Cupping therapy can generally be described as a technique that uses cups placed over the skin to create negative pressure through suction.
Cupping therapy goes back to ancient times and was used around the world. In 400 BC, Herodotus listed wet and dry cupping as a treatment for many ailments including maldigestion, lack of appetite, and headaches. Hippocrates advocated cupping for gynecological complaints, back, and extremity illnesses, pharyngitis, lung diseases, and ear ailments. Cupping therapy was mentioned in the famous Papyrus Ebers in Ancient Egypt (1550 BC). In the Middle East, cupping was advocated for by prominent physicians like Abu Bakr Al-Razi (AD 854-925), Ibn Sina (AD 980-1037), and Al-Zahrawi (AD 936-1036). In China, cupping was recorded as a medical treatment in the Mawangdui Silk texts (sealed in 168 BC). Cupping therapy was used in ancient Europe as well. In the first century AD, Celsus advised cupping therapy for extracting poison from bites and for abscesses. In the 2nd century AD, Aretaeus treated prolapse of the uterus, cholera, epilepsy, and ileus with wet cupping. Galen was an advocate for cupping therapy and detailed variarity of materials that could be used for cups like horn, glass, and brass.
There are two types of cupping methods, dry and wet. Dry cupping is noninvasive with no bloodletting. Wet cupping is invasive and includes bloodletting. It is further is subdivided into traditional wet cupping and Al-hijamah. Al-hijamah comes from the Arabic word hajm which means sucking, expansion, and bloodletting. Traditional wet cupping is commonly used in China, Korea, and Germany. Al-hijamah is more common in the Middle East and North Africa.
The specific mechanism in which cupping exerts its therapeutic effect has not been identified. However, a number of theories have been proposed. One method, called Taibah, suggests wet cupping mimics an artificial kidney. Where an in vivo kidney filters hydrophobic materials through the glomeruli via normal pressure filtration, wet cupping filters both hydrophilic and hydrophobic material through high-pressure filtration. The high pressure from suction leads to increased blood volume which leads to increased capillary filtration rate leading to the expulsion of filtered and interstitial fluid in the area. Filtered fluid collected contains disease-related and disease-causing substances as well as prostaglandins and inflammatory mediators. The scratches made with the scalpel increase innate and acquired immunity by stimulating inflammatory cell migration and endogenous opioid release. This action leads to improved blood flow, removal of toxins, restored neuroendocrine balance, improved oxygen supply, and tissue perfusion.
There are many anatomical sites used in cupping therapy. These sites are chosen based on the ailment being treated. Areas where there are abundant muscles are the most common points where cups are placed. These include the back, chest, abdomen, and buttocks.
Anatomical sites avoided are those with abundant hair, those that have little muscle tissue, and those that don’t have enough surface area to place the cups.
Cupping therapy is indicated for both healthy patients and those suffering from ailments. Localized ailments that benefit from cupping therapy include a headache, lower back pain, neck pain, and knee pain. Systemic illnesses that have seen benefits with cupping therapy include hypertension, rheumatoid arthritis, diabetes mellitus, mental disorders, heart disease, hypertension, infections, and skin disorders.
Absolute contraindications to cupping therapy include cancer patients, those suffering from any organ failure and those using a pacemaker or suffering from hemophilia or a similar blood disorder. Cupping therapy is not recommended for geriatric patients, pediatric patients, and pregnant and menstruating women. Those with high serum cholesterol are at higher risk of developing cardiovascular ailments with cupping.
Anatomical contraindications include sites with deep vein thrombosis, open wounds, and bone fractures. Cupping should not be done directly on nerves, arteries, veins, varicose veins, skin lesions, body orifices, lymph nodes, eyes or areas with skin inflammation. Cupping done over excoriated, oozing or infected areas may cause an increase in D-dimer levels.
Those suffering from chronic diseases (like cardiovascular diseases), using anticoagulants or have an acute infection should generally avoid cupping therapy.
Cups can be fabricated from a variety of different materials including bamboo, glass, and clay. However, disposable cups are preferred, as non-disposable cups require advanced sterilization and disinfection procedures before they are reusable. Size of the cups is dependent upon the location they are being used.
A sharp surgical blade is commonly used to create the superficial lacerations in al-hijamah wet cupping.(4) An auto-lancet needle is more commonly used in the two-step traditional wet cupping method.
Traditional wet cupping is a two-step technique - superficial scarification of the skin followed by cupping. Al-hijamah is a three-step technique - cupping, superficial scarification, cupping. Traditional wet cupping is a 5 step process that includes demarcation, sterilization, scarification, cupping, and sterilization. Al-hijamah is a 6 step process including demarcation, sterilization, cupping, scarification, cupping, and sterilization.
In Islamic medicine it is recommended to perform Al-hijamah in the third quarter of the lunar month, particularly the 17th, 19th, and 21st days. A study on the effects of lunar phases on blood pressure showed that mean arterial blood pressure was higher in the third quarter of the lunar month in those with a decreased physical fitness index. The authors attributed the result to the gravitational pull of the moon and its possible effect on cardiovascular function in humans.
To create the necessary negative pressure in the cups, there is manual pumping, automatic pumping, and the fire method. For dry cupping, using fire to create a suction is the most popular choice and the primary method used in China. In the fire method, a glass cup is rinsed with methylated spirits before being set alight and then placed in the appropriate anatomical point on the skin.
In Al-hijamah wet cupping, honey is used to fix the cups and for the scarification, which aids in healing.
Cupping therapy is generally safe with adverse events being infrequent. Those that are reported range from mild to moderate in severity. Preventable adverse events reported include scar formation, burns, bullae formation, abscess and skin infection, pruritus, anemia, and panniculitis.
Nonpreventable adverse events reported include Koebner phenomenon, headaches, dizziness, tiredness, vasovagal attack, nausea, and insomnia. Risk of infection, vasovagal attacks and scarring are seen more in wet cupping. Standard results of dry cupping include: bruising, erythema, and ecchymosis. There is an increased risk of burns if fire is used for suctioning.
The strongest evidence for Cupping therapy’s therapeutic benefit is for the treatment of pain. Particularly musculoskeletal pain and migraine or tension headaches. In one study, there was a 66% reduction in mean headache severity following wet cupping treatment. The number of headaches per month for these patients also decreased an equivalent of 12.6 days. Cupping therapy has been shown to provide pain relief in lumbar sprain, scapulohumeral periarthritis, brachialgia paraesthetica nocturna, arthritis, and neuralgia pain.
Dry cupping is commonly used for musculoskeletal pain and muscular tension. Dry cupping has shown benefit to patients suffering from chronic back pain in both behavioral variables of pain and physiological parameters when applied to the lumbar or cervical regions. For chronic back pain treatment, results indicated on average, five sessions of cupping therapy, with 3-4 day intervals between sessions, and with cups applied to the skin for around 8 minutes achieved significant effects in reducing overall pain.
Overall, dry cupping showed the most benefit in generalized pain conditions, while wet cupping showed the most benefit in inflammatory pain (such as herpes zoster).
There have been studies done that have shown the benefits of Cupping therapy beyond pain management. In a German study, traditional wet cupping was shown to be effective in treating carpal tunnel syndrome. Wet cupping was also shown to treat thalassemia and autoimmune diseases effectively. Cupping therapy demonstrated to be effective against a cough, dyspnea, and acne.
Detailed measures for infection control are vital for preventing infections from cupping therapy. Hand washing and wearing the appropriate protective equipment (gloves, mask, protective eyewear, gown) are essential in preventing the spread of infection. Disinfecting beds or chairs used during treatment ensure a sterile environment. Using disposable equipment for cups, surgical blades and vacuum pumps is preferable to disinfecting.
To minimize complications and side effects of cupping, a detailed medical history is recommended. Compiling a checklist that includes known contraindications to cupping therapy would be a simple and effective method of automating the initial encounter. A physical exam should also be performed to evaluate if the patient has any other abnormalities that would hinder or contradict treatment.
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