Cupping Therapy: An Overview From A Modern Medicine Perspective

Abstract

Cupping therapy is an ancient traditional and complementary medicine practice. Recently, there is growing evidence of its potential benefits in the treatment of pain-related diseases. This article gives an overview of cupping therapy practice. Furthermore, this article suggests a new classification of cupping therapy sets, a new classification of cupping therapy adverse events, and an updated classification of cupping therapy types. Keywords: Cupping therapy, Hijama, Types, Classification, Adverse events, Indications

Full text

Review Article
Cupping Therapy: An Overview from a
Modern Medicine Perspective
Tamer S. Aboushanab
1,
*, Saud AlSanad
1,2
1
National Center for Complementary and Alternative Medicine, Ministry of Health, Riyadh,
Saudi Arabia
2
College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi
Arabia
Available online 7 February 2018
Received: Nov 9, 2017
Revised: Nov 25, 2017
Accepted: Feb 1, 2018
KEYWORDS
Cupping therapy;
Hijama;
Types;
Classification;
Adverse events;
Indications
Abstract
Cupping therapy is an ancient traditional and complementary medicine practice.
Recently, there is growing evidence of its potential benefits in the treatment of pain-
related diseases. This article gives an overview of cupping therapy practice. Further-
more, this article suggests a new classification of cupping therapy sets, a new classifica-
tion of cupping therapy adverse events, and an updated classification of cupping therapy
types.
1. Introduction and brief history
Cupping therapy is an ancient technique of healing [1].
Cupping is performed by applying cups to selected skin
points and creating a subatmospheric pressure, either by
heat or by suction [2].
Eber’s papyrus (1550 BC) from Ancient Egypt is one of the
oldest medical texts to mention cupping therapy. Cupping
therapy is part of numerous ancient healing systems, such as
Chinese, Unani, traditional Korean, Tibetan, and Oriental
medicine [3]. The ancient Greek physician Hippocrates
compiled extensive descriptions of the cupping application.
* Corresponding author. National Center for Complementary and Alternative Medicine, Ministry of Health, 11662, P.O 88300, Riyadh, Saudi
Arabia.
E-mail: tamer.shaban@gmail.com (T.S. Aboushanab), s.alsanad@nccam.gov.sa (S. AlSanad).
pISSN 2005-2901 eISSN 2093-8152
https://doi.org/10.1016/j.jams.2018.02.001
ª2018 Medical Association of Pharmacopuncture Institute, Publishing services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies
journal homepage: www.jams-kpi.com
J Acupunct Meridian Stud 2018;11(3):83e87

He described two different types of cups: one with a narrow
opening and a long handle and the other with a wider
opening. The first type was used to treat deep accumulation
of fluids, while the second type was used to treat the spread
of pain [4]. Cupping therapy was a popular historical treat-
ment in Arabic and Islamic countries. It was recommended by
Arabic and Islamic physicians such as Ibn Sina (AD 980e1037),
Al-Zahrawi (AD 936e1036), and Abu Bakr Al-Razi (AD
854e925). Al-Zahrawi described cupping sites and illustrated
cupping tools with diagrams [5]. Cupping therapy practice
spread to Italy and, subsequently, the rest of Europe be-
tween the 14
th
and 17
th
centuries, during the Renaissance.
Cupping was a very popular treatment of gout and arthritis in
Italy during this period [6].
2. Mechanisms of action and reported effects
of cupping therapy
The mechanism of action of cupping therapy was not
clear until now [7]. The main proposed mechanisms of ac-
tion were effects of subatmospheric pressure suction,
promoting peripheral blood circulation, and improving im-
munity. [8].
Reported effects of cupping therapy include promotion
of the skin’s blood flow [9], changing of the skin’s biome-
chanical properties [10], increasing pain thresholds,
improving local anaerobic metabolism [11], reducing
inflammation [12], and modulation of the cellular immune
system. [13].
Many theories explain the mechanism of action of
cupping. Guo et al. suggested the immunemodulation the-
ory, suggesting that cupping and acupuncture had the same
mechanisms of action. Immunemodulation theory suggests
that changing the microenvironment by skin stimulation
could transform into biological signals and activate the
neuroendocrine immune system [14]. Shaban and Rarvalia
proposed the genetic theory, which suggested that skin’s
mechanical stress (due to subatmospheric pressure) and
local anaerobic metabolism (partial deprivation of O
2
),
during cupping suction could produce physiological and
mechanical signals which could activate or inhibit gene
expression. In wet cupping therapy, superficial scarifications
could activate the wound-healing mechanism and gene-
expression program [15]. Modulation of genetic expression
was reported in various acupuncture studies [16,17].
In summary, there is no clear identified mechanism of
action of cupping therapy. Clinical studies in the field of
cupping therapy mechanisms of action are highly
recommended.
3. Classification of cupping therapy types
Early classification of cupping therapy categorized it
broadly into dry and wet cupping [18]. Another classification
of cupping therapy was developed in 2013, categorizing
cupping into five categories. The classification was updated
in 2016 [19]. The updated classification categorized cupping
therapy into six categories. The first category is “technical
types”, which includes dry, wet, massage, and flash cupping.
The second category is “power of suction”, which
includes light, medium, and strong cupping. The third cate-
gory is “method of suction”, which includes fire, manual
vacuum, and electrical vacuum cupping. The fourth category
is the “materials inside cups”, which includes herbal, water,
ozone, moxa, needle, and magnetic cupping. The fifth
category is “area treated”, which includes facial, abdom-
inal, female, male, and orthopedic cupping. The sixth cate-
gory is “other cupping types”, which includes sports,
cosmetic, and aquatic cupping [19].
This article suggested a new update of cupping therapy
classification by merging category five and six into one main
category: “condition and area treated”. The name of the
fourth category was changed from “materials inside cups”
to “added therapy types”, and aquatic cupping was added
to this category. The aim of this update is to give a precise
classification of cupping therapy types [Fig. 1].
4. Classification of cupping therapy sets
A typical cupping therapy set should contain six or more
different-sized cups and a method of suction. Cupping
therapy sets can be classified into three main categories:
the first category is “cupping sets related to the types of
cups”, which includes plastic, glass, rubber, bamboo,
ceramic, metal, and silicone cupping sets. The second
category is “cupping sets related to the methods of
suction”, which includes manual, automatic, and self-
suction cupping sets. The third category is “cupping sets
related to uses”, which includes facial, female, male, and
massage cupping sets [Fig. 2][20].
5. Indications
Cupping therapy has been used for health promotion,
preventive, and therapeutic purposes. Cupping therapy has
reported benefits in the treatment of lower back pain
[21,22,23], neck and shoulder pain [24,25,26,27], headache
and migraine [28,29], knee pain [30], facial paralysis
[31,32], brachialgia [33], carpal tunnel syndrome [34], hy-
pertension [35,36], diabetes mellitus [37], rheumatoid
arthritis [38], and asthma [39,40]. These diseases can be
categorized into localized diseases (neck pain, lower back
pain, and knee pain) and systematic diseases (diabetes
mellitus, hypertension, and rheumatoid arthritis).
Cupping therapy sites are selected according to the
treated ailment. The back is the most common site of
application, followed by the chest, abdomen, buttocks, and
legs. Other areas, such as the face, may also be treated by
cupping [41].
6. Contraindications
In general, cupping is contraindicated directly on veins,
arteries, nerves, skin inflammation, any skin lesion, body
orifices, eyes, lymph nodes, or varicose veins. Cupping is
also contraindicated on open wounds, bone fractures, and
sites of deep vein thrombosis.
Cupping therapy contraindications can be classified into
absolute and relative contraindications. Until we have suf-
ficient information regarding the safety of cupping therapy,
it is absolutely contraindicated in cancer patients and those
84 T.S. Aboushanab, S. AlSanad

Figure 1 Classification of cupping therapy types.
Figure 2 Classification of cupping sets.
Cupping Therapy Overview 85

with any organ failure (renal failure, hepatic failure, and
heart failure). It is also absolutely contraindicated in pa-
tients using a pacemaker and those suffering from hemo-
philia or similar conditions. Relative cupping therapy
contraindications include acute infection, using anticoagu-
lants, severe chronic disease (such as heart diseases),
pregnancy, puerperium, menstruation, anemia, recent wet
cupping session, recent blood donation, medical emergen-
cies, and patient’s refusal of the procedure [42,43,44].
7. Adverse events
Cupping therapy is relatively safe. Cupping therapy
adverse events (AEs) are infrequently reported but are not
rare. Most AEs are mild to moderate in severity [45].
Most AEs related to cupping therapy are scar formations,
followed by burns. Other observed AEs are headache, pru-
ritus, dizziness, tiredness, muscle tension, anemia, nausea,
bullae formation, small hematoma or pain at cupping site,
abscess formation, skin infection, insomnia, hyperpigmen-
tation, and vasovagal attack [46]. This article suggested a
new classification of cupping therapy AEs into those that
are preventable and nonpreventable [Table 1].
8. Infection control measures
Following infection control measures is an essential part
of the clinical practice for preventing cupping therapy-
related infection. Hand washing is a critical component of
any infection control program. Wearing personal protective
equipment such as gloves, masks, protective eyewear, and
gowns is important. Disinfection of the skin before cupping
by US Food and Drug Administration (FDA)-approved or
hospital-grade solutions is very important. Disinfection of
patients’ beds or using disposable plastic bed covers is very
important after treating each patient. Following medical
waste segregation and disposal guidelines is essential. Using
disposable cups, vacuum pumps, and surgical blades is rec-
ommended. Try to use a secondary disposable container for
lubricants/skin disinfectants used on a single patient before
disposal. Use on another patient is prohibited [47,48,49].
9. Summary
In summary, cupping therapy is an ancient traditional
and complementary medicine practice. There is growing
evidence of its potential benefits in the treatment of some
diseases, especially pain-related conditions. Following
infection control measures is a very important component
of the cupping therapy practice. This article suggested a
new classification of cupping therapy sets, a new classifi-
cation of cupping therapy AEs, and an updated classifica-
tion of cupping therapy types.
Disclosure statement
None declared.
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Cupping Therapy Overview 87