The Medical Perspective Of Cupping Therapy Effects And Mechanisms Of Action

[Ara Kistner]

Cuppingtherapy is the traditional treatment method applied in the far east for thousands of years. Cupping therapy is applied to the skin by vacuuming through various equipments [1,2]. While vacuuming was used with cups made of bamboo, metal and soil in ancient times, today it is applied with specially produced sterile glass and plastic cup [3].

According to the cupping therapy application method, it is divided into two as dry cupping and wet cupping (blood letting) [1,2]. Dry cupping is the process of applying vacuum by creating negative pressure with mug to certain areas on the skin [1,3,4]. In dry cupping, there is no incision or liquid draw on the skin. The goal of dry cupping therapy is to increase the blood flow by creating a massage effect in the applied area, to create a pain relieving effect and to operate the lymphatic system [2,4].

It has been observed that the efficacy of the treatment is increased in combination with far east treatment methods such as acupuncture and moxa applied locally after dry cupping therapy [2,3]. Dry cupping therapy can also be applied in patients where wet cupping cannot be applied or in patients who do not want to make an incision on their skin [4].

The blood letting treatment is applied to the back, head, shoulders, waist, chest, legs and other body parts depending on the complaint [4]. Blood letting process takes about half an hour. It is recommended to have at least 3-4 hours of fasting before the procedure, and it is recommended not to consume food of animal origin such as meat, milk, yoghurt, eggs, butter for approximately 72 hours before the procedure, the day of the procedure and the day after the procedure [4].

After the area where blood letting is to be applied is disinfected, firstly negative pressure is applied to the area with the help of a cup and the blood flow of the area is ensured to increase. Later, the cups are removed and small scratches are applied with the help of sterile scalpel, so that their length does not exceed 1 cm and the depth does not exceed 1-2 mm. Then vacuum is applied to this area again. It is waited until liquid stops coming and the liquid in it freezes. Then the mugs are opened, the incoming liquids are collected. After cleaning, it is closed with dressing. It is recommended not to take a shower at least 12 hours after the procedure [4].

Traditional and complementary medicine applications applied in Far Eastern medicine are generally applied together and the points where vacuum is applied in cupping therapy are acupuncture points [1].

Although blood letting treatment seems to be an easy practical procedure, it is a medical intervention that should be applied by physicians. If not careful, there is a risk of undesirable effects such as skin burns, skin abscesses and skin infections. In addition, cup treatment is not a treatment method that can be applied in every patient. It should not be used in patients with deep vein thrombosis, hypotension, varicose veins, cancer, severe anemia, heart failure or kidney failure. Bloodletting treatment should also be avoided in women who are in menstrual periods or pregnancy. Again, patients who use blood thinning medication should be very careful in their blood letting applications.

Using 'cupping therapy' as a keyword; the data were taken from the international database Pub-Med system in this meta-analysis searching for the therapeutic effect of cupping therapy, regional databases were not included in the study. In the Pub-Med database filters section; classical article, clinical study, meta-analysis, review and case studies were selected. The year range was determined as 1950-2019. Cupping therapy studies combined with other complementary therapies such as acupuncture, moxa and hidrotherapy were also included.

RCS contains herpes zoster pain, active herpes simplex infection, fibromyalgia, low back pain, headache, neck pain, injury, constipation, osteoarthritis, rheumatoid arthritis, allergic rhinitis, chronic urticaria, acne vulgaris, facial paralysis, chronic fatigue syndrome, ankylosing spondylitis, gout arthritis, carpal tunnel syndrome, acute eczema, asthma, hiccups, metabolic syndrome, hypertension, hyperlipidemia, obesity, heart rhythm, insomnia, effect on quality of life in chronic patients, depression in diabetes, neurodermatitis, chloasma, postoperative nausea, cervical spondylosis, peroneal nerve palsy, cerebral palsy, its effect on iron overload therapy, brachial paresthesia, upper extremity spasticity, its effect on the immune system, its effect on oxidative stress and forensic medicine.

The efficacy of cupping therapy was high in all 22 RCSs performed in cases of pain such as Herpes zoster pain, fibromyalgia, low back pain4, neck pain3, migraine pain2, tension-type headache, acute injury pains. In the reviews on fibromyalgia, low back pain and headache, it was concluded that cupping therapy is effective in the treatment of pain, but more studies are needed [5-10].

In addition, in 4 studies in which its effects on osteoarthritis were investigated (4 pieces), in 34 RCSs performed on diseases such as rheumatoid arthritis (1 piece), ankylosing spondylitis (2 pieces), gout, carpal tunnel syndrome (2 pieces), cervical spondylosis and limb spasticity, cupping therapy was found to be effective in bone / musculature diseases. In the reviews on osteoarthritis, carpal tunnel syndrome, ankylosing spondylitis, it has been concluded that cupping therapy is effective in musculature diseases [11-14].

In a randomized controlled study on the effect of cupping therapy on hypertension, a significant decrease in systolic blood pressure was observed in the group having cupping therapy and 4 weeks after the procedure, but in the 8-week follow-up, the blood pressure was observed to increase again in the blood letting group. Local studies were also included in a review evaluating the effect of cupping therapy on hypertension. Studies involving cupping therapy and comparisons with acupuncture concluded that cupping therapy was effective in hypertension [28]. In another review performed on hypertension, there is not enough evidence that cupping therapy can be effective in hypertension, but further studies are needed .

In the study on the effect of cupping therapy on autoimmune diseases, autoantibody, inflammatory mediators and serum ferritin levels were examined and it was concluded that cupping therapy was promising in autoimmune diseases [31].

There are studies investigating the effect of cupping therapy on heavy metal detoxification, which concluded that it was effective in removing heavy metals such as aluminum, lead, mercury and silver from the body [4,34].

Apart from these, there are case reports that cupping therapy is effective in the treatment of superficial thrombophlebitis, its therapeutic effect in mastitis, insect sting with lymphangitis, epicondylitis treatment, gluteal nerve junction syndrome and epistaxis treatment [35-38].

Survey studies on cupping treatment are about evaluating the knowledge and interests of the public and physicians on alternative medicine and cupping treatment. These studies were performed in Korea, China, Norway, England, Vietnam, Saudi Arabia, Thailand and Iran [39-44].

In addition, there are studies performed on the use of placebo silicon in cupping treatment, the effect of differences in anatomical back structure instead of mug, awareness of cup trace in forensic autopsies and cupping therapy device innovations [46,47].

20 of the case reports are related to the effectiveness of cupping therapy, and 44 case reports are on the side effects of cupping therapy. Most of the case reports on side effects were made in the last 10 years. Case reports related to their negative effects were mostly on side effects on the skin. There are case reports related to burns, bullae, keloid, hyperpigmentation reaction, infection, skin scar, skin abscess, epidural abscesses. There are also cases of koebner phenomenon in psoriasis. One case was related to lipoma formation after dry cupping. Cardiac hypertrophy due to anemia was reported after a prolonged cupping. In one case, extracranial vertebral artery rupture was reported after hematoma occurring in the nape after cupping therapy. It was stated that all these side effects were mostly occurred after wet cupping therapy performed by non-competent people [48,49].

The distribution of all these studies by years and regions can be seen in Fig. 1, 2. Although all studies have increased in recent years, there has been an increase especially in RCSs in recent years (Fig. 1, 3).

Many theories have been proposed regarding the possible mechanisms of action of cupping therapy. These effects can be classified as local effects, gate control theory, effects on the neural system, effects on the hematological system, effects on the immune system, reflex mechanisms, and placebo effect [4].

Kutivisceral reflex theory is one of the neuronal mechanisms of action. According to this theory, there are relations with internal organs in the relevant skin areas along the segments that the spinal nerves innervate. These relationships are defined as a kutivisceral / viserokuteneal reflex. In a pathological condition to occur in the organ, the signal to the relevant skin area may cause skin changes or pain in this area. According to this theory, starting from this mechanism, it is possible to contribute to the treatment of the organ with cupping therapy to be made to the segment related to the diseased organ.

Another important mechanism is the gate control theory. According to the gate control theory, it stimulates the thick unmyelinated A delta fibers with incision and vacuum created in wet cupping application, and closes the entrance doors of pain signals reaching the spinal core with the group C thinner myelinated nerve fibers in the substantia gelatinosa. In addition, by stimulating the mechanoreceptors, other pain stimulation is prevented over nociceptive afferent fibers and the stimulation is prevented from moving upward [7].

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