short-term follow-up, although these data are not statistically significant. No differences were recorded in the medium and long term. Clinical rehabilitation impact: Contrary to popular opinion among medical professionals, and despite pathophysiological cues, the currently available data offer no support for the effectiveness of autologous blood injections in medium- and long- term follow-up. Further studies are necessary to establish which treatment has more impact on pain in lateral epicondylitis. These data could be then used as a basis for practical guidelines and new protocols of treatment.
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• Objective: Negative pressure wound therapy (NPWT) is a widely accepted treatment modality for open or infected wounds. Premature ending of NPWT occasionally occurs due to negative effects on the quality of life (QoL), however, the actual impact on QoL is unknown. The aim of this review is to analyse the effect of NPWT versus standard wound care (SWC) on QoL when used for the treatment of open or infected wounds. •Method: a systematic literature search in a range of databases (PubMed, CINAHL, Medline, Web of Science, Science Direct Freedom collection, SwetsWise, PSYCArticles and Infrotrac Custom Journals) using the following search terms; 'standard wound care', 'wound dressing', 'dressing', 'treatment', OR 'negative pressure wound therapy [MESH]', OR 'vacuum assisted closure' AND 'quality of life [MESH]', 'patient-satisfaction', OR 'experiences' was performed. Methodological quality was assessed using the methodological index for non-randomised studies (MINORS) checklist. • Results: There were 42 studies identified, five matched the inclusion criteria: two randomised clinical trials (RCTs), one clinical comparative study, one exploratory prospective cohort study and one quasi experimental pilot study. Median MINORS-score was 75% (58%-96%). There were seven different questionnaires used to measure QoL or a subsidiary outcome. QoL in the NPWT group was lower in the first week, though no difference in QoL was observed thereafter. • Conclusion: This systematic review observed that QoL improved at the end of therapy independent of which therapy was used. NPWT led to a lower QoL during the first week of treatment, possible due to aniexty, after which a similar or better QoL was reported when compared with SWC. It could be suggested that NPWT might be associated with increased anxiety. • Declaration of interest: All authors of this publication have received no financial support or have personal interests conflicting with the objectivity of this manuscript.