Myofascial Cupping – A New Spin on an Old Modality

I consider myself a fairly traditional, conservative practitioner, and I like to keep things simple. I've used certain techniques with great effect for years. It seems that just about every time you open a professional magazine or mailer, someone is promoting a "new" therapy that is really just a new spin on an old, well-established technique. This is not always a bad thing – as professionals, we should always work to better understand and develop our art. But there has to be a balance – I don't think you can really grow and expand if you don't have a good foundation in the basics.

Another issue we face today in the "complementary and alternative" realm  is that the lines continue to blur. There is an increasing crossover of techniques and modalities within the disciplines. It has long been known that the founders of chiropractic and osteopathy had a firm foundation in Eastern medical theory; and based much of their early protocols on the Merck system of spinal reflexes, and focused on manipulation of the spine to activate the Du points. Now you also have tuina manipulation in Chinese medicine, and passive and active mobilization techniques in PT and massage therapy.

The Art of Cupping

When I first studied acupuncture, cupping was almost a side note. I did not get a lot of exposure to cupping for several years. (I do still have the first set of fire cups given to me by my teacher.) I was taught that cupping was designed to pull the internal toxins or congestion so the body could break up the irritation and flush it from the tissues. It was gentle. I was taught that – just like needling – more is not better; the light suction of the fire cup was sufficient to stimulate a response from the body.

With the advent of vacuum cups, a practitioner can really crank up the suction; i.e., "more is better." I have a hard time rationalizing actively bruising the tissues – causing damage – just because I can. The end goal of cupping is to improve the circulation, not cause a bruise. But I am surprised how many patients actually think "you didn't do it enough" if you don't leave them with concentric circle bruises.

Cupping exploded in popularity a few years ago with pictures of circle hickies on a certain Olympic swimmer – everyone wondered what they were; then everyone wanted that same technique. I recently attended a seminar on myofascial cupping, as the brochure piqued my interest. I was the only DC or LAc in the room – everyone else was a PT, a PTA or a massage therapist. (The instructor was surprised there were no OTs or DOs in attendance). Despite my initial skepticism, I was impressed with the program and the research discussed to validate the practice. The program began with a good discussion of the history of cupping, back through Eastern medicine and into its Ayurvedic roots. The instructor then came forward and talked about more modern research, and presented some great information on the physical effects of cupping.

Why It Works: The Interstitium

Modern science has recently defined the interstitium as a separate and distinct organ – making it a larger organ than the skin. The interstitium is not just a dense layer of fibrous connective tissue, but is also now understood to be a lattice of fluid channels. There are ligament fibers connecting the layers of skin to the interstitium to the underlying muscle. Imaging studies have shown that the decompressive effect of cupping can help to open and separate these layers, reducing congestion and increasing fluid dynamics in the tissues. However, it was also (again) recognized that while some is good and promotes both healing neural and enzyme responses, too much suction on the tissues would actually cause trauma that again would be counter to the benefit of the therapy.

This program focused on using silicone cups to create a gentle draw on the tissues, but also to grab the tissues so you could mobilize them to stretch and reduce adhesions that limited circulation of the interstitial fluid. This was then combined with stretching, active movement and exercise against resistance to further stabilize the area against recurring dysfunction and injury.

At the end of the day, I was impressed. There is more application to cupping than using it to draw a few drops of blood after a plum-blossom or bladed needle stick. It was also discussed that this technique will not be beneficial for everyone – this application was specifically for addressing myofascial congestion and was used in tandem with other therapies for maximal benefit. Of course, we ended with a discussion on proper documentation.

A Word of Caution: More Is Not Necessarily Better

While cupping is a good, viable modality, please be careful with the application. As discussed above, it has been my experience that many patients (and  practitioners) think more is better and that circular bruises are necessary for effective treatment. Neither of these ideas is correct.

It does not take a great amount of vacuum force to create negative pressure and open up the layers of the interstitium. Using more suction for longer time will not be therapeutic and only cause tissue damage. Bruises are not the end goal – that indicates rupture of the small vessels. While this may happen with some patients, the end goal of the treatment is not just to make bruises; it is to open up the congestion to help with circulation and healing.

I had a patient in my office today who had sets of perfect circle hickeys over both scapulae and both sides of the lower back. He said his doctor told him the bruises were good "because that meant it was working." Outside of getting a bruise, the patient had no idea why he was getting the therapy. I anticipate the more modern name for this modality with be something like "interstial decompression." Call it cupping, or vasopneumatic therapy, or vacuum therapy, or even a type of neuromuscular re-education, but if you are going to use this modality, please make sure you understand the tissue dynamics of what you are doing. Reducing adhesions and improving circulation is not the same as tissue trauma. Take the time to understand the modality and how it is best applied in the appropriate clinical setting.

There is no one single modality that will meet the needs of every patient.  Given your personal experiences, you may have developed strong preferences.  You may or may not like this-or-that technique; you may not wish to pursue some specialized therapy – including cupping. Make sure you are open-minded enough to recognize when a patient may not be responding to your plan of care, and when you should be referring for co-management with a competent para-practitioner.