Cupping and the Injured Athlete – Does It Work?
Throughout history, there have been many eastern and western forms of medicine that have come and gone. Some have survived the test of time. Others have been considered to be more “trendy” while other techniques are meant to repeat themselves over time.
Today, myofascial decompression, better known as cupping, has made a return to western society, especially in physical therapy and athletic training room settings.
What are those reddish-purple, round bruises displayed on the bodies of some of the athletes competing in the 2016 Rio Olympics? It seems that in addition to training with the latest state-of-the-art techniques and equipment, some athletes are turning to ancient practices to keep their edge.
“The athletes are looking for any edge — real or imagined — they can get,” says Mayo Clinic anesthesiologist Dr. Michael Joyner, who studies elite athletes.
The bruises are caused by the traditional Chinese medicine therapy of cupping. The theory behind cupping is that it moves or stimulates your body’s natural energy — also called qi. Cupping is said to increase blood supply to a specific area, and athletes use it in recovery to help heal sore tired muscles.
The question is: Does cupping work?
Dr. Joyner says, “There is no evidence pro-con that shows cupping works or does not work. This is true for a lot of mainstream ideas about warm-up and recovery. It is also true for a lot of outside-the-box ideas. There can be placebo effects for these sorts of things, and what I tell athletes is that if they think it helps and there are no downsides, then, if it feels good, do it. The key is to not try anything brand new the day of competition.”
Cupping therapy involves heating the air inside a glass cup, which removes some of the air from the cup. The cup is then quickly placed on the skin, and the resulting vacuum pulls the skin partially into the cup, causing a bruise. Some people say they do experience a release in muscle tension afterward, but there’s not much research to prove one way or the other.
Dr. Joyner says studying the physiological effects of cupping on an Olympic athletes’ performance would be difficult because the change would likely be minimal. Mayo Clinic experts say if an athlete wants to try cupping, he or she should talk to a specialist who is well-versed in the practice.
The 2016 Olympics have come and gone. Our Olympians pushed their bodies to the limit and brought home the gold. In doing so, many of these outstanding athletes relied on the help of physical therapists to perform their best on and off the field (or pool).
As with many Olympics, our athletes seek out any form of treatment that may prove beneficial and take advantage of “new” treatments that really may not be new at all. For example, in the previous Olympics, we saw a lot of taping. The multiple colors and configurations received a lot of attention.
This time around was no different.
What were those mysterious circular marks on Michael Phelps’ shoulders? How did he get them? Do they hurt? Is there any benefit?
Cupping has been around for quite a while. It’s been used by many professions, in many countries, and by many cultures. Some professions use cupping to treat ailments and other illnesses, particularly within the respiratory system. As with any “remedy” it has evolved and entered into the mainstream as a gentle treatment.
The answer to the question “what is cupping” depends on which professional you ask. As a physical therapist, I can tell you we’ve used cupping in my clinic for years as a way to manipulate the soft tissue. We use our hands and elbows but can also use instrument-assisted soft tissue manipulation, dry needling where permitted, cupping, and a variety of other methods, all to get those tissues moving. Our goal is to increase mobility, promote healing, and restore function.
As far as the Olympics go because swimmers are susceptible to shoulder injuries, keeping the tissue mobile and healthy is paramount, especially for someone like Michael Phelps.
The application of cupping also varies in the types of cups, size, and treatment methods. One type of cup creates a vacuum by being heated up, placed on the skin, and slowly cooled down. As the inside of the cup cools, suction is formed and pulls or lifts the skin and fascia up. Another cup type is attached to an electrical vacuum or pump. In either case, the cup is placed on the skin, the suction is created and the tissues are lifted. Since heat is not used and cooling does not occur, the suction is eventually released after a period of manipulation. Last but not least, suction can be applied using cups with a simple bulb on the end that can be squeezed to varying degrees determining the level of vacuum. The tissues are manipulated and the vacuum is released. Regardless of the cup type, the cup may be left in one place or moved around, but all treatment methods are gentle and very specific.
The circular marks on Michael Phelps’ shoulders are bruises. As the cup is allowed to cool and the suction lifts the tissues, it can leave a bruise, however, the bruising does not indicate the outcome of the treatment. Although not particularly attractive, they are not painful and resolve quickly.
Cups are often placed in areas of high stress, such as muscle origins and insertions. They can also be applied to high-stress areas of fascial convergence, where multiple planes intersect or overlap, or they can be used to improve mobility of scar tissue. Treatment can be applied outside the area and gently moved into and around the restricted areas with the help of a lubricant.
How cupping works to manipulate soft tissue, improve blood flow, and promote healing is not exactly known. Explanations are borrowed from other soft tissue techniques and related to fascial research. One thought is the lifting or “unloading” of the tissue via suction allows creep, decompression of the blood vessels, and therefore improved blood flow. Another thought is more mechanical. It is thought that perhaps pulling on tissue manipulates the collagen, which imparts stresses to fibroblasts, and in turn triggers a chain reaction causing the tissues to relax, and perhaps improve blood flow and healing.
As we saw with Phelps, the most common application for cupping is to assist with healing in “overuse” type circumstances. Little is known regarding the length of treatment benefit. Similarly, the evidence for the length and intensity of treatment is empirical at best and varies from patient-to-patient.
Lastly, I should mention something about the adverse effects or side effects. In extreme cases bleeding can occur, however, this is rare and is usually limited to a special type of cupping called blood cupping. In the majority of cases, the most common side effect has already been displayed by Phelps: bruising. All traces of his treatment were gone a few days after the closing ceremony.
Although the treatment length and intensity, and long term benefit of cupping is still not known, cupping is a safe form of soft tissue manipulation that has been incorporated by physical therapists and is easy to use.
as displayed the same marks on his shoulders, swimmer Nathalie Coughlin has also been seen with the marks on her chest and the US track and field team are also reportedly fans of the practice.
Some of the benefits for athletes as faster recovery, improved muscle movements, and reduced aches and pains.
But what exactly is it?
Cupping is a form of alternative therapy designed to relieve pain by improving blood flow in the affected area. It’s been linked with relieving muscular pains and providing more flexible muscles. This is because cupping acts as an inverted massage: rather than applying pressure, the skin is pulled away with similar effects.
This can also be seen in the smooth sheet of connective tissue (fascia) that covers the muscles. Connective tissue can become stiff, restricting muscle and joint movements. Cupping may relieve stiff fascia, making it more elastic and pliable, increasing mobility.
Cupping is historic practice, having roots in Ancient Egyptian and traditional Chinese medicine where it has been used as a remedy for many disorders.
How does it work?
According to the British Cupping Society, there are four common theories as to how cupping works: the pain gate theory, detox theory, immune system activation theory, and muscle relaxation theory.
The pain gate theory describes stimulating specific nerve fibers at the location of the pain. Applying the heated cup stimulates neurons that may block these pain signals, reducing pain in the individual.
Detox theory believes that restoring homeostasis is key. The negative pressure relieves the body from congestions due to poor circulation.
Immune system activation theory offers an explanation through promoting the production of natural killer cells and cytokines which secrete anti-inflammatory properties.
Finally, the muscle relaxation theory dictates that vasodilation increases parasympathetic nervous activity, leading to muscle relaxation.
How is it done?
First, oxygen in the cup must be removed before application. Usually, a cotton ball is soaked in alcohol, or a similar flammable liquid then set alight before being placed in the cup.
This heats the cup, allowing a vacuum to be created when applied to the patient’s skin. As the air inside cools, the skin is gently pulled away from the body, allowing blood to pool in the area. The cups can remain in place on the skin for several minutes, allowing affected tissue to receive more nutrients and oxygen. Circular red or purple bruises may remain on the skin for up to two weeks after a session due to ruptured capillaries and improved circulation in the area.
This is all known as ‘dry’ cupping, and a suction pump may be used in place of a flame. The ‘wet’ form of cupping (or ‘hijama’) involves making a small incision in the skin before applying the cup. Umm says that wet cupping releases toxins. This occurs because drawing out a small amount of blood activates the immune system, destroying pathogens and lowering blood pressure.
A 2016 study published in the Evidence-Based Complementary and Alternative Medicine journal found that a group of patients with shoulder and neck pain reported significantly less pain after receiving cupping therapy.
Umm says improving circulation will improve poor Qi (‘vital energy’) by placing the cups at selected meridian points. Umm mentions that pain can be caused by blood congestion if blood cells are deprived of oxygen and plasma. The darker the marks left by the cups, the more sluggish the person’s circulation.
The British Cupping Society claims cupping therapy can be used to treat physical conditions like back pain, osteoarthritis, or rheumatism, in addition to psychological conditions such as anxiety.
Who can’t cup?
Umm cites the neck, shoulders, and back as the most common areas of the body to cup as this is where the majority of toxins build up. Areas to be avoided include the front of the neck, inner wrists, in front of the ears, the armpits, and genitalia. Broken skin, eczema, psoriasis, varicose veins, and recent surgical scars should also be avoided. Children and the elderly should be treated by an experienced practitioner as a result of their sensitive skin. People with a history of heart problems and taking blood-thinning medications should be monitored carefully.
New Methods of Myofascial Decompression (Cupping) for Athletes
The most challenging part of myofascial decompression (MFD), better known as cupping, is the bruise marks. Almost everyone, athletes included, is left with circular marks from the negative pressure of the cups. These can last anywhere from three to seven days, sometimes even longer. Believe me, I make sure the athlete knows what he or she is in for. Each time, the athlete has been receptive, saying, “I’ll try it if it will help me get better.” But MFD for athletes is different from your traditional version for relaxation. Work is required by the athlete in order to see some of the best benefits possible.
I’ve been using MFD in my practice for over a year now. I’ve used it therapeutically to treat almost any injury, from plantar fasciitis to hamstring strains to myofascial restrictions unrelated to the injury. I’m surprisingly pleased with how many of the athletes are asking for repeat treatments. Although they all complain about how sore it makes them, they are pleased and excited with the outcomes: increased flexibility, fewer restrictions, and an overall feeling of being better.
Those keywords from the athletes are what keep me using and expanding my knowledge of MFD. I’ve even done a before and after with several of them. I assess their range of motion before the treatment, especially hamstrings, and compare it with post-treatment results. I have found three techniques that are most helpful. Two of the three require active movement from the athlete after the cups have been placed:
- The first is an active flexion/extension movement. Although painful at the start, most of the athletes indicate more movement. After treatment the range of motion increases by ten to fifteen degrees.
- The more aggressive technique has that athlete prone, leg off the table, hip flexed, and knee flexed. The goal is to get the heel down and extend the knee. If they can get the heel to touch the ground then that is excellent progress. For runners, this mimics more the motion required to propel forward. Again, this is painful when the person moves, but the gains are invaluable.
Swimmers have also inquired about MFD and there are two clients, in particular, I’ve worked with. Both were having “reach and pull” issues on their strokes. The focus was placed on the latissimus dorsi and teres major. After the cups were placed, they were asked to extend and slightly pull down with the arm. The motion increased in both. One of them even had the fastest swim of his career! He is so happy with the results he plans on doing another treatment before the conference. It’s wonderfully exciting to see the success achieved by the athletes.
MFD has benefits for everyone. I tend to focus on athletes and their return to play or improved performance enhancement. I cannot say if it is the right treatment for everyone. It depends on what you are trying to achieve. My focus is on active motion with MFD. Other professionals prefer to use MFD as a way of relaxation.
The traditional way of using MFD is to follow the meridian lines of the body. The cups are placed along these particular lines to elicit change within the body. I’ve even seen someone cry after being treated because it fell along with one of the emotional lines. It was surprising to see, but I knew to expect it. I have also known people who had it done to help with general back pain and soreness. Funny thing is, they fell asleep with the cups on them. When it’s being used in this manner, anything is possible.
Two completely different methods, using the same equipment, can elicit such different results. It’s really interesting to see the old methods intertwined with new concepts and theories. As we move forward with research and literature, we continue to see so many amazing changes to traditional theories, with MFD being a good example. From the early years, where it was solely used for medicinal and relaxation to purposes to the current trend of using movement patterns with MFD, the treatment practice has grown immensely. Now, it’s the en vogue treatment for athletes and weekend warriors.
Anyone who is interested in experiencing either form of this treatment needs to seek out a practitioner qualified in MFD. If you want a relaxing experience with MFD, then it is recommended to seek out a licensed acupuncturist. Most will generally have knowledge and skill in the use of MFD. If you are seeking the more aggressive MFD utilizing movement, that will be more difficult to locate. In the athletic realm, some physical therapists and athletic trainers have taken coursework in incorporating MFD and movement. More professionals on the West Coast may have exposure to such techniques. As with anything, please make sure to ask questions before jumping into something new. Make sure it’s what is right for you.
Cupping therapy is an ancient form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing. Suction is created using heat (fire) or mechanical devices (hand or electrical pumps). It is known in local languages as Meyboom,baguan/baguar, badkesh, banki, bahnkes, bekam, buhang, bentusa, kyukaku, giác hơi, Hijamah, kavaa (ކަވާ), mihceme, and Singh among others.
Through either heat or suction, the skin is gently drawn upwards by creating a vacuum in a cup over the target area of the skin. The cup stays in place for five to fifteen minutes. It is believed by some to help treat pain, deep scar tissues in the muscles and connective tissue, muscle knots, and swelling.
There is reason to believe the practice dates from as early as 3000 BC. The Ebers Papyrus, written c. 1550 BC and one of the oldest medical textbooks in the world, describes the Egyptians‘ use of cupping. Archaeologists have found evidence in China of cupping dating back to 1000 BC. In ancient Greece, Hippocrates (c. 400 BC) used cupping for internal disease and structural problems. This method in multiple forms spread into medicine throughout Asian and European civilizations.
Broadly speaking there are two types of cupping: dry cupping and bleeding or wet cupping (controlled bleeding) with wet cupping being more common. The British Cupping Society (BCS), an organization promoting the practice, teaches both. As a general rule, wet cupping provides a more “curative-treatment approach” to patient management whereas dry cupping appeals more to a “therapeutic and relaxation approach”. Preference varies with practitioners and cultures.
The cupping procedure commonly involves creating a small area of low air pressure next to the skin. However, there is a variety in the tools used, the method of creating low pressure, and the procedures followed during the treatment.
The cups can be various shapes including balls or bells and may range in size from 1 to 3 inches (25 to 76 mm) across the opening. Plastic and glass are the most common materials used today, replacing the horn, pottery, bronze, and bamboo cups used in earlier times. The low air pressure required may be created by heating the cup or the air inside it with an open flame or a bath in hot scented oils, then placing it against the skin. As the air inside the cup cools, it contracts and draws the skin slightly inside. More recently, a vacuum can be created with a mechanical suction pump acting through a valve located at the top of the cup. Rubber cups are also available that squeeze the air out and adapt to uneven or bony surfaces.
In practice, cups are normally used only on softer tissue that can form a good seal with the edge of the cup. They may be used singly or with many to cover a larger area. They may be used by themselves or placed over an acupuncture needle. The skin may be lubricated, allowing the cup to move across the skin slowly.
Depending on the specific treatment, skin marking is common after the cups are removed. This may be a simple red ring that disappears quickly, the discoloration left by the cups is normally from bruising especially if dragging the cups while suctioned from one place to another to break down muscle fiber. Usually, treatments are not painful.
Fire cupping involves soaking a cotton ball in 70% alcohol. The cotton is then clamped by a pair of forceps and lit via match or lighter. The flaming cotton ball is then, in one fluid motion, placed into the cup, quickly removed, and the cup is placed on the skin. By adding fire to the inside of the cup, oxygen is removed (which is replaced with an equal volume of carbon dioxide) and a small amount of suction is created by the air cooling down again. Massage oil may be applied to create a better seal as well as allow the cups to glide over muscle groups (e.g. trapezius, erectors, latisimus dorsi, etc.) in an act called “moving to cup“. Dark circles may appear where the cups were placed due to rupture of the capillaries just under the skin, but are not the same as a bruise caused by blunt-force trauma.
Wet cupping (Al-Hijamah or medicinal bleeding)
While the history of wet cupping may date back thousands of years, the first documented uses are found in the teachings of the Islamic prophet Muhammad According to Muhammad al-Bukhari, Muslim ibn al-Hajjaj Nishapuri and Ahmad ibn Hanbal, Muhammad approved of the Hijama (cupping) treatment.
A number of hadith support its recommendation and use by Muhammad. As a result, the practice of cupping therapy has survived in Muslim countries. Today, wet cupping is a popular remedy practiced in many parts of the Muslim world.
Alternatively, mild suction is created using a cup and a pump (or heat suction) on the selected area and left for about three minutes. The cup is then removed and small superficial skin incisions are made using a cupping scalpel. A second suction is used to carefully draw out a small quantity of blood. The procedure was piloted and developed by Ullah et al 2005 and has been endorsed by the British Cupping Society which aims to promote, protect, and develop professional standards in cupping therapy.
In Finland, wet cupping has been done at least since the 15th century, and it is done traditionally in saunas. The cupping cups were made of cow’s horns with a valve mechanism in it to create an underpressure on them by sucking the air out. Cupping is still used in Finland as alternative medicine.
Traditional Chinese medicine cupping
According to traditional Chinese medicine (TCM), cupping is a method of creating a vacuum on the patient’s skin to dispel stagnation— stagnant blood and lymph, thereby improving qi flow — to treat respiratory diseases such as the common cold, pneumonia, and bronchitis. Cupping also is used on back, neck, shoulder, and other musculoskeletal conditions. Its advocates say it has other applications, as well. Cupping is not advised over skin ulcers or to the abdominal or sacral regions of pregnant women.
Limited bruising cupping
New silicone therapy cups are claimed to alleviate bruising associated with traditional cupping. The cups are easier to use and are pliable, unlike glass or plastic, allowing for home use. Due to the lack of bruising and overall comfort, silicone cups are mainly smaller in size and used for facial cupping. Hydration before and after the therapy and general massage can also help reduce the bruising from cupping.
Cupping is claimed to treat a broad range of medical conditions such as blood disorders (anemia, hemophilia), rheumatic diseases (arthritic joint and muscular conditions), fertility and gynecological disorders, and skin problems (eczema, acne), and is claimed by proponents to help general physical and psychological well-being.
Cupping is widely used as an alternative treatment for cancer. However, the American Cancer Society notes that “available scientific evidence does not support claims that cupping has any health benefits” and also that the treatment carries a small risk of burns.
A 2012 review of the evidence in an article published in PLOS ONE said that studies appeared to show that cupping therapy was effective for treating a number of conditions, but that “nearly all included trials were evaluated as high risk of bias” – better-designed studies would be needed in order to reach definitive conclusions
Very few scientific studies have been conducted on the validity of cupping as an alternative medical practice. In fact, a significant amount of studies either do not support cupping practices or are unable to reach a conclusion concerning its effectiveness.
Traditional Persian medicine in Iran takes advantage of wet cupping practices, for the belief that cupping with scarification may eliminate the scar tissue, and cupping without scarification would cleanse the body through the organs (Nimrouzi et al., 2014). Research suggests that this practice is indeed harmful, especially to thin or obese patients. It may be noted that individuals of profound interest in the practice are religious and seek purification. According to Jack Raso (1997), cupping results in capillary expansion, excessive fluid accumulation in tissues, and the rupture of blood vessels. Although bruising caused by this practice is common, minor, and temporary, continuation may cause burns of the skin. Individuals have been performing the action for over 3,000 years, it is still yet to be scientifically proven. The practice is performed unsupervised, without any medical background, and often indicates more risks than obvious benefits.
In a recent controlled study by Cho and colleagues (2014), traditional East-Asian medical practices were evaluated in terms of effectiveness against lower back pain. Cupping was evaluated by the current Clinical Practice Guidelines (CPGs) and with evidence from current systematic reviews and meta-analyses. They found that out of thirteen CPGs, only one recommended cupping. The researchers therefore weakly recommended cupping for both (sub) acute and chronic lower back pain. It may be that cupping is more a traditional act of “faith healing” rather than an act of medicine.
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