The Use of Cupping Massage in Musculoskeletal Medicine

Cupping (also known as Hijama in Arabic or Ba Guan in Chinese) has been practiced by different cultures throughout history, but the true origin of cupping remains uncertain (Ashton et al., 2021; Qureshi et al., 2017). The practice of cupping is a technique where a vacuum is created in a cup, drawing the skin up and decompressing the layers of the epidermis and subcutaneous superficial fascia.

Cupping massage is a modern version of a traditional therapy, often carried out using plastic cups and a manual hand-pump to create the vacuum. The vacuum draws the soft tissue perpendicular to the skin, providing a tensile force, which can be left in one site or moved along the tissue. The practitioner can control the intensity of the desired suction from 80 mmHg to 250 mmHg.

The most common sites of application are the back, chest, abdomen and hips. The cups are typically left in place for 5-15 minutes depending on the client’s reaction and sensitivity. To cover a wider area, cupping massage can also be used with varying amounts of suction.

How Does Cupping Work?

The responses to cupping are multifactorial - physiological and psychological factors interplay in a complex manner. The enactive-biopsychosocial approach provides a practical framework for investigating the complex interplay between cupping and clinical outcomes. Based on the biopsychosocial model, investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation. An observed favorable outcome may be explained by overlapping mechanism in the periphery, spinal cord, and brain including, but not limited to:

Specific Effects - Cupping can modulate neuro-immune processes correlated with disability and the experience of pain.
Affective Touch - Interpersonal touch and therapeutic stimulation of somatosensory nerves (C-tactile afferent) mediates the release of oxytocin. Which can result in reduced reactivity to stressors and improved mood/affect.
Mechanical Factors - Gentle stretching of neurovascular structures and muscles induces a molecular response that helps diminish edema and expedite clearance of noxious biochemical by-products of inflammation (cytokines, prostaglandins, and creatine kinase).
Neurological Factors - The skin, subcutaneous tissue and fascia are all embedded with mechanosensitive nerve fibers, so the application of cupping invokes a number of neurophysiological responses. One being input from low-threshold Aβ fibers inhibits nociceptive processing and contributes to the activation of endogenous pain inhibitory mechanisms.

Contextual Effects - A positive therapeutic encounter is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning.
Non-Specific Effects - Musculoskeletal pain may resolve spontaneously.

Is Cupping Safe?

Cupping is generally considered a safe therapy with minor side effects such as erythema, edema, and ecchymosis in a characteristic circular arrangement. The longer a cup is left on the skin and the higher tensile stress inside of the cup, the more of a circular mark is created; this is due to capillary dilation. Cupping encourages blood flow to the cupped region (hyperemia), often the patient may feel warmer and/or hotter because of vasodilatation taking place, slight sweating may occur.

Key Takeaways

Cupping is a technique where a vacuum is created in a cup, drawing the skin and subcutaneous superficial fascia up into the cup. The use of cupping originated as early as 3000 B.C.E in a pre-scientific era and much of the reasoning once used to explain the effects do not make sense in the light of what we know today. In terms of clinical response to cupping, outcomes may be attributed to specific effects (affective touch, mechanical factors, and neurological factors), contextual effects (patient-therapist relationship, set and setting), and non-specific effects (natural history, regression to the mean).

References and Sources

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Ashton, R., Nocivin, I., Ashton, R. H., & Levell, N. (2021). Cupping on ancient Greek coins: A numismatic case series and its relationship to dermatology. Clinics in dermatology, 39(2), 344–347. https://doi.org/10.1016/j.clindermatol.2020.05.002

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