Author’s note:  If you haven’t read the original post (The Magic Show), you may wish to before continuing on.  The post will provide a background and basis for this series on passive modalities.

Part 3 of the passive modalities series will discuss another modality returning to vogue at the Rio Olympics – cupping.  Michael Phelps, and other skin bearing athletes, re-popularized this modality by being televised with purplish-red circles on their upper torso for the world to see.  Suddenly, the internet was in a frenzy over it. Cupping turned into the pet rock of the 2016 fall season. It had been around for 1000’s of years, served absolutely no use, but had filled the minds of both spectators and clinicians alike.

Social media was in no short supply of clinicians justifying either the use or avoidance of the modality – unfortunately, the majority for.  Most were capitalizing on the free Olympic-level advertising by immediately posting themselves performing cupping on athletes in their clinic while singing its praises.  Yet few were questioning what the evidence had to say about the modality. Michael Phelps’s own athletic trainer made the statement that asking him about cupping for Phelps’s performance was the equivalent of asking a famous chef about the garnish on a plate.1 One, the athletic trainer comparing himself to a famous chef speaks volumes about the ego and the role clinicians can think they have in an athlete’s performance. Two; if Thomas Keller garnishes a plate with dog shit, chances are he’s going to be questioned over it no matter how many Michelin stars he has. The majority of the pro-arguments were solidified in an appeal to antiquity – “Cupping has been around for thousands of years – therefore, it is a valid intervention.”  Yes, cupping has been around since humans first needed a better vessel from which to drink, but the age of an idea does not provide validation.  Appeals to antiquity make the illogical assumption that historical longevity of an idea brings us closer to Truth.  The rock has been around since the formation of Earth but it onfire-cupping-e1418255872220ly took one good marketing campaign to call it a “pet”. If Instagram had been around during the height of the pet rock era there would have been countless pictures of rocks sitting on top of rocks with narratives about the adventures of their pet rock, hopefully named something fancy like Ashi.  The issue is when evidence is unsupportive or non-existent, all that exists is the narrative of the clinician.  If cupping has been around for thousands of years, storytelling has been around since humans have been bipeds. In the case of cupping, the evidence is fairly non-existent and research that has been done is of very poor quality. However, with the right filter – even a flame around a cup tells a story.  The question then exists if the filter is to keep the patient from knowing lack of effect of the modality. We need to first remove that filter in order to see the actual effectiveness of cupping.

What exactly is cupping? 

In order to assess the current evidence regarding cupping we need to define what cupping is exactly. For those unfamiliar, cupping involves placing cups (glass, plastic, etc.) on parts of the body which forms a suction to the skin.  Some gurus choose to call it “Myofascial Decompression”.  Two forms exist:  wet and dry.  Dry cupping is simply placing a cup on the skin and then using fire or a pump to create a suction.2

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Wet cupping (aka Hijama)  involves scarification of the area to be cupped.  Scarification means the clinician will make a superficial incision in the skin and then applies a cup to the area.  The suction of the cup causes blood to be pulled from the underlying area – another way of describing wet cupping is bloodletting.2

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There are ample protocols in existence regarding how/when/where to place the cups and the duration of treatment – those details can be found elsewhere.2,3 But this idea of multiple protocols presents an interesting argument.  A modality that has existed for thousands of years yet still lacks agreement on the details of performing the treatment.  If anything, an appeal to antiquity should provide plenty of time for a protocol to be refined and perfected to increase the likelihood of positive patient outcomes.

What are the proposed benefits of cupping?  

Clinicians utilizing cupping will claim a myriad of benefits from help with digestive issues (IBS, constipation, and diarrhea), musculoskeletal pain, migraines, autonomic nervous system regulation, menstruation issues, respiratory issues (bronchitis and asthma), sickness like the flu, and to even circulatory issues such as hypertension.2  The two primary recurring themes of how cupping does all these things are: improvement of blood flow and removal of toxins.  Traditional viewpoints of cupping have a premise that blood stagnation or congestion can be linked to the majority of diseases, pain, and problems plaguing us humans.  The hypothesis is blood stagnation blocks the normal flow of vital force (debunked in an earlier blog – read here).  An added benefit of cupping is removal of toxins by bringing said toxins to the surface of the skin to be released.2  Unfortunately, this is another case where the premise has yet to be validated as actually occurring or being beneficial.  The issue with an appeal to antiquity as the premise fails to account for modern germ theory.  Instead the intervention’s premise is being viewed in the light of being well defined and substantiated, when in fact, it is antiquated.  The outcomes should not be a part of the discussion if a false premise is in operation.

Should this intervention be utilized in clinical practice based on current evidence?

Again, high quality (or any quality for that matter) research is lacking on this modality, and yet it has managed to permeate the physical medicine field.  The studies that have been completed on the modality are rampant with bias or of low quality.  Randomized controlled trials (RCTs) remain one of the best pieces of evidence we can use to weigh the risk vs benefits or pros vs con of an intervention.  Unfortunately, cupping has very few RCTs and those that do exist typically lack assessor blinding, have small sample sizes, and overestimate their effect size.4  

The proposed effects of cupping need to be examined further.  No study exists supporting the claim of toxin removal via cupping, or through any modality. It is ludicrous to think our best line of defense for our immune system can suddenly become permeable in one direction for the removal of harmful toxins.  Modern medicine has demonstrated the liver and kidneys are the major detoxification organs of the body, and the integumentary system is capable of excreting solutes – an evolutionary benefit far exceeding that of placing a cup on the surface of our epidermis.  Therefore, implying cupping results in detoxification is not scientifically correct on a biological level.

Toxin is an ambiguous term as well, no literature has even been established regarding what toxin, in what amount, or even if the removal of said toxin is harmful. Instead, this is fear mongering of taking a word with a negative connotation and using its removal as a means for justification of treatment. Furthermore, no studies have correlated the removal of specific toxins, through the skin or through bloodletting, as treatment for a specific ailment.

In regards to mitigating pain, the evidence is lacking.  The RCTs currently published are of extremely low quality and high bias.  The effectiveness of cupping for pain management can not be accurately assessed.5  Therefore, our patients’ money and time would be better served through the utilization of interventions demonstrated to mitigate pain and build autonomy – such as therapeutic exercise.6,7  Furthermore, an argument can be made pain mitigation is not the only part of our job as clinicians, and may not even be the most important objective when working with patients.8

Increasing blood flow is an interesting argument.  Such a claim is ambiguous, lacking meaning and implications.  Blood flow can be increased by all sorts of measures, most notably movement.  Again, we have not found an intervention that expedites healing – we as clinicians simply guide the process.

Some other claims, such as reducing hypertension, have actually been studied.  Evidence demonstrates cupping does not decrease high blood pressure.9

BUT, placebo…..

At this point, typically the placebo argument is invoked.  Placebo as a basis for any treatment is a slippery slope and immediately invokes an ethical dilemma.  Patients buying into placebo can become classically conditioned to  the modality – each time something hurts or doesn’t feel right rushing to the clinician for a fix.10  We as clinicians should instead be building confidence in our patients.  For those playing sports, we should be helping them realize their training and dedication to the sport coupled with raw talent has allowed them the opportunity to compete at the highest level – not a random suction cup stuck to their bodies like a leech.  Perhaps we are the leeches sucking confidence and money from our athletes by reinforcing their dependency on non-efficacious treatments.

We must not neglect the risks of any treatment – especially given the evidential support for cupping’s supposed benefits are lacking.  There are reports of cupping being linked to issues like herpes simplex infections.11  Others have reported incident of anemia and altered skin pigmentation due to excessive cupping therapy – again the heterogeneity of protocols for application allow for such issues to occur.12

The claims made as to cupping’s ability to correct patient ailments are based on unfounded anecdotes and a false premise.  The modality lacks efficacious support to be considered for patient treatment.3,5,13  In order to adequately assess the usage vs non-usage of an intervention we require evidence, not just a narrative, to cause a tipping point towards either pro or con – we do not have the evidence and the narrative is illogical regardless of the filter applied. Any usage of the intervention should cease pending further investigation.  Will this happen? Most likely not.  But in order to maintain evidence informed clinical practice we as clinicians need to be assessing the current evidence – hopefully, if anything, this blog has helped elucidate the topic of cupping and cause consideration of the premise of the intervention.  Is the treatment truly doing what is being claimed or are we confirming our own biases and reinforcing the patient’s?

We can do better as clinicians – we must do better in order for our field to continue with evidence based medicine and ethical patient treatment.

As always, if you want to discuss the article with us on Twitter, or just recommend a beer for us to try you can find us at:

@DMilesPT

@MichaelRayDC

References:

  1. Thanks, Michael Phelps, for glamorizing cupping quackery! (2016). Retrieved October 31, 2016, from http://scienceblogs.com/insolence/2016/08/09/thanks-michael-phelps-for-glamorizing-cupping-quackery/
  2. HIJAMA, OR CUPPING. (n.d.). Retrieved October 19, 2016, from http://www.greekmedicine.net/therapies/Hijama_or_Cupping.html
  3. Huang CY, Choong MY, Li TS. Effectiveness of cupping therapy for low back pain: a systematic review. Acupuncture in medicine : journal of the British Medical Acupuncture Society. 31(3):336-7. 2013.
  4. Albedah A, Khalil M, Elolemy A, Elsubai I, Khalil A. Hijama (cupping): a review of the evidence. Focus on Alternative and Complementary Therapies. 2011;16(1):12-16. doi:10.1111/j.2042-7166.2010.01060.x.
  5. Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for treating pain: a systematic review. Evidence-based complementary and alternative medicine : eCAM. 2011:467014. 2011.
  6. Gordon R, Bloxham S. A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare (Basel, Switzerland). 4(2):. 2016.
  7. Naugle, Kelly M., Roger B. Fillingim, and Joseph L. Riley. “A Meta-analytic Review of the Hypoalgesic Effects of Exercise.”  The Journal of Pain : Official Journal of the American Pain Society.  U.S. National Library of Medicine, 2012. Web. 19 Oct. 2016.
  8. Lee TH. Zero Pain Is Not the Goal. JAMA. 315(15):1575-7. 2016.
  9. Lee MS, Choi TY, Shin BC, Kim JI, Nam SS. Cupping for hypertension: a systematic review. Clinical and experimental hypertension (New York, N.Y. : 1993). 32(7):423-5. 2010.[MR1]
  10. Peerdeman KJ, van Laarhoven AI, Keij SM. Relieving patients’ pain with expectation interventions: a meta-analysis. Pain. 157(6):1179-91. 2016.
  11. Jung YJ, Kim JH, Lee HJ. A herpes simplex virus infection secondary to acupuncture and cupping. Annals of dermatology. 23(1):67-9. 2011.
  12. Kim KH, Kim TH, Hwangbo M, Yang GY. Anaemia and skin pigmentation after excessive cupping therapy by an unqualified therapist in Korea: a case report. Acupuncture in medicine : journal of the British Medical Acupuncture Society. 30(3):227-8. 2012.
  13. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PloS one. 7(2):e31793. 2012.