Cupping Therapy

JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

PRACTICAL GUIDE T0 CUPPING THERAPY by Ilkay Chirali

T

he first time I came across cupping was when I had a bad cold and my mother put some cups on my back. I could feel the edges of the glass sinking deep into my flesh. As the bruises appeared, my mother took the cups off, only to replace them with fresh ones! After cupping I was rubbed with home made alcohol and made to stay in bed, covered with plenty of blankets in order to make me sweat. Sure enough, within half an hour the bed was soaked with sweat. As soon as the sweating was over I was pushed into a hot bath and then returned to bed.The next day I was able to play outside with the other children and my cold was history. This story is, perhaps surprisingly, not one which took place in China, but in my native country of Cyprus. I was seven years old when I had my first cupping experience, and in the following years, I remember cupping was the only method used in our home for treating cold conditions such as sneezing and runny nose with headache and stiff back due to working in the rain or wind, and was even used for bed wetting (In Turkish folk medicine, bed wetting is considered to be a symptom of weak back due to “catching cold on the back”, or due to some kind of shock). My grandmother, who was the only midwife in the area, also used cupping quite extensively for the treatment of many female complaints, such as painful or irregular periods, cold in mother’s milk 1, miscarriage due to weakness of the back 2 and many more general complaints. She would use different sized drinking glasses and marmalade jars for cupping. Her favourite method was to take her patients to a Turkish bath, apply the cups in the cold

room, and then let them stay in the steam for ten to fifteen minutes in order to induce sweating. This was a useful approach since few people had Turkish baths in their own homes. Almost every home in Cyprus has a set of cups in their cupboards. In the old days olive oil wicks and ordinary drinking glasses or empty marmalade jars were used for cupping. Nowadays properly designed thick edged cupping glasses are imported from France or the Far East. This very ancient Chinese medicine practice was introduced to the Mediterranean region by the Ottoman Turks who originally came from Turkistan, now part of the People’s Republic of China (Sinkiang Uighur Autonomous Region of the People’s Republic of China, East Turkistan). As the Ottomans moved West, and eventually into Europe, this tradition came with them. Today most of the Mediterranean cultures still use cupping, especially the Turks, Greeks, Arabs, Southern Italians, Southern French and Spanish. While cupping was always a folk medicine in these countries, it was used more scientifically in English hospitals in the past. Frieda Sandwith in “Surgeon Compassionate”3 describes the work of her great grandfather William Marsden and the use of cupping in hospitals in the 1830’s to treat contagious diseases. She refers to “paid cuppers” working in these hospitals. Unfortunately, as modern drugs were developed, cupping along with other simple but effective methods, as well as the traditional Apothecary, were excluded from general practice, being contemptuously regarded as “old women’s remedies”. It is very ironic that we, as alternative practitioners, have to prove to today’s medical profession that cupping - and in-

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JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

deed many more previously practised therapies do work effectively and are as cost effective today as they were then.

Chinese healing art. More emphasis on cupping and its benefits during practical as well as theoretical training would be helpful.

Which cups to use

Benefits

Sets of cups are available in different sizes and are made of thick glass. Bamboo cups can also be found but, personally, I do not find them practical, especially when it comes to sterilisation4. In addition, the bamboo version tends to cause more discomfort, as the edges are thinner than those of the glass cups. The Chinese accept some degree of discomfort when treated but we, in the West should try and make the treatment as pleasant as possible. Most suppliers prefer to sell the cups as a set, rather than supplying single size cups. Most sets include one very large, two medium, and one very small size. Caution should be exercised when washing glass cups as they break quite easily.With bamboo cups there is no danger of breaking. Both types of cups are easily obtainable from Chinese medicinal suppliers.

Cupping regulates the flow of Qi (energy) and blood, and can add strength and effectiveness to a great many therapeutic applications. It is particularly beneficial in the following situations: - cold and wind attacking and penetrating the body - Qi stagnation - poor circulation - weakness of the digestive system (poor appetite, diarrhoea and dull ache in the lower abdomen) - asthmatic conditions - chronic back aches due to kidney energy deficiency - on Ashi points to relieve blood stagnation - to draw out pathogenic dampness, especially from arthritic joints

Before using cups

There are eight different methods of cupping: Weak, Medium, Strong, Moving, Needle Cupping, Moxa Cupping, Empty cupping, and Full cupping (bleeding). Weak Cupping: this is done with minimum suction, just enough to hold the cup in place.This type of cupping is particularly suitable for debilitated patients and for children. Cups are normally left for 10-20 minutes in adults and 2-5 minutes in children, but in weak cupping they can be kept in place for a longer period if needed.Weak cupping should not induce bruising or any sensation of pulling. If it does, then the suction is too strong, so remove the cups and and re-apply. Each time new cups are applied make sure that the skin is moistened with enough oil. Medium Cupping: with medium cupping, the suction is firmer, and the skin rises just a little inside the cup. This method is suitable for children between seven and fourteen years of age. Medium cupping can also be applied to adults on the stomach and abdomen. Very little bruising will appear even if the cups are left for a long time. With a new patient, I usually start with medium cupping, and increase the suction as the treatment progresses - helping to build up the patient’s confidence. I would advise all practitioners never to apply strong cupping at the first consultation. Strong Cupping: strong cupping should normally only be used on patients who have experienced medium strength cupping previously, so that they know what to expect. Whenever strong cupping is used for the first time, it is advised not to leave the cups in place for more than 3-5 minutes, and always massage the area after removing the cups. This type of cupping is not suitable for children, or weak or elderly patients. It causes bruising very rapidly and drains the energy if the cups are left for a long time. Strong cupping is best used on robust adults. Strong cupping is not suitable on the abdomen or stomach. and is mainly applied on the back, shoulders and knees. Moving Cupping: this is the most painful method of cupping. It is done by moving the cups while they are in

Before attempting to use cups, always make sure that your patient is fully relaxed. Many people are nervous about a fire lit next to their skin. Explain your intentions and the benefits of cupping, and show the cups to the patient (and let him or her touch and feel them). Most people will tell you that they have indeed seen cups on television programs and read about the technique but have never actually seen it done to anybody. Explain that the suction will cause a pulling sensation on the skin but not pain. The suction is less noticeable with thin and hairy people5, and more on smooth and fat skin. It is also important that you ask your patient to sit still and not to make sudden movements while cupping. If children are involved, always ask the mother or father to be present in the treatment room with you. It is advisable to try to hide the fire from the child, in order to reduce their fear to a minimum. You can apply cups with the patient in a sitting position, or lying prone or supine, whichever is the more comfortable. For the elderly and for people with severe asthmatic or heart conditions an upright sitting position is advised. Firm suction is desirable in order to achieve good therapeutic results from cupping. To ensure good suction, always moisten the treatment area with oil. Any vegetable oil will do, but olive oil is particularly beneficial. Coconut oil may be used for more sensitive skins. Avoid irritating oils such as Eucalyptus, Wintergreen and Clove.

When and where to use cups Cupping may be used by massage, acupressure (shiatsu) and other tactile therapists, and integrated to suit their particular technique. As far as acupuncturists are concerned, cupping can be used independently or in conjunction with acupuncture (while the needles are in position or following their removal), although cups are most frequently used on their own. Cupping therapy in this country is unfortunately used by few acupuncturists, and it makes me very sad to see so many acupuncturists who do not make use of this valuable traditional

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The Eight Methods of Cupping

JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

place on the skin. It is mostly used in excess heat conditions, and only on strong adults. Whether the suction applied is medium or strong, movement of the cups while in place will be uncomfortable to say the least. Before attempting the moving method, it is essential to make sure that enough oil has been used on the desired area. Also when moving the cups, rest between movements and apply massage to the bruised area. The most common area of application is the back, especially the Back-Shu points. The purpose of moving cupping is to draw out pathogenic heat and regulate the flow of blood. This will cause bruising very rapidly, which is the desired effect, indicating heat coming to the surface. It will be noticed that, as treatment progresses, less bruising will appear in subsequent sessions. Needle Cupping: cups can be applied over needles,whilst the needles are in the desired position. Again this method is used in Shi conditions, e.g. red, painful and swollen knees and shoulders. With this method, some blood may be drawn into the cup. This is quite normal, especially if the suction is strong. Obviously one should not attempt the moving method while the needles are in position. Moxa Cupping: moxa is placed on the needle in the normal way for warm-needle technique, and lit. As soon as the moxa has stopped smoking, and while it is still very hot, place the cup over the needle. It is advisable to use a small piece of paper or card over the skin to protect it from hot ash. This method is used when tonifying and moving the Qi. Empty Cupping: this is actually a strong cupping method, but the duration of the suction is very short, i.e. less than one minute, and it can therefore be applied to very weak persons, children and adults. The technique is easy: choose the cupping area and apply five to ten cups simultaneously, then immediately remove the first one, replacing it with a new one. Continue replacing the cups until bruises appear. This may take up to 5 minutes. This method is very effective when the effect of “drawing out cold” is desired, especially on Xu patients, since it does not drain the energy excessively. Full Cupping (Bleeding): with this method, the full understanding and cooperation of the patient is essential. In the 1830’s when antibiotics were unknown in England, this was the method used to draw out and elimi-

nate poisons and infections from the body. The bleeding method is only used when excess Blood-Heat is involved. A small cut is made on the back - usually in the upper part of the body - and the cup is placed over the cut. The vacuum created will draw blood into the cup which will fill rapidly. In Turkish folk medicine this bleeding method was used when a sudden rise in blood pressure endangered life (the face appears to be ready to burst with blood, the eyes are bloodshot, and there is a feeling of heaviness over the shoulders and neck). The bleeding method should be used with caution and not more than once a month. The amount of blood drawn may vary from half a cup to one cup at a time. Do not apply this method on children or patients with weak constitution. Careful sterile technique is essential both during and after the treatment.

Safety First I always make safety a top priority when I use cupping treatment. I remember very clearly the tragic story of how our neighbour burned her husband to death after attempting cupping. The traditional practice in Turkish homes, after cupping, is to massage the patient with alcohol and cover them in order to promote sweating. In this case the poor woman used the alcohol to massage her husband before she put the cups on. Consequently, as she struck the match, her husband caught fire. He had a bad cold and instead of curing him, she burned him alive! This horrifying example clearly emphasises the dangers of cupping if not correctly applied. You must remember that you are dealing with oil, alcohol and fire all at the same time! Never rush when using cupping. When in a hurry you are liable to make costly mistakes, such as dropping the burning cotton wool on the carpet (or worse on your patient). It takes a long time to build up a successful practice, but it does not take long to make a bad name for your clinic. There should be no inflammable objects nearby, like plastic bags or polyester covers (cotton covers are warmer and safer).

How to apply cups Prepare the cups beforehand, remembering to wash them with soapy water after each use, to maintain cleanliness and eliminate the risk of transferring perverse

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energies between patients. If the cups have been in contact with blood, soak in Miltons solution for twelve hours or sterilise in an autoclave. Remember to explain beforehand what you are about to do and why you are doing it, and explain the importance of relaxing the whole body. Decide the location of the cupping; choose the size and number of cups to be used, and take them close to the location. Apply oil to the skin area to be cupped to ensure a good suction (see above). Suction is created by briefly introducing a flame into the cup.This is done with a piece of cotton wool which is held in a long pair of forceps, dipped into alcohol and lit. Small rolls of cotton wool can be prepared beforehand and kept soaked in alcohol in a tightly closed jar. Firmly squeeze the cotton ball to remove any excess alcohol (to prevent flaming alcohol dropping on to the skin). Hold the cup in one hand, close to the skin, quickly and briefly introducing the flame into the mouth of the cup, and then turn it upside down and place it on the skin. In this way suction is created and the cup will be held in the desired position. The more you practice, the quicker you will get. Suction strength can be regulated by the size of the flame and the length of time you leave the flame in the cup. In winter months the glass cups are very cold, so before the cups are turned on the skin, the rims should first be warmed by briefly holding the flame just below the rims, before introducing the flame into the cup. Over-heating the rim of the cup can result in burning the skin of the patient! After applying the cups, cover the patient and keep them warm. When the desired cupping time is complete, remove the cups by pressing firmly with the index finger between the base of the cup and the skin, allowing some air into the cup for the suction to cease . The same index finger pressing technique is used when the suction is too strong and you wish to reduce the strength. When removing cups, make sure that the cup is held away from your face, to eliminate the risk of absorbing perverse energies which have been drawn out 6. After the cups are removed the skin becomes very tender, so clean the area using soft paper, and apply fresh oil while gently massaging the area to relax the patient. Where cupping is done for the first time, there will be nearly always be a bruise mark at the site of application, the degree of bruising depending on the strength of cupping. In any case it will fade away in a week or less. Summer holiday months are not the best time for cupping, as patients will not be pleased when having to explain unsightly bruises on exposed flesh. When cupping is applied to the same area for a second time, bruises are much reduced, and are even lighter at the third and subsequent applications until they disappear totally as the stagnation in the affected area disappears and the flow of blood and energy is regulated. As a a rule, leave the cups on for a shorter period the first session, and each time cupping takes place they can be left for a longer period, until the circulation improves and stagnation disperses. In some cases a blister can appear, particularly when

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strong cupping is applied on a very sensitive skin, e.g. elderly people or children. It is preferable to stay with your patient all the time and monitor the progress, and if blisters start to appear then use your index finger to reduce the suction.When blisters do occur, lightly pierce the skin and let the fluid out, but do not apply cups to the affected area until the blister heals.

Cupping on Children Cupping is very safe for children over three years of age. The reason for this age limit is the fact that the skin of a child under three years old is very susceptible to blisters and bruises. Children generally prefer cupping to acupuncture, but remember that some children are petrified of fire, so take extra care to relax them before treatment. I usually ask the mother if I can demonstrate the technique on her, and using her forearm, I put a small cup there for the child to touch and feel. When I am convinced that the child is ready I then proceed. Never force cupping on a child if he or she is showing substantial fear. When cupping children use small size cups. The suction of these small cups is quite sufficient for children. Give the cups to the child to see and hold. The parent can help by holding the child and talking to them. Children under five need most attention, so ask the parent to hold the child firmly, as they can turn very suddenly and touch your hand or try to push the flame away. Once the cup is on they usually don’t mind at all. The most common complaints for which cupping is used on children include asthmatic and digestive conditions, and all Back-Shu points can be used safely. One golden rule when using cups on children is never to leave the cups on for more than five minutes as this can cause bad blisters and bruises and also drain the Wei-Defensive Qi. The strength of the cupping should be low to medium, but not strong.

Cupping on Adults When using cups on adults one must consider the energetic level and age of the person. I find that no matter how healthy the elderly look, there is always an energy deficiency. This is a normal energetic situation, so when cupping is performed on the elderly, do not leave the cups on for a long time, and do not use the strong method as their energies can be drained, leaving them more tired than when they arrived. Cupping time should also be short, and a low to medium strength method used, on younger adults with any deficiency syndrome. In syndromes of Yang excess, the skin will be hot and tender in places, and the cups can be left in place for longer time (20-30 minutes) and the strong or moving method can be used. The most common sites for cupping on adults are: the knees (Xiyan), Zhongwan REN-12, Zhangmen LIV13, all Back-Shu points, the shoulders and points on the lower back .

How often can cupping be used? Cupping can be used every day until the condition improves, but as this may not be practicable in western countries, once a week is a typical frequency. One can use cups on the same points even when the bruises are not cleared completely. As mentioned earlier, it is rec-

JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

ommended to start cupping with a low to medium strength, and increase the suction as the treatment progresses.

Contraindications of cupping i. Avoid strong cupping in the abdomen and stomach. ii. Do not apply cups over scaly or burned skin. Do not use cupping in any form on patients with Yin or Yang depletion. iii. During pregnancy never apply cups to the abdominal or stomach regions, or back points, especially the lower back. Otherwise cupping can be used with safety up to the seventh month of pregnancy.

The treatment of common complaints by cupping Frozen Shoulder: Binao L.I.-14, Jianyu L.I.-15, Jugu L.I.16, Jianjing GB-21. Knees: For painful and swollen knees Xiyan (Extra), Liangqiu ST-34. Digestive Complaints: Zhongwan REN-12, Zhangmen LIV-13, Weishu BL-21. For Damp-Heat and stagnation of Qi, use the same points but use the moving method on Weishu BL-21 until bruises appear. Digestive weakness (Spleen-Qi Xu): Riyue GB-24, Zhangmen LIV-13, Zhongwan REN-12 and Pishu BL-20. Lower backache: Mingmen DU-4, Shenshu BL-23, Guanyuanshu BL-26, Pangguangshu BL-28 and Zhishi BL-52. Headache due to hypertension and Yang excess: Dazhui DU-14 and Jianjing GB-21. Asthma: Dingchuan (Extra - 0.5 to 1 cun lateral to Dazhui DU-14) and Feishu BL-13. Rheumatic and arthritic conditions: Use local points and Dashu BL-11 (Influential point of the Bones). Kidney Qi Xu: Jingmen GB-25, Mingmen DU-4 and Shenshu BL-23. Heat syndromes: All types of boils, furuncles, eczema and psoriasis: Dazhui DU-14 and Geshu BL-17 (Influential point of the Blood). Also moving method can be used on the whole length of the Back-Shu points until heat comes up to the surface, indicated by the appearance of bruising. Hiccup: Strong method on Geshu BL-17 and Jueyinshu BL-14. Menstrual disorders: Zhangmen LIV-13, Riyue GB-24, Dahe KID-12, Mingmen DU-4 and Guanyuanshu BL-26. Bedwetting: Mingmen DU-4, Shenshu BL-23 and Pangguangshu BL-28. As I mentioned earlier, bedwetting is considered as lower back (Kidney energy) deficiency. This condition is very common if children are frightened or experience some kind of shock which drains their Kidney energy.

Conclusion Always remember the potential dangers of cupping treatment; you are dealing with fire and alcohol at the same time. Before lighting the cotton wool make sure that you have squeezed out the excess alcohol. Inform

your patient, and familiarise and relax them before applying the cups. Do not use strong cupping method or long duration cupping at the first visit. Stay with the patient in the cubicle and remove the cups if they are hurting. When treating children ask the parent to remian and help you if necessary. Blisters can form very rapidly if the suction is strong; in this case remove the cups without delay. Be gentle when removing the cups, never pulling them, but use the index finger pressing method at the base of the cup and the suction will cease. Hold the cups away from your face when removing and wash the cups with soapy water. In cases of blood contaminating the cup, hold the cup under running hot water and place in a bucket with Miltons solution for twelve hours before using the same cup again. Alternatively sterilise in an autoclave. End the cupping treatment with a gentle massage to the treated area and reassure your patient that any bruising should fade away within a week.

Notes 1. Cold in the mother's milk: this is a very common syndrome with mothers who breast-feed their children. When the mother catches cold or over-indulges in cold food, her milk may become thick and her breasts painful. This condition is usually relieved by massaging with warm olive oil and drinking hot soup for a few days. 2. Women are prone to miscarry between 3 and 5 months. In Turkish folk medicine this is said to be due to 'weak back', the equivalent of Kidney-Xu in TCM. 3. First published in Great Britain by Cox and Wyman Ltd, Reading, Berks. 4. I previously used Cidex solution for sterilising cups. It has just now been brought to my attention that Cidex solution is a highly dangerous carcinogenic agent and should be handled with care. If used, the room should be well ventilated and one should avoid contact with the skin. 5. Bamboo cups can successfully be used over hairy areas, using a light or medium method and with the liberal use of oil. The cups can normally only be retained for five to ten minutes before air seeps in and reduces the suction. 6. By my understanding, heat represents energy in any form and shape. During the removal of the cups, you are bound to draw out some kind of energy, usually

CASE HISTORIES 1. Male, 9 years old Complaint: asthma since birth. Appearance: white forehead, wheezing, good build. Phlegm: thick phlegm, worse in the mornings. Medication: inhaler 5-7 times a day. Diagnosis: chronic cold with retention of phlegm. Treatment: Chize LU -5, Lieque LU-7 (needles), Feishu BL-13, Pishu BL-20 (moxibustion), Dingchuan (Extra), Feishu BL-13 (5 minutes cupping). On the first five visits I used acupuncture and moxibustion only, resulting in improvement in the wheezing but still very thick and persistent phlegm. On following

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weeks I added cupping to the treatment. After three such treatments the quantity of phlegm was significantly reduced, he was able to stop using the inhaler and was much more active at school. He still continues treatment once a month.

2. Female, 45 years Complaint: arthritic knees for five years. Pulse: rapid at all levels. Tongue: thick whitish coating. Medical history: breast cancer surgery five years ago, HRT for two years, generally feels tired and has stopped working. Diagnosis: Blood-Xu with phlegm retention. Treatment: moxibustion and reinforcing acupuncture on points such as Zhongwan REN-12, Zhangmen LIV-13, Qihai REN-6, Zusanli ST-36 and Sanyinjiao SP-6, and Needle-Cupping method at bilateral Xiyan (Extra) and Liangqiu ST-34. At the end of a course of treatment both knees were free of pain and she was able to return to work.

3. Female, age 24 Complaint: psoriasis spreading all over the body, itchy, thirsty. Medication: various types of corticosteroids for three years resulting in fine creases on the face. Pulse: rapid. Tongue: dry with red tip. Diagnosis: Yin-Xu, wind, damp-heat rising. Treatment: the most common syndrome I find with pso-

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riasis sufferers is Yin-Xu and wind in the channels indicated by dryness and itching. Reinforcing needling was applied to Zhongwan REN-12, Zhangmen LIV-13, Qihai REN-6, Zusanli ST-36 and Sanyinjiao SP-6. Medium cupping was applied to the Back-Shu points weekly to help reduce heat in the channels and restore energy circulation. After three months of treatment her psoriasis has almost cleared. She has relapses with flare-ups especially when under emotional stress and still comes for treatment andCASE evaluation once a month. HISTORIES