Practiced in various cultures for more than 3,000 years, cupping therapy is a traditional form of alternative medicine on par with acupuncture and Chinese massage (tui na). The technique uses cups and suction to create negative air pressure next to the skin to stimulate the flow of body fluid and energy. While research has yet to conclusively support the practice, therapists who use it say this age-old modality decreases muscle pain, improves lymph flow, and can even reduce cellulite.

Cupping Principles  
Cupping therapy, as practiced in traditional Chinese medicine (TCM), is based on the concept of balance between yin (feminine) and yang (masculine) energy in the body. The energy, known as qi, flows in a closed network of channels and locks commonly referred to as meridians and pressure points. In TCM, chronic pain is regarded as an indication that qi is not flowing freely in the body: “tong ze bu tong; tong jiu bu tong (pain means no free flowing; free flowing means no pain).”
Stagnated blood is considered the primary block that impedes the free flow of qi. Through negative air pressure, cupping breaks the capillaries to let out stagnated blood and sets off a chain reaction of repair and restoration, resulting in the formation of distinctive, circular skin markings on the treatment area. The body’s metabolic process rebuilds the “managed bruising” of the local tissues, absorbs the bruises into the bloodstream for waste disposal, and restores the free flow of body fluid and energy. Skin marking from cupping usually disappears in 5–7 days.
There are several ways cupping is administered. I utilize suction for my cupping therapies, using a pump to create the negative air pressure. A more traditional technique is to use fire (applying rubbing alcohol to the inside of the cup and lighting it on fire before placing it on the client’s skin), although the obvious risks with this technique must be considered carefully, as they are not covered under many professional liability insurance policies. Another variation on cupping that is well outside the scope of massage practitioners is wet cupping, where controlled medicinal bleeding becomes part of the treatment.
Although acupuncture is often used in conjunction with cupping, it is not essential to the therapy’s viability. Massage can also be a component of cupping: when oil is applied to the client’s skin beforehand, suction cups can then be moved easily around the body to address areas of pain.
The objectives of cupping therapy include keeping meridians open, promoting circulation of qi and blood, dissolving stagnated blood, relieving chronic pain, moderating yin qi and yang qi, clearing “internal heat,” and dispelling internal cold and dampness. Cupping therapy is another way of using external approaches to treat internal problems—a treatment strategy in TCM.

Three Cases  
I have had a variety of experiences incorporating cupping into my therapeutic sessions. Here, I note three cases that indicate how I interpreted my clients’ cupping results.

Case 1 is a male client in his mid-30s. He reports having back pain, due perhaps to his posture at work. Cups are applied on his posterior lower back, their suction focused on the bladder meridian (the quadratus lumborum area). The darker red color of the lower right posterior skin marking shows a high level of excess yang energy in his lower back. The marking is on dachangshu (BL25), indicating that his lower back pain is due to congestion in the large intestine, as well as muscular adhesion in the lower back.

Case 2 is a female client in her late 60s. She reports having tightness in her back, due perhaps to her sleeping position. Cups are applied on her posterior upper back, inferior to the scapulae, their suction focused on the bladder meridian and the erector spinae group. The darker red color of both posterior superior skin markings show a high level of excess yang energy in her upper back. The markings are on jueyinshu (BL14), indicating that the back pain is due to congestion in the chest, as well as muscular adhesion in the upper back.

Case 3 is a female client in her mid-40s. She reports feeling uncomfortable, due to stomach bloating. A single cup is applied on her anterior lower abdomen (what TCM identifies as the dantian area) where gas bubbles are present; its suction is focused on the inferior segment of the ren meridian. After the cup is removed, there is no change of skin color or texture, indicating that the bloating is due to excess yin energy. The gas bubbles are released through guanyuan (CV4), a key pressure point on the ren meridian.

Contraindications and Indications
As with all therapies, it’s important to understand the circumstances under which cupping should be avoided. Cupping therapy is not advised for persons with a bleeding tendency, cancer, edema, high fever, infection, sensitive skin, spasms, twitching, or ulcers. It should also not be applied over the abdominal or sacral regions of pregnant women.
Cupping therapy is effective for shoulder and back pains, joint pains, soft-tissue injuries, and several internal conditions.
The typical sites for treatment of shoulder and back pains include points on the bladder, conception (ren), gall bladder, governing (du), large intestine, small intestine, sanjiao, spleen, and “extraordinary head-neck” meridians. These specific points are dazhu (BL11), fengmen (BL12), geshu (BL17), ganshu (BL18), shenshu (BL23), ciliao (BL32), weizhong (BL40), qihai (CV6), fengchi (GB20), jianjing (GB21), yaoyangguan (GV3), dazhui (GV14), quchi (LI11), binao (LI14), jianyu (LI15), jianzhen (SI9), tianzong (SI11), jianwaishu (SI14), waiguan (SJ5), sanyinjiao (SP6), and bailao (Ex-HN15). The courses of these meridians are in the posterior body and anterior arms, so cups should be applied on these areas of the body.
The typical sites for treatment of internal conditions such as constipation or abdominal bloating include points on the bladder, conception (ren), governing (du), kidney, spleen, stomach, and “extraordinary back” meridians. These specific points are geshu (BL17), pishu (BL20), weishu (BL21), zhonglushu (BL29), ciliao (BL32), guanyuan (CV4), qihai (CV6), dazhui (GV14), dahe (KI12), sanyinjiao (SP6), diji (SP8), guilai (ST29), zusanli (ST36), and shiqizhui (Ex-B7). The courses of these meridians are in the anterior lower abdomen, posterior lower- and mid-back, and medial legs.   

Cupping at Work  
Cupping is a technique that can be easily combined with other hands-on modalities. Here is a brief overview of what cupping looks like to the practitioner.
To begin, lightly lubricate your hands and glide over the areas of pain or discomfort on your client to feel for muscular adhesion and tightness (stagnated blood or fluid). Then, lubricate the problem area liberally. Place a vacuum cup over the area and extract air pressure from the cup with a suction gun. Adjust suction according to the client’s condition and reaction. Use two or three cups along the same meridian, as needed. Remove the cups after 10–15 minutes. Apply effleurage or petrissage strokes to the distal segment of the meridian while the cups are on the skin. Wipe off lubrication after the cups are removed, and sanitize the cups using Standard Universal Precautions.

Interpreting the Results
After removing the cups, you can further discern the client’s condition by evaluating what you see.
• If the skin marking appears moist and water-filled, the client’s internal condition is “damp” and yang-deficient.  
• If the skin marking is colored dark red or purple-black, is filled with spotted bruises, and is warm to the touch, the client’s internal condition is “overheated” and yang-excessive.
• If the skin marking is colored dark red or purple-black, but there are no spotted bruises and it’s not warm to the touch, the client’s internal condition has stagnated blood.
• If the skin marking has no change of color and is not warm to touch, the client’s internal condition is “cold” and yang-deficient.
• If the skin marking is itchy or wrinkled, the client’s internal condition is cold and gaseous.
Conclusion  
The mechanics of cupping are relatively simple. Although the theoretical basis of cupping therapy revolves around meridians and pressure points, its application can be adapted according to Western understanding of human anatomy and physiology—knowledge that therapists have acquired in their initial training and refined in their clinical practices.
Cupping therapy, especially using vacuum cups, can be an invaluable tool for massage and bodywork therapists, and it can be learned in a short time, ideally in a workshop under the supervision of a cupping expert.

Cupping Cautions
Use no more than six cups in a cupping treatment session to allow for focused treatment. Ensure that the cups do not remain on the skin for more than 15 minutes, and for the initial treatment, limit the time to 10 minutes. Allow a 3–5 day interval between treatments.
Even in a dry cupping session, there is potential (though rarely) for exposure to blood for the practitioner. Before removing a cup, the practitioner should examine the treatment area to see if blood has oozed out under the cup. If blood is present, wear gloves for protection before removing the cup and use Standard Universal Precautions to clean the area and any tools that come in contact with the blood. (Note: In my several years of doing cupping, I have encountered only one client who had blood oozing from the treatment area in a dry cupping session.)

Client Take-Home Instructions
When sending your cupping client home after a session, be sure to offer these home-care tips:
• Keep yourself warm. Don’t be exposed to cold air.
• Don’t take a bath or shower immediately after treatment.
• Don’t vigorously rub the treatment area.

Samuel Wong is a research massage therapist based in Northern Virginia. Trained in Western massage, Wong is also a practitioner of tui na and trained in China. His research focus is using massage to treat fibromyalgia. Reach him at drsamwong39@gmail.com.