Expert Insights on Cupping

Cupping has grown greatly in popularity over the past 10-plus years, and has become a modality used by many massage therapists.

Here, several cupping educators provide insight into ways of approaching cupping as a specialty and applying cupping as technique, with information on mechanisms of action, myths surrounding cupping, dynamic cupping therapy and benefits of cupping for athletes.

In this article, Shannon Gilmartin discusses cupping therapy’s mechanisms of action; Michelle Roos looks at myths, such as “cupping removes toxins”; Tony Mikla explains dynamic cupping for neck and shoulder pain; and Dominador Perido, Mark Perido and Jesse MacLean discuss the benefits of cupping for athletes.

Cupping Therapy’s Mechanisms of Action

One of cupping’s most notable benefits is the encouragement of blood circulation, venous return and lymph fluid movements. These photos show how the person’s overall blood distribution has increased exponentially through gentle, non-aggressive cupping applications. Courtesy of Shannon Gilmartin

By Shannon Gilmartin, CMT

Cupping therapies have been the subject of much curiosity, speculation and subsequent research in recent years. Today we have scientific standards of measurement and proof of efficacy available, thereby offering some insight into why cups have been used for overall wellness throughout recorded history.

To understand how cupping therapies work, it is important to specify the mechanisms of action that occur on a physiological level. Research has identified three primary, physiological responses that occur simultaneously: negative pressure, vasodilation and enhanced fluid exchange.

Once applied, cups lift the tissue and begin to take effect with negative pressure. This pressure creates a pulling action which offers decompression and allows for the separation of fused or adhered tissue. Cupping has been designated as “Myofascial decompression (MFD)” in current Western medicine cultures.

Similar to the pressure of massage, the applied negative pressure stimulates a local reflex response, promoting the release of vaso-activating chemicals (histamines, acetylcholine), which in turn encourages the lumen of blood vessels to dilate and allows for fluids to rush into or through an area more efficiently. Due to their suction pump effect on the body, cups stimulate and enhance the body’s respective fluid exchange processes.

The combination of negative pressure, vasodilation and enhanced fluid exchange allows for some incredible therapeutic reactions to take place. Here is an overview of how cups affect the human body through various application:

Cups encourage circulation. One of cupping’s most notable benefits is the encouragement of blood circulation, venous return and lymph fluid movements. The adjacent thermographic photos (see images) show how the person’s overall blood distribution has increased exponentially through gentle, non-aggressive cupping applications.

Cups alleviate adhesions. Adhesions are defined as any two anatomical surfaces stuck or growing together that do not naturally connect. From cellulite to scar tissue, cupping offers improvement that is immediate, palpable and lasting.

Cups clear congestion and stagnation. Anything stagnant in an otherwise healthy internal environment predominantly leads to dysfunction and disease. Cups help clear stagnation from the skin, muscles, bones, joints, organs and even energies (whether emotional energies from trauma, or in reference to ‘qi’ or ‘chi,’ as is used in Traditional Chinese Medicinal cupping applications).

Cups can lift, rehydrate and manipulate fascia. Fascia is a connective tissue that benefits from manipulation, hydration and improved pliability. Cups force hydration into and through these fluid-rich structures, while the negative pressure allows for a lifting and stretching mechanism to occur; this provides an opportunity to create space and pliability where it may have been lacking.

Cups can cause microtraumas in tissues. This is the point of much discussion surrounding a true cupping mark versus a painfully adverse reaction to cupping. Cupping can bring about beneficial inflammation to encourage deep-seated restrictions to clear and rebuild healthy tissue, thus encouraging the body’s own process of regeneration.

Cups encourage neovascularization. Speaking of the body’s healing potential, neovascularization is the process by which new blood vessels form from already existing healthy vessels, bringing a fresh supply of nutrients and oxygen to previously deficient tissues. Cupping can stimulate this response in areas of injury or damaged tissue, which in turn can speed recovery.

Cups help alleviate excessive pressure on sensory organs in soft tissue, which leads to a reduction in pain. The benefits of cupping begin at the skin level, stimulating the various sensory receptors, which inevitably take effect on every adjacent structure. Some applications intend to affect the central nervous system by addressing the regional sympathetic nerves, plexuses, and the various organs innervated from the relative nerves. From superficial skin sensitivities like some fibromyalgia conditions to deeper levels of anatomy involved in musculoskeletal pain, the negative pressure of cupping has a positive influence on nociceptors, which in turn releases pain patterns, ultimately changing the peripheral feedback to the central nervous system.

Do Your Research

There are many articles, research papers and pieces of literature available to verify and elaborate on each of these physiological responses and potential therapeutic benefits, all of which support how positively therapeutic the negative pressure of cupping therapy truly is.

Shannon Gilmartin

Shannon Gilmartin, CMT, started her massage therapy career in 2000, and began cupping practices in 2004, teaching cupping internationally soon thereafter. She has published numerous articles, been interviewed, authored “The Guide to Modern Cupping Therapy: A Step-by-Step Source for Vacuum Therapies,” and co-owns Modern Cupping Therapy Education Company. Her articles for MASSAGE Magazine include “Cupping the Pediatric Client” and “Cupping the Geriatric Client.”

Cupping Removes Toxins — and Other Myths, Busted

A popular myth is that leaving a cup on longer than three to five minutes is out of scope of practice for a massage therapist. This timing of cupping therapy might be too long for some clients, or it might not be enough treatment time for others. Courtesy of Michelle Roos

By Michelle Roos, LMT, BCTMB

There are many myths around cupping therapy that are circulating within the massage industry.  It is important for the massage therapist to do research to ensure what they are saying and doing doesn’t make someone question their education or sanity.

One of the most common myths is that cupping removes toxins.  What toxins are we talking about here? We have been asking therapists who take our basics course to explain to us what toxins they are talking about when asked the previous question.

Generally speaking, they either don’t know specifically what toxins they are removing, or they may answer lactic acid, cellular debris or more recently pharmaceuticals, drugs or environmental substances. For most of these things we as massage therapists are not able to test for the presence of them in the client’s body. If we are not testing for it, how do we know we are removing it? 

Secondly, there is a physiological pathway for the elimination or recycling of the things that can be eliminated and there is no research that cupping can influence any of these pathways. Historically, wet cupping has been used on insect and snake bites, which are toxic, and this is where this idea probably comes from. Wet cupping is out of scope for massage therapists as it involves piercing or cutting the dermis (skin) to cause bleeding. There is also some mention in Chinese medicine about toxins, but these are specific to the pathophysiology of Chinese medicine and not the same thing we talk about in Western physiology.

Two additional myths revolve around timing. One that is constantly circulating in social media is that five minutes of cupping therapy is like 30 minutes of deep tissue massage. This claim does not quote any research and does not tell us anything specific about the treatments given or outcome received. Because of this, it is an opinion more than anything else and it is passed on like a fact.

Another popular myth is that leaving a cup on longer than three to five minutes is out of scope of practice for a massage therapist. This is misinformation at best. We cannot find any documented rule from a regulatory body that says this. Three to five minutes of cupping therapy might be too long for some clients, or it might not be enough treatment time for others.   It is the therapist’s job to understand the risks and benefits of cupping, assess the health history of the patient and make an informed decision as to how long each client should receive cupping. Leaving a cup stationary for three to five minutes can cause bruising on some clients, while others might not mark at all.

Many therapists use a cup mark or bruise as their delineation as to whether the treatment has been successful or not rather than looking at the soft tissue outcome they are seeking. Every single client is different so every single cupping treatment will be different. As with all modalities, the therapist should check with their local governing bodies, association and liability insurance provider to ensure they are working within their limits.

Another myth is the advice to avoid hot or cold temperatures after receiving cupping. This advice comes straight from Chinese medicine and is specific to the pathophysiology of disease progression. In Chinese medicine there is a concept that weather or environmental effects influence health outcomes and disease processes, an idea that is not accepted in Western physiology.

I live in South Florida, where temperatures can top 100 degrees Fahrenheit, and my husband lives in Winnipeg, Manitoba, Canada, where winter temperatures can be -40 degrees Fahrenheit. It is impossible to avoid extreme hot or extreme cold in many situations where we live. We provide cupping therapy daily and have clients who work in these extreme temperatures, and they have perfectly normal outcomes for the treatments given. 

Many of these myths may stem from practitioners mixing the completely different pathophysiology of Eastern and Western medical systems. Most clients in the U.S. and Canada are somewhat versed in Western physiology in that they took classes in junior high and high school. Most massage therapists have not been educated in Chinese medicine appropriately.

The use of Chinese medicine terms may do the clients a disservice in that it can break their idea of how their body works if not explained as a separate system of medicine, as they most likely have never taken courses in Chinese medicine.

Michelle Roos

Michelle Roos, LMT, BCTMB, is an author, educator and a mobile massage business owner in South Florida. She owns an education company and Facebook group, Mobile Massage Mastery, for those interested in advancing their mobile massage career; and also co-owns Cupping Canada and Cupping USA with her husband, Paul Kohlmeier. Her articles for MASSAGE Magazine include “Meet Clients Where They Are: Mobile Massage Therapy Offes New Opportunities.”

Dynamic Cupping for Neck and Shoulder Pain

Internal glide is when the massage client is moving underneath the cupping application. External glide describes the cup moving or pulling the tissue while the client is static. Courtesy of Tony Mikla.

By Tony Mikla DPT, MSTP, CSCS

As a movement and sports physical therapist, cupping is one of my favorite tools I use daily in my practice. As a ROCKTAPE FMT and RockPods cupping instructor, I teach many concepts about cupping, with dynamic cupping being one of the best techniques.

Dynamic cupping can be described as the application of an internal glide or an external glide. Internal glide is when the massage client is moving underneath the cupping application. External glide describes the cup moving or pulling the tissue while the client is static.

Both strategies are fantastic for restoring a myofascial glide or myofascial release between fascial layers. There is mounting evidence that improving the glide of the superficial fascia on the deep fascial layer has benefits in pain reduction and increases benefits with the quality of movement.

Of these two strategies, internal glide is my preferred technique. I believe the body is made to move, and through movement the body learns and adapts more rapidly. Compare this to the concept, “People may retain 10% of the information they hear, but if they teach it, this demonstrates the complete knowledge of the subject.”

The same seems to be true for the body. When the person can move themselves, their mobility and their movement quality is enhanced exponentially when compared to us doing something to the client as a practitioner.

Internal glide is a preferred strategy when the person has a mild pain or mild mobility deficit and needs to restore myofascial tissue glide. A great example of an internal glide is placing pods on a client’s low back while the person is positioned in quadruped, then have them rock back into a child’s pose position or perhaps do a cat-cow maneuver with the pod located on the low back.

You’ll notice that as the client moves, the cups, or pods, hold the skin taught at the surface and the fascial layers below the surface will have to glide underneath. Our intent is to hold the superficial fascial layer through the pod, while the movement causes the deep fascial layer underneath it to move. The shear between these two layers is what yields the results. This concept can be used throughout the body but is most commonly used around the low back, knee and shoulder, where movement is often restricted by muscle tightness or soft tissue limitations and in which this technique has a direct impact.

External glide is best described as the practitioner moving the pods or cups on the client. The cups can potentially slide on the skin surface creating a rolling skin and lifting effect. The cups could also be stable but pulled in different directions like a handle pulling on the skin. This would again cause shearing of the superficial layer on the deep layer.

Each of these strategies work very well around scars or tissue with adhesions limiting motion. The strategies allow the practitioner to do two things:

First is to assess the direction of the restriction by pulling on the cup. The second allows the practitioner to mobilize the restriction in any direction. This ability to custom the angle of pull can provide great results for gaining tissue mobility and range of motion.

Tony Mikla

Tony Mikla, DPT, MSTP, CSCS, wrote this article on behalf of ROCKTAPE. Mikla is a sports physical therapist, performance coach and researcher. He speaks and teaches nationally on sports physical therapy. He previously served as the physical therapy manager at EXOS, as the medical director for the Sacramento Sports Commission, and as adjunct faculty in physical therapy at Sacramento State and Northern Arizona universities. ROCKTAPE educational articles for MASSAGE Magazine include “The Meaningful Movement Experiment: A Biopsychosocial Approach to Preventing Chronic Pain.”

Benefits of Cupping for Athletes

Athletes complain of cramps, tense muscles, shin splints and painful motion. There is greater need of blood in these areas and cupping is one of the best ways of addressing this need. Courtesy of International Cupping Therapy Association.

By Dominador Perido, MD, CCE, CCT, Mark Perido, MSOM, MHCL, CCT, CCE, and Jesse MacLean – ND, CST, MCI, CCT, LMP, CBI, CCE

Is the lack of hard evidence enough to dismiss the technique of cupping for athletes and place it among numerous tools that offer nothing but placebo effect? Is the absence of proof the proof of absence? A few simple laws of physics indicate this is not so.

Using Bernoulli’s principle and Poiseuille’s Law, decompression techniques result in pressure reduction within the tissues, causing an increase in the velocity of blood within the capillaries. There is an increase distribution of blood carrying oxygen, glucose and other nutrients, minerals and immunoglobulins. According to Bernoulli’s Equation, diminished pressure results in increased velocity.

Movement is the essence of life. Any method that increases movement, or the velocity of blood, helps in the nourishment of muscle, ligaments, nerves, connective tissues, tendons and bone.

Most athletes have specific areas of aches and pains due to injuries or overuse. Swimmers have shoulder and latissimus dorsi pain. Basketball players and baseball players have hamstring, thigh, and arm pain. Runners have plantar fasciitis and leg cramps. Extremely strenuous activities like football, skiing, boxing, gymnastics and marathons result in rapid production of lactic acid and other toxic metabolites.

Athletes complain of cramps, tense muscles, shin splints and painful motion. There is greater need of blood in these areas and cupping is one of the best ways of addressing this need.

In inflamed areas, where there is slowing movement of lymph and blood due to congestion, cupping together with anti-inflammatories can help ease the pain. Extreme exertion results in massive fluid loss, making blood more viscous. According to Poiseuille’s Law, increasing fluid intake reduces the viscosity of blood, to help increase its velocity. Adding electrolytes to the fluid prevents water intoxication.

What is Cupping for Athletes?

SportsCupping is a type of cupping for athletes. It is the application of cupping methods to an athlete with the purpose of enhancing their preparation for, performance during and recovery from the physical demands of training and competition.

According to anecdotal evidence, SportsCupping allows the athlete to train longer and at higher levels. There is also reduction of strain and discomfort during training and diminution of muscular and tendinous injuries. Furthermore, the increase in circulation during treatment accelerates healing of acute injuries and reduces scar tissue. This helps prevent chronic conditions.

Methods Used During SportsCupping

Three primary cupping methods used on athletes include a combination derived from stationary, massage and dynamic cupping. Which protocol used is dependent on the needs of the individual athlete and whether occurring pre- or post-event.

Pre-Event

Cupping used before an event prepares the athlete for the inevitable need for more oxygen, sugar proteins, and fats that extreme exertion requires.

The athlete’s brain is alert to danger because neurons are fed by nutrients carried by the increased circulation. The eyes, ears and nose, and the Pacinian corpuscles enhance vision, hearing, smell, and feel that muscles need to achieve success and avoid disasters like colliding with other athletes or objects.

Post-Event

Cupping used post-event allows the body to expel most of the toxic metabolic products created during the competition. The improved circulation that results from cupping helps repair damaged tissues.

Specific SportsCupping Techniques

• Intermittent(flash): sans movement, use a pumping action to stimulate blood flow

• Cross fiber friction: perpendicular movement to the muscle fiber and fascia
• Vibrational: muscle attachments cup placement of a joint and gently vibrate the joint in all directions at low amplitude (centimeter displacements) and high frequency (three times per second).
• Stripping: smooth muscle fiber directional gliding of cups

• Joint mobilization (dynamic cupping): direct cup placement of joint or muscle attachments, assist the joint through all normal ranges (flexion, extension, rotation, circumduction) at low frequency(three to five seconds)—PROM, AROM and RROM—depending on need.
• Lymph drainage: gentle suction and slow glide of the cup along natural lymphatic watershed
direction.

Adjust accordingly based on phase of sports activity:

• Training/maintenance (conditioning): all SportsCupping techniques
• Pre-event (off-site): all SportsCupping techniques
• Pre-event warm-up (on or off-site): 1. Quick-flex muscle sports (such as sprinting, soccer, tennis): intermittent, lymphatic drainage; 2. Slow-flex muscle sports (such as long-distance running): all SportsCupping techniques

• Intra-event: 1. Quick-flex muscle sports (such as sprinting, soccer or tennis) use intermittent, lymphatic drainage; 2. Slow-flex muscle sports (such as long-distance running) use all SportsCupping techniques
•Post-event (on-site or off-site within one hour of the event): use lymphatic stimulation
•Post-event (off-site within 24 hours of the event): all SportsCupping techniques
•Rehabilitation (from injury or overtraining): all SportsCupping techniques

In Summary

Cupping creates a pressure-reducing vacuum in swollen and inflamed tissues, thus speeding the velocity of blood. In athletes who suffer from strains, cramps, or tense muscles and fascia, the resulting improvement in circulation feeds cells, thus promoting and enhancing repair at the same time the dead cellular debris and toxic products of metabolism, like lactic acid, ammonia urea and creatinine, are taken away to the organs of excretion.

With cupping, athletes can look forward to improved performance, greater energy, range of motion, reduction of pain and faster recovery from competition, and thus be ready to compete another day.

About the Authors:

Dominador Perido, MD, CCT, CCE, is a board-certified general surgeon who practiced in the southwest corner of Kansas for over 40 years. He had his surgical residency at St. Vincent’s Medical Center in Staten Island, New York, from 1971 to 1975 and moved to Elkhart, Kansas, immediately after residency. After seeing the failures in surgery and orthopedics, he discovered the overwhelming benefits of cupping and acupuncture. Perido is a cupping educator for the International Cupping Therapy Association.

Mark Perido, MSOM, MHCL, CCT, CCE, is an Oriental Medicine Practitioner in Olathe, Kansas. With a master’s of science in Oriental Medicine from KCCM and his bachelor of arts in psychology from Boston University, he also holds an MHCL from Friends University in Wichita, Kansas, and certification in surgical technology from Seward County CC in Kansas. He is a member of the National Acupuncture Detoxification Association and sits on the steering committee of the International Cupping Therapy Association.

Jesse MacLean

Jesse MacLean, ND, CST, MCI, CCT, LMP, CBI, CCE, Jesse manages EarthSpa R&D, cupping equipment design, production and research and is the current sitting director of education for the ICTA. She advocates and educates insurance companies, legislative groups and medical professionals in the equipment, applications and benefits of cupping therapy. These ongoing efforts have led to a growing widespread validation, acceptance and insurance coverage for cupping professionals. MacLean works to bring together cupping professionals from all over the world in support of equipment advancements, research and protocol development and the integration of cupping therapy into the mainstream health care industry.

Expert Insights on Cupping