Cupping for recovery: cure all or con?

Trevor Langford looks at the practice of ‘cupping’. Can it really improve your recovery and performance, and are there other ways to achieve the potential benefits?

Athletes will often go to extreme lengths to improve their performance, prevent injuries and to gain an edge over their competitors. There are a wide range of products and treatment techniques on offer and one of these was widely used during the 2016 Rio Olympics. This was ‘cupping therapy’, which some of you might have heard of in relation to the swimmer Michael Phelps (see figure 1).

Although cupping was well publicised during this summer’s Olympic games, it is a traditional form of Chinese medicine that has been used for 2000 years - mostly in Asia but also in Egypt (known as Hijama in Egypt) and Scandinavia too^{J of Trad Chinese Med Sci, 2014, 1, 1, 49-61}. Traditional Chinese medicine is used to treat pain that is caused by insufficiency in blood circulation or disorder to the body’s energy channels^{J of Trad Chinese Med Sci, 2014, 1, 1, 49-61}. It uses the body’s energy pathways to restore a balance between the ‘yin’ (passive, negative, dark, water) and ‘yang’ (positive, active, bright, fire)^{J of Traditional & Complementary Medicine, July 2015, 5, 127-134}.

Chinese medicine states that pain may be acute or chronic in nature, involving musculoskeletal structures such as muscle, fascia, tendon, ligaments, bone, and joints. Pain may also be related to skin, nerves, disease such as cancer, and may be referred from a central source such as a spinal deformity or internal organ dysfunction. Pain is often presented as the state of an individual’s psychological well-being and should be factored into any treatment plan.

Figure 1: Olympic swimmer Michael Phelps

How is cupping performed?

Cupping therapy works by applying a glass cup to the skin in order to create a vacuum (see figure 2). The sizes of the cups vary in size from 3-10cm in diameter and the number needed is dependent on the patient’s symptoms and the body location involved – and therefore becomes a therapist decision.

There are several different types of cupping techniques available (see table 1). The cups are generally located at sites where there is an abundance of muscle tissue such as the back, shoulders, thighs, abdomen and calf muscle. The cups are applied for five to ten minutes at a single treatment session^{J of Traditional & Complementary Medicine, July 2015, 5, 127-134}. The therapist will determine the most effective technique for the individual and each patient may prefer a specific cupping approach. A partial vacuum (suction) effect can be created in the cup by applying it to the skin hot and allowing it to cool. However, cups with air suction pumps attached can also be used (see table 1).

Figure 2: Cupping in action

Table 1 Cupping applications and their potential benefits

Figure 3: Potential adverse effects of cupping

Purpura rash

Skin Abrasion

Ecchymosis

The cupping vacuum (or partial vacuum) results in increased blood flow - known as vasodilation - to a specific body part as well as enhanced circulation under the skin’s surface^{J PIONEER MED SCI, Oct 2016, 6, 4, 127}. Enhanced blood flow in turn can assist in the removal of toxic waste products that may lead to muscle cramps and muscle dysfunction. The observed red circle arises from the effect of vasodilation.

Cupping therapy is also claimed to improve joint movement, arthritic pain and lower back pain^{J of Traditional & Complementary Medicine, July 2015, 5, 127-134}. Due to the increased blood flow, it is not uncommon for the patient to feel warmth close to the applied cup and therefore sweating to occur. But this will soon settle after treatment.

There can be adverse effects from cupping therapy if it is not applied correctly. These include skin abrasions, ecchymosis and purpura (a rash on the skin surface – see figure 3). Skin should be monitored closely to ensure that it doesn’t come into contact with any potential irritants that may cause infection. Given the above, cupping therapy should only be provided by a trained medical professional. Cupping therapy has been used in palliative care but is contraindicated (meaning not suitable for) for patient groups that include pregnant women, children under seven years of age, geriatrics and menstruating women^{J of Traditional & Complementary Medicine, July 2015, 5, 127-134}.

What does the research say?

Is cupping is just a gimmick based on hearsay, or does it have scientific validation in research studies? One study looked at the effect of cupping on patients with neck and shoulder pain. Sixty participants were divided into two groups with thirty receiving cupping therapy and thirty receiving no treatment^{Evidence Based Complementary and Alternative Medicine, 2012, 7, 1-7}. Cups were heated and applied to three specific acupuncture points with an application on the left and right sides of the body for ten minutes on each point.

The skin surface temperature and pain levels (via a visual analogue scale with 10 being high pain and 0 being no pain – see figure 4 overleaf) were measured in both groups. The results showed that the neck pain reduced from 9.7 to 3.6 in the cupping group but from 9.7 to only 9.5 in the control group. The results were ‘significantly different’ implying that that benefits from cupping therapy observed in terms of relieving neck and shoulder pain were real, and were not a statistical fluke.

Figure 4: Visual Pain scale

Non-specific lower back pain is a common ailment in physiotherapy clinics worldwide and as therapists therefore, we are always interested in exploring different approaches to managing back pain. In another study, researchers separated 32 participants into either a cupping therapy group using a wet cupping approach, and the
remaining twelve into a control group^{Biomed Central Trials, 2011, 12, 146}. The cupping group received six applications of wet cupping therapy over a 2-week period. Although the results showed a reduced pain response in the therapy group, there was no overall significant effect between the groups and therefore the positive response perhaps occurred by chance.

WHAT THE PAPERS SAY

Although a number of athletes report positive benefits from cupping therapy, some academics remain less convinced. Here are some of the contrasting views as reported in the media:

• “There is no evidence for its efficacy. It has not been submitted to clinical trials.” Professor Edzard Ernst from the department of complementary medicine at the University of Exeter (BBC News website, 2016)
• “That’s been the secret that I have had through this year that keeps me healthy,” Naddour told the USA Today newspaper, adding that it had saved him from “a lot of pain”. USA Gymnast Alex Naddour. (BBC News website, 2016)
• “I’ve been doing it for a while,” Michael Phelps (Newstateman, 2016)
• “Hocus pocus. It’s just pulling up a bit of skin, it is not going to affect the muscle to any noticeable extent. And taken to extreme, it can cause harm. It usually doesn’t, but it’s usually just a – what [British physician] Ben Goldacre would call - a voluntary tax on the gullible.” Pharmacologist Prof David Colquhoun, from University College London. (BBC News website, 2016).

Should you cup?

In theory, athletes might be able to benefit from cupping during periods of heavy training load to reduce tension points in muscles. During injury, cupping may also become a useful treatment tool to alleviate stresses in an involved area. In a knee injury for example, it may be beneficial to alleviate tension points in the quadriceps and hamstring muscles to promote enhanced range and ease of movement at the knee joint. However, due to the risks involved, and the inability to apply the cups safely and effectively in a specific location (particularly on the back of the body), it isn’t possible to apply the cups yourself – ie ‘self cup’. However, the following website can help you to locate a therapist in the United Kingdom that can carry out a cupping therapy treatment (www.therapydirectory.org.uk/articles/cupping.html).

If you don’t have access to a trained cupping therapy clinician, there are other self-help tools available to athletes to improve muscle tissue quality and these include using a foam roller (watch out for an article on this in the next issue), developmental stretching, regular massage therapy with trigger point pressure and activities such as yoga and Pilates. Although these activities don’t exert the same physiological effects as cupping, they do work to restore a sense of balance throughout the body, with an aim of preventing injury and improving physical conditioning - much as cupping therapy is claimed to do.

The verdict

There’s certainly some evidence that cupping can be an effective tool in managing musculoskeletal disorders, as well as other pathological diseases. However, research also indicates that there are limitations in its effectiveness. Ideally, we need more studies to explore the use of cupping in specific musculoskeletal disorders such as lower back pain. Despite this, cupping can be a useful additional treatment tool for managing soft tissue and joint disorders in athletes. What is not in doubt is that cupping therapy should be applied by a trained clinician. It’s also important to understand that cupping shouldn’t replace self management tools such as stretching, core stability and foam rolling. It’s absolutely essential that you are able to take as much ownership as possible for your own well being!