What’s the Scoop on Cupping?

My first exposure to cupping was seeing the perfectly circular bruises on Michel Phelp’s during the 2016 Summer Olympics. Since then, I have come across it many times in the University of Delaware athletic training room seeing athletes performing exercises with cups suctioned to their back. I have even tried it myself a couple of times to see what the hype was about and if I felt a difference using this type of recovery method. 

Figure 1. Michael Phelps swimming with visible cupping markers (bruises) on his shoulders. 

Now if you haven’t heard about cupping you may be wondering: what is cupping? Cupping is the application of plastic, glass, bamboo, or ceramics cups [1] to the skin via suction. The suction can either be created naturally by heating up the inside of the cup using a flame and allowing it to cool on the skin creating negative pressure and lifting/stretching the skin up. The other way to get this pressure is to use a suction device.[1] There are also two types of cupping, similar to needling; there are both wet and dry methods. Dry cupping is exactly the procedure I described above while wet cupping is when small cuts are made on the skin before the cup is applied and blood is drawn out. [1] The original idea behind this technique was that it was regulating Qi in the body. More recently, people claim that it promotes blood flow and therefore has a positive effect on the healing process, reducing soreness and pain. There are still many who find cupping bizarre and disgusting due to the often dark bruising and the odd look of the skin suctioned into cups. In particular, a Forbes article by Steven Salzberg goes as describes it as “someone giving you a massive hickey, and then doing another dozen or so all over your back, or legs, or wherever ” [2]. So by now, you should have a pretty clear image that while there are many advocates and cupping has been gaining interest (especially if professional athletes on the world stage have used it), there are still many skeptics and people who say it is harmful. Let’s see exactly what the research says about cupping. Is it beneficial? Harmful?

 

An article published in The Journal of Alternative and Complementary Medicine by a group of Australian and German researchers performed a systematic meta-analysis of clinical trials evaluating the effects of cupping on athletes. [3] They found 11 valid (according to their criteria) trials with a combined total of 498 participants from China, the United States, Greece, Iran, and the United Arab Emirates. Participants received cupping 1 to 20 times in daily or weekly intervals either alone or in combination with another procedure, like acupuncture.[3] The study found no conclusive results however. Even though there were improvements to the participant’s perception of pain, an increased range of motion, and lower levels of creatine kinase, there were large variations between symptom intensity and recovery measures, and other metrics.[3] There are also some limitations to this study. One of the main concerns is the reliability of the data. The researchers report an unclear or high risk of bias in many of the trials and they also mention that none of the trials reported safety. 

 

Another study published in 2016 in the Journal of Novel Physiotherapies evaluated the effects of various soft tissue mobilization techniques, including cupping, on active myofascial trigger-points in 20 amateur soccer players.[4] Athletes received cupping once a week for three weeks. They found that all techniques used, including cupping, improved pain pressure threshold and pain sensitivity significantly. [4] The researchers concluded that more research must be done to fully be able to draw a conclusion. Some limitations of the study were the small sample size (n = 20) and that the study was limited to only amateur soccer players. Other studies, including the previously mentioned study viewed multiple different sports instead of one. This also provided a much larger sample size compared to this study.  

 

Overall, there appears to be no definite answer, at least at this time, on if cupping helps promote healing and reduce pain and muscle soreness. For some, it appears to be beneficial in relieving pain but due to a limited number of studies and the questionable accuracy of others, there is no conclusive data for or against cupping. As the first-mentioned study by Bridgett et. al stated, “ No explicit recommendation for or against the use of cupping for athletes can be made. More studies are necessary for conclusive judgment on the efficacy and safety of cupping in athletes.” [3].

 

 

References:

[1] NCCIH. “Cupping.” November 2018. Retrieved from: https://www.nccih.nih.gov/health/cupping

[2] Steven Salzberg. “ The Ridiculous and Possibly Harmful Practice of Cupping”.  May 2019. Retrieved from: https://www.forbes.com/sites/stevensalzberg/2019/05/13/the-ridiculous-and-possibly-harmful-practice-of-cupping/#57ce2d2331f3

[3] Rhianna Bridgett, Petra Klose, Rob Duffield, Suni Mydock, and Romy Lauche.The Journal of Alternative and Complementary Medicine.Mar 2018. 208-219.http://doi.org/10.1089/acm.2017.0191

[4] Fousekis, Konstantinos et al. “The Effectiveness of Instrument-assisted Soft Tissue Mobilization Technique(Ergoné Technique), Cupping and Ischaemic Pressure Techniques in the Treatment of Amateur AthletesàMyofascial Trigger Points.” (2016).

 

Questions to Consider:

  1. Have you ever gotten cupping done? If yes, what are your thoughts? Did you find it beneficial? If no, was there a reason why?
  2. How do you think studies looking at cupping should compare its effects for the most accurate evaluation? Should they compare across different sports because the benefits should not be sport dependent or within one sport to get a better comparison?

Enough (N)SAID about Ibuprofen & Soreness

If I’m being honest here, it’s been a while since I’ve had a solid gym routine. But this semester I’ve been going pretty regularly, and let me tell you, I’ve felt the burn. My muscles have felt pretty sore in the 2-3 days following my workouts, so I’ve had to turn to ibuprofen a few times to relieve the pain. But even after taking ibuprofen in the morning, I’ve felt sore again by the end of the day. This got me thinking: how effective is ibuprofen at reducing muscle soreness?

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly served over-the-counter at pharmacies. Some common forms you may recognize include aspirin and ibuprofen (Motrin, Advil). NSAIDs are taken for many reasons; they reduce pain and inflammation, lower fevers, and reduce clotting action.[1,2] The typical dosage for adults who are looking to reduce mild-moderate pain is 400 mg every 4-6 hours. For adults who have pain caused by osteoarthritis, the typical prescribed dose is 1200 mg.[3] However, despite their pain reducing use, NSAIDs could yield negative side effects such as increased risk in developing nausea, stomach pains, or an ulcer.[1]

The mechanism of NSAIDs when it comes to reducing pain and inflammation is known and understood. After intense workouts, prostaglandins are produced by muscle cells. They aid in the healing process of muscle, but this often leads to inflammation, pain, and fever. Enzymes called cyclooxygenases (COX-1, COX-2) produce the prostaglandins that promote inflammation, pain, and fever. The goal of NSAIDs is to inhibit COX-1 and COX-2 from producing prostaglandins, thus decreasing the pain. However, the COX-1 enzyme is responsible for creating prostaglandins that protect the stomach lining and support platelet aggregation, so the inhibition of the enzyme is what could lead to stomach ulcers and the promotion of bleeding.[1,2,4] The science behind NSAIDs seems promising, but clinical research may prove otherwise.

Athletes commonly take NSAIDs after performing physical activity because they claim the drugs reduce pain and decrease recovery time. But here is the issue: only very few studies have been able to support this claim. Some studies have reported results that do indicate a beneficial effect, by stating NSAIDs used prophylactically mitigate exercise-induced inflammation, circulating creatine kinase levels, and muscle soreness.[5] On the other hand, these claims made by athletes lack scientific support. NSAIDs are known to treat inflammation, but many histological studies have proven that most overuse injuries are caused by tissue degeneration and not inflammation. Also, NSAIDs temporarily “mask” the pain caused by tissue degeneration or soreness. This does not ensure that muscles or tissues are actively getting healthier; it only hides the pain from the athlete. [5] Clearly, there are many different opinions about the use of NSAIDs, specifically ibuprofen, in the sports medicine field. Let’s take a look at what the “research says” about it. 

A study at the University of Saskatchewan was conducted to determine the effects of ibuprofen on muscle hypertrophy, strength, and soreness during resistance training. Participants (12 males, 6 females) trained their left and right biceps for six weeks, alternating arms on each day. The training program called for concentric curls at 70% of RM and eccentric curls at 100% of 1 RM. Every day after their training, they either received a 400 mg dose of ibuprofen or a placebo. On training days, each participant was asked to rate their soreness on a scale from 0-9. For both the placebo and ibuprofen, the participants reported soreness during the first week and that soreness decreased throughout the program to the point where participants felt no soreness in either arm during the final week. The researchers concluded that ibuprofen was not effective in reducing perceived soreness during the training. However, the researchers do not reflect on the limitations of their own study.  They had a small and uneven sample size when it came to gender and there could have been discrepancies and residual effects that came along with taking ibuprofen inconsistently. Additionally, they seemed pretty convinced by their findings, but maybe the dose they chose was not strong enough to show any reduction in soreness in a long term study.[6]

On the other hand, another study drew opposite conclusions. Researchers in Greece conducted a study to determine the effects of ibuprofen on delayed onset muscle soreness (DOMS) and muscular performance. Participants (14 men, 5 women) who have not done strength training in the last 6 months performed eccentric leg curls at 100% RM. Nine (9) subjects were given a 400 mg dose of ibuprofen every 8 hours for 48 hours after exercise, while the remaining 10 subjects received a placebo. The subjects rated their amount of soreness on a scale of 1-10 prior to exercising, 24 hours after exercising and 48 hours after exercising.  The results showed that muscle soreness was significantly lower for the ibuprofen group at both 24 hours and 48 hours after exercising. Similar to the previous study, the researchers did not evaluate the limitations of their study. The number of participants and number of each gender were low and uneven, respectively. Also, the soreness results were not discussed much in the conclusion of the paper. The researchers did not support why the soreness decreased with scientific evidence, which is what they did for the other the parameters they were testing for.[7]

Clearly, both studies came to different conclusions. However, both studies were conducted for different amounts of time, contained different exercises, and with subjects of different athletic abilities. There have been plenty of studies conducted to determine how effective ibuprofen is at reducing soreness, but each study contradicts the next. 

Overall, many studies show that ibuprofen is a short term solution to hiding muscle soreness, but it may not be effective long term. Though, I’m still going to keep on using it to treat my soreness.

Questions to consider:

  • Do you take NSAIDs to reduce your soreness after working out? How effective do you find them to be?
  • Do you think there’s a better way to measure soreness and how ibuprofen affects our muscles?
  • Do you think the length of the study has any correlation with the effectiveness of ibuprofen?

Sources: 

  1. (n.d.) Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Retrieved from  https://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm#what_are_nsaids_and_how_do_they_work
  2. Tscholl, M., et al (2016). A sensible approach to the use of NSAIDs in sports medicine . Swiss Sports & Exercise Medicine , 65(2), 15–20.
  3. (n.d.) Ibuprofen (Oral Route). Retrieved from https://www.mayoclinic.org/drugs-supplements/ibuprofen-oral-route/proper-use/drg-20070602 
  4. (n.d.) What Are NSAIDs? Retrieve from https://orthoinfo.aaos.org/en/treatment/what-are-nsaids/
  5. Stuart J. Warden (2010) Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment, The Physician and Sportsmedicine, 38:1, 132-138, DOI: 10.3810/ psm.2010.04.1770
  6. Krentz , J. (2008). The effects of ibuprofen on muscle hypertrophy, strength, and soreness during resistance training. Applied Physiology Nutrition and Metabolism , 33(3), 470–475. doi: 10.1139/H08-019

Dry Needling: Is it Worth the Pain?

Arriving at a physical therapy appointment to have a needle stuck deep into the body’s muscles only to leave hobbling and sorer than before doesn’t seem like an effective method for rehabilitation. However, the post-treatment benefits have made dry needling one of the many techniques individuals are using to treat and prevent injury from exercise.

What is Dry Needling?

While wet needling uses hollow needles to inject corticosteroids into muscle [7], dry needling (DN) consists of inserting a fine needle, similar to those used in acupuncture, deep into the muscle without injections. The needle is then twisted and moved around the area without being fully removed from the skin. The needling itself can be uncomfortable, feeling like a pinch, cramp, or deep prick, and can result in local soreness post-treatment. Physical therapists seek to insert the needle into a myofascial trigger point (MTrP) to relieve myofascial pain syndrome (MPS), the most common muscle pain disorder seen in clinical practice [1]. In exercise science, MTrPs are defined as “hyperirritable local point(s) located in taut bands of skeletal muscle or fascia which when compressed causes local tenderness and referred pain” [10]. Potentially caused by muscle overuse [2], this pain is commonly described as having a knot in a muscle and creates localized tenderness, pain to deep touch, and restricted movement [1].

The video above shows a physical therapist performing the dry needling technique on various muscles. Created by Dynamic Physical Therapy, Covington, LA (2013).

Dry needling is used as a rehabilitation technique to decrease the pain MTrPs can cause. The “fast-in and fast-out needle technique” applies high pressure stimulation to the MTrP, often causing a twitch response. These twitch responses are the result of a spinal reflex generated by the activation of nociceptors and mechanoreceptors. These receptors respond to the painful mechanical irritation and stretch the needle causes within the muscle [1]. When this occurs, a single motor unit fires and a visible, isolated contraction – the “twitch” – can be seen. These twitch responses can occur local to the needle or within muscles on the opposite side of the body. This phenomenon has led researchers to believe that the pain associated with MTrPs is due to central nervous system (CNS) changes [1]. 

How is Dry Needling Portrayed in Healthcare?

Healthcare providers, such as MedStar National Rehabilitation Network and ChristianaCare, have been advocates for dry needling. They mention DN is “an effective physical therapy modality…in the treatment of orthopedic injuries” [5] and that it can even be used for preventing pain and injury [4]. There have been many personal accounts of the wonders of dry needling in recovery from nagging injuries. AshleyJane Kneeland, who struggles with muscular pain due to lupus, fibromyalgia, and postural orthostatic tachycardia syndrome, cites DN treatment as relief for her painful spasms and headaches, as well as providing general relaxation [6]. But how effective is dry needling, really? Is there science to back up these claims?

What Does the Science Say?

Elizabeth A. Tough and co-authors performed a meta-analysis in 2009 of seven studies assessing the effectiveness of DN in managing MTrP pain. This study provides an update for the systematic review by Cummings and White, which found no evidence suggesting injections through wet needling generate a better response than dry needling [3]. One study found by Tough et al. suggests DN is more effective in treating MTrP pain than undergoing no treatment, two studies produced contradictory results when comparing DN in MTrPs to DN elsewhere, and four studies showed DN is more effective than other non-penetrating forms of treatment (placebo controls). However, when combining these studies for a sample size of n=134, no statistical significance was found between DN and placebo treatments. 

While the authors conclude the overall direction of past studies trend towards showing that DN is effective in treating MTrP and MPS [10], there is no significant evidence yet. The lack of statistical significance could be due to low consistency in study design for studies included in the meta-analysis, as each employed varying mechanisms for needle placement, depth, and treatment frequencies, along with there being an overall small sample size. Therefore, further studies are required to significantly conclude that DN is effective in MTrP rehabilitation.

Ortega-Cebrian et al. recognized the limitations in previous studies and thus sought to create a significant evaluation of the ability of DN to decrease pain and improve functional movements. The authors use a myometer (MyotonPro, [8]) and surface electromyography (sEMG) to assess the mechanical properties of muscle in subjects (n=20 M) with quadricep muscle tension and pain [9]. 

The MyotonPro allows researchers to quantify muscle tone and stiffness. While no standards exist for describing these parameters with respect to changes after rehabilitation techniques, researchers found the device to be reliable through inter-rater reliability (comparing values of the MyotonPro to another rater). Pain was assessed by subjects using the Visual Analogue Scale (VAS) and a goniometer was used to measure small range of motion (ROM) improvements. DN was performed by one of two experienced therapists until twitch responses ceased [9].

Authors report that DN resulted in statistically significant pain reduction and an increase in flexion ROM. However, the ROM was very small and could be within the range of measurement error of the goniometer. Also, the p-values reported in-text for these parameters do not match the corresponding table which presents a question of the reliability of author reporting. All sEMG parameters, except for decreased vastus lateralis activity, were not significantly changed by DN, as well as all MyotonPro parameters, besides a decrease in vastus medialis decrement (muscle elasticity) and resistance. In a power analysis performed after the study, authors report needing 198 subjects for statistically significant results – much higher than the 20 subjects used [9]. Therefore this study continues the uncertainty in the benefits of DN, but does present significant subject-reported pain reduction.

Is it Worth the Pain?

So is dry needling worth the pain? After being put to the test through experimental studies, there is no clear evidence that dry needling is more beneficial than alternative rehabilitation methods such as wet needling, placebo needling, or acupuncture [9]. However, while the mechanisms of changes in muscles with trigger points due to dry needling are unknown, subjects do report pain reduction. Dry needling should be taken on a case-by-case basis since current knowledge of widespread benefits is limited. Essentially, if dry needling treatment alleviates pain more than other rehabilitation methods and the pain of the procedure is bearable, why not give it a try?

 

Questions to Consider:

  • Would you be willing to try dry needling regardless of uncertainties in the literature?
  • Do you believe it is a problem that healthcare providers claim dry needling is effective despite a lack of conclusive evidence?
  • What should future studies do to ensure significant results?

 

References:

[1] Audette, J. F., Wang, F., & Smith, H. (2004). Bilateral Activation of Motor Unit Potentials with Unilateral Needle Stimulation of Active Myofascial Trigger Points. American Journal of Physical Medicine & Rehabilitation, 83(5), 368–374. doi: 10.1097/01.phm.0000118037.61143.7c. 

[2] Bron, C., & Dommerholt, J. D. (2012). Etiology of Myofascial Trigger Points. Current Pain and Headache Reports, 16(5), 439–444. doi: 10.1007/s11916-012-0289-4. 

[3] Cummings, T., & White, A. R. (2001). Needling therapies in the management of myofascial trigger point pain: A systematic review. Archives of Physical Medicine and Rehabilitation, 82(7), 986–992. doi: 10.1053/apmr.2001.24023. 

[4] Dry Needling®. (n.d.). Retrieved from https://christianacare.org/services/rehabilitation/physicaltherapy/dryneedling/

[5] Dry Needling. (n.d.). Retrieved from https://www.medstarnrh.org/our-services/specialty-services/services/dry-needling/

 [6] Dry Needling: The Most Painful Thing I’ve Ever Loved. (2015, March 25). Retrieved from https://www.everydayhealth.com/columns/my-health-story/dry-needling-most-painful-thing-ever-loved/

[7] Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), 252–265. doi: 10.1179/108331913×13844245102034. 

[8] Muscle Tone, Stiffness, Elasticity measurement device. (n.d.). Retrieved from 

 [9] Ortega-Cebrian, S., Luchini, N., & Whiteley, R. (2016). Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients. Physical Therapy in Sport, 21, 57–62. doi: 10.1016/j.ptsp.2016.02.001. 

[10] Tough, E. A., White, A. R., Cummings, T. M., Richards, S. H., & Campbell, J. L. (2009). Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials. European Journal of Pain, 13(1), 3–10. doi: 10.1016/j.ejpain.2008.02.006.

A Closer Look At: Cupping

Among Olympic athletes you may have noticed something different in recent years – spots. Big red spots. Elite athletes from a variety of different sports have been spotted with – well- spots. But where are these markings coming from?

Michael Phelps, Alex Naddour, and Natalie Coughlin are a few of many athletes who have utilized cupping, an ancient therapeutic technique that has given them their spots.

Michael Phelps, male US swimmer, 2016 Rio Olympics

Cupping is a practice used in traditional medicine in which suction is created using a glass, bamboo, plastic, or ceramic cup. Negative pressure is generated within the cup and used to lift the skin and surrounding tissues. There are over ten different types of cupping therapy, each utilized to treat a variety of ailments. Most broadly cupping can be categorized in to wet cupping, where incisions are made on an indiviudal prior to applying negative pressure via cup, and dry cupping, where no incisions are made. However, treatments can be further classified by their power of suction, method of suction, and material inside the cup [1].

Since 3500 BC cupping has been practiced across several cultures. The earliest references to cupping therapy are found in the Ebers Papyrus, one of the oldest and most important medical papyri of ancient Egypt dating back 1550 BC. However, this form of therapy has not just been exclusively used by the Egyptians, rather it has been used across many cultures for thousands of years. In ancient Macedonia, cupping therapy was used to treat diseases and health disorders. Ancient Arab practitioners utilized cupping therapy to treat hypertension, polycythemia, headache and migraine, and drug intoxication. Hippocrates advocated cupping therapy as a treatment for many ailments in his treatise Guide to Clinical Treatment. Greek and Roman practitioners regularly used wet and dry cupping to treat a variety of diseases. To this day, Cupping therapy acts as one of the cornerstones of traditional Chinese medicine [2].

Today, athletes utilize cupping to decrease recovery time between training sessions, improve range of motion, alleviate inflammation, and reduce pain [3,4,5].

Research suggests that cupping may alleviate pain in individuals. A 2012 pilot study was conducted to assess the effects of a single wet cupping session on pain. Fifty individuals suffering from non-specific chronic neck pain were selected to receive a single wet cupping therapy session. Relative pain levels were measured through participant questioners and mechanical sensory and pain threshold values. Measures taken directly before therapy sessions and three days after treatment and were compared to assess changes in pain levels. Participants reported a statistically significant reduction in pain three days after treatment; however, because measures in reduction of pain are directly correlated with patient reporting, findings may be based on placebo effect or patient bias making it difficult to draw significant conclusions from this study [6].

Several systematic reviews (SR) assessing the impact of cupping on pain relief suggest there may be a positive correlation between the treatment and pain reduction. Several published randomized clinical trials including cupping interventions have been associated with a reduction in pain; however, these studies are limited by size and potential bias, and share a poor study design. Many studies are limited in longevity, participant sample size, and lack of a sufficient placebo for cupping therapy making it difficult to draw significant conclusions regarding the impact of cupping on pain relief [7,8,9,10].

Little is known about the mechanism of action of cupping. Several theories look to explain the pain relief experienced by individuals, including the following two:

  • The Pain Gate Theory: Chronic pain is influenced by altering pain signaling at the nociceptor level. Through stimulating pain via cupping, the frequency of nociceptor impulses will be increased, leading to the closure of pain gates and inevitably pain reduction.
  • Diffuse Noxious Inhibitory Controls: “Cupping therapy may produce an analgesic effect via nerves that are sensitive to mechanical stimulation. This mechanism is similar to acupuncture in that it activates A∂ and C nerve fibers which are linked to the DNICs system, a pain modulation pathway which has been described as ‘pain inhibits pain’ phenomenon”[9]

The potential mechanisms by which cupping may alleviate pain are not well understood, and certainly require validation by scientific studies. However, in addition to participant pain relief, reported effects of cupping also include increased blood flow to the skin [11] and a reduction in inflammation [12]. These physiological impacts may also influence pain relief experienced in clinical trial participants; however, further research is required to draw any conclusions about the mechanisms by which cupping works to potentially reduce pain.

Although it is difficult to draw significant conclusions relating cupping therapy with pain relief, research study participants, athletes, and thousands of other people claim cupping has helped reduce their pain. Cupping has been practiced for over 5000 years across a number of cultures and has alleviated the pain of many. It’s long history of helping indiviudals enduring pain and illness gives it promise as an effective treatment method. Bottom line- whether it directly facilitates pain relief or acts as a placebo – cupping has helped alleviate pain for thousands of years and can be beneficial.

Questions to consider

  • Cupping therapy – placebo or effective? Does it matter?
  • Measures of patient pain have been qualitative in many clinical trials, is an effective way to evaluate the impact of treatment? Are there any other ways to measure pain that may be more effective?
  • Recently cupping has become more commonly seen in popular culture – featured in films such as The Karate Kid and The Gua Sha Treatment and publicly displaced on the bodies of Olympic athletes: what impact does the integration of this traditional treatment in popular culture have on public perception?

References

[1] Aboushanab, T.S., AlSanad, S. (2018). Cupping Therapy: An Overview from a Modern Medicine Perspective. Journal of Acupuncture and Meridian Studies, 11(3), 83-87.

[2] Qureshi, N. A., Ali, G. I., Abushanab, T. S., El-Olemy, A. T., Alqaed, M. S., El-Subai, I. S., & Al-Bedah, A. M. (2017). History of cupping ( Hijama ): A narrative review of literature. Journal of Integrative Medicine,15(3), 172-181. doi:10.1016/s2095-4964(17)60339-x

[3]How Cupping Therapy Benefits Athletes. (2018, August 31). Retrieved from https://www.communityacupuncture.org/2018/05/01/how-cupping-therapy-benefits-athletes

[4] Is cupping therapy effective among athletes?. (2018, January 13). Retrieved from https://medicalxpress.com/news/2018-02-cupping-therapy-effective-athletes.html

[5] What is Cupping Therapy? (Or Why Do Athletes Have Red Spots?). (2019, January 29). Retrieved from https://wellnessmama.com/129773/cupping-therapy/

[6] Lauche, R., Cramer, H.,Hohmann, C., Choi, K.E., Rampp, T., Saha, F.J, Musial, F., Langhorst, J., Dobos, G. (2011). The Effect of Traditional Cupping on Pain and Mechanical Thresholds in Patients with Chronic Nonspecific Neck Pain: A Randomised Controlled Pilot Study. Evidence-Based Complementary and Alternative Medicine, 2012. doi:10.1155/2012/429718

[7] Kim, J.I., Lee, M.S., Lee, D.H., Boddy, K, Ernst, E. (2011) Cupping for Treating Pain: A Systematic Review. Evidence-Based Complementary and Alternative Medicine, 2012.

[8] Kwon, Y.D., Cho, H.J. (2007). Systematic Review of Cupping Including Bloodclotting Therapy for Musculoskeletal Diseases in Korea. Korean Journal of Oriental Physiology and Pathology, 21(3), 789-793.

[9]Al-Bedah, A.M.N., Ibrahim, S.E., Qureshi, N.A., Aboushanab, T.A., Ali, G.I.M., El-Olemy, A.T., Khalil, A.A.H, Khalil, M.K.M., Alqaed, M.S. (2018). The medical perspective of cupping therapy: Effects and mechanisms of action. Journal of Traditional and Complement Medicine, 1-8.

[10] Mehta, P., Dhapte, V. (2015) Cupping therapy: A prudent remedy for a plethora of medical ailments. Journal of Traditional and Complementary Medicine, 5(3), 127-134. 

[11] Liu, W., Piao, S.A., Meng, X.W., Wei, L.H. (2013). Effects of cupping on blood flow under skin of back in healthy human. World Journal of Acupuncture, 23(3), 50-52.

[12] Lin, M.L., Lin, C.W., Hsieh, Y.A., Wu, H.C.,Shih, Y.S., Su, C.T., Chiu, I.T., Wu, J.H. (2014). Evaluating the effectiveness of low level laser and cupping on low back pain by checking the plasma cortisol level. 2014 IEEE International Symposium on Bioelectronics and Bioinformatics.

Cupping Therapy: Is it Worth the Bruises?

By Daniel Owens and Jeremy Grunden

Cupping is form of alternative medicine that is said to help with pain, inflammation and blood flow. All of this can lead to better well-being and relaxation as it acts as a form of deep tissue massage. While not that popular, you may have seen it being used during the Rio Summer Olympic games in 2016. Many athletes, such as Michael Phelps, were seen with large purple spots along their body. This is the result of cupping therapy. Cupping is usually put into two categories; wet and dry. Dry cupping involves the suction of the skin into the cup. Wet cupping has one extra step in which an incision is made, and blood is drawn from the suctioned area. While Olympic athletes seem convinced, is there any scientific data to support cupping as a valid therapy for recovery and rehabilitation?

First, we will look into rehabilitation. A study from Evidence-Based Complementary and Alternative Medicine attempted to prove the efficacy of cupping therapy for treating chronic neck and shoulder pain. The three things that they were looking for was skin surface temperature, blood pressure, and pain intensity. They had a cupping and a control group and found cupping to be statistically significant in raising the skin surface temperature and lowering the pain intensity (Figure 1). The conclusion was that cupping causes vasodilation and can increase blood circulation and is therefore an effective therapy for chronic neck and shoulder pain. These results are not without some cause for concern. First off the sample size was relatively small and similar. Also the increase in skin surface temperature is to be expected, however the pain intensity could be attributed to a number of things. Pain tolerance between patients is different and the decrease in pain intensity of the cupping group could be a result of the placebo effect.

One case study looked into utilizing cupping therapy as a means of treatment for vascular thoracic outlet syndrome. Vascular thoracic outlet syndrome is when blood vessels and nerves near the collarbone are compressed. This restricts blood flow and can lead to pain and numbness along the shoulder and down to the fingers. The case study focused on a collegiate baseball pitcher who had been diagnosed with the disease. The pitcher was put on a program that included cupping therapy on alternating days combined with certain range of motion exercises. The patient began to pitch again and noted no swelling, increased range of motion and significantly less pain. All of this would suggest that the cupping therapy was effective in treating this ailment. However, some issues with the case study is that they did not continue to follow up with the patient after the 3 week period and the sudden improved health could be attributed to a number of different factors. The authors do admit that more research and testing must be conducted to fully understand the efficacy of cupping therapy.

In regards to recovery, a study was done by a team of Greek researchers to find how cupping therapy compares to other treatments in the combating of myofascial pain syndrome. Myofascial pain syndrome is caused by painful spots in the fascia surrounding the skeletal muscle due to repetitive injury, training overload, and muscular overuse. Cupping was done to 20 amateur soccer athletes once a week for three weeks, and their pain pressure threshold (PPT) and visual analogue scale (VAS) was taken before and after the treatment sessions. An increase in PPT and a decrease in VAS was observed in the athletes after cupping. These changes suggest that cupping does have an effect on the body. It’s stated in the article that researchers believe cupping causes hyperemia and local stretching, which is similar to what the first study concluded.

These results show that cupping seems to improve recovery, however other recovery techniques appear to be more effective. Cupping saw the smallest change in the pre and post values. Additionally, it’s always important to consider each participant’s pain tolerance varies. This helps to explain why the standard deviation was ~1.5 for all values in table one.

Compiling all of the evidence, it seems cupping does have an effect on rehabilitation and recovery. Cupping causes vasodilation and hyperemia. This increase in blood circulation and dilation of the blood vessels helps to combat illness that are caused by constricted/compressed blood vessels, like vascular thoracic outlet syndrome. According to the third article though, cupping may not be the most effective recovery solution. When considering the cost of each treatment method, availability, and preference, cupping may not always be the best solution for recovery.

Questions to Consider:

 

  1. When would cupping therapy be ideal to use?
  2. How is cupping therapy better than other therapies?
  3. Can cupping therapy be combined with other techniques to boost its performance?

Further Readings/References:

Ahmadi, Alireza, et al. “The Efficacy of Wet-Cupping in the Treatment of Tension and Migraine Headache.” The American Journal of Chinese Medicine, vol. 36, no. 01, 2008, pp. 37–44., doi:10.1142/s0192415x08005564.

Bridgett, Rhianna, et al. “Effects of Cupping Therapy in Amateur and Professional Athletes: Systematic Review of Randomized Controlled Trials.” The Journal of Alternative and Complementary Medicine, vol. 24, no. 3, 2018, pp. 208–219., doi:10.1089/acm.2017.0191.

Jun, Wu. “Experimental Study on Treatment of Chronic Soft Tissue Injuries with Fire-Needle Therapy.” Chinese Acupuncture & Moxibustion, 2002, doi: R245.316.

“Fire Cupping-2.” Flickr, www.flickr.com/photos/psit/4827714792.

Platelet Rich Plasma Therapy — Out of Pocket Cost for Peace of Mind?

/WebMaterial/ShowPic/860386Since its first clinical efficacy introduction in 1987, Platelet Rich Plasma (PRP) therapy has had its share of support and skepticism as a method to promote tissue repair and regeneration. Through centrifugation, the plasma becomes five to ten times more concentrated with platelets, growth hormones, and plasma proteins such as fibrin and fibronectin.  PRP is typically injected into areas of trauma to stimulate the body stages of wound healing. This type of therapy is widely associated with the treatments of musculoskeletal injuries. Additionally, PRP therapy can be used in cardiovascular treatments such as heart surgery and angiogenesis, as well as dermatology treatments such as acne scars, contour defects, androgenic alopecia, wound ulcers and striae distensae. Different types of growth factors in PRP have been categorized into their subgroups and associating functions depending on characteristics of platelet-derived, vascular-endothelial, insulin-like, transforming, hepatocyte, fibroblast and epidermal; however, PRP mechanisms of actions are not completely understood by the scientific community. In other words, there is not enough evidence to completely support the efficacy and uses of PRP for clinical treatments.

/WebMaterial/ShowPic/860388Even in the early introduction of PRP, the serum was utilized in a progressive way through the use of injections directly into the trauma site of a patient.  A study in 1998 called “Platelet Rich Plasma, Growth Factor Enhancement for Bone Grafts”, was intriguing in the amount of efforts taken to observe PRP effects. In this study, a bone graft harvester along  and ElectroMedics 500 gradient density separator is used to extract the platelets from the plasma. One group of the subjects received the cancellous cellular marrow grafts without PRP, while the other group received grafts with PRP added during the bone-milling process and applied topically after replacement of the defect. The bone grafts were allowed to sit and consolidate for 6 months, with panoramic X-ray observation every two months. Looking specifically at the growth factors PDGF and TGF-b (platelet-derived and transforming, respectively), the bone grafts treated with the PRP showed a 338% increase of platelet count. At 2,4 and 6 months respectively, the PRP treated grafts had 2.16, 1.88, and 1.62 times more platelets than the control group, with a p value for each comparison being .001 showing statistical significance. Does this mean that PRP will absolutely enhance growth factors?  Identifying only 2 of the many growth factors is an oversimplification of human physiology. Even though PDGF and TGF-b are not the only ones with properties of angiogenesis, vascularization, mitogenic, and osteogenesis, the insight of this study still illustrates the significant of PRP in recovery.

On the contrary, studies also showing no correlation between PRP and growth factor activation. In a study by Earl G. Freymiller called “Investigation of Platelet-Rich Plasma in Rabbit Cranial Defects: A Pilot Study,” 15 rabbits received 4 equal defects 8 mm in diameter on their cranium.  The sample group was then given grafts of autogenous bone, PRP injection, grafts of autogenous bone with PRP, and no treatment as control. Observation occurred at 1, 2 and 4 month intervals with 5 rabbits per interval. The results show Bone with PRP has higher percentage bone area recovery than Bone group; however, no statistical significant can be observed (p<0.02) radiographically or histomorphometrically.  Does this mean that PRP has no effect on the rat cranium? An important note is the size of this study The sample size and cranium defects were relatively small. Furthermore among the 4 groups, no statistical differences can be observed in bone density at the 4 months interval. This question the precision of measuring technologies and methods. A reasonable conclusion could be PRP does not adversely affect the process of bone recovery or the study is not precise and therefore inconclusive. 

Given some context, these two studies have merit that does not necessarily contradict each others.  Overall, PRP has been shown to be effective in cosmetics and treatment of chronic tendon injuries but lack scientific proofs in treatments of acute ligament, muscle, and fractures injuries.  Though the scientific community has a understanding of PRP components, the lack of understanding in its holistic mechanism of action brings forth doubt in the clinical setting. This controversy remains prevalent because of its clinical and financial constigents.  In the academic community, Healio posted Orthopaedics Today 2018 containing issues of the demands for PRP definition, comprehensive description, healing mechanisms, and functional outcome. To normal society, PRP efficacy recognition is so limited that few to no insurance plans and workers’ compensation would provide even partial reimbursement.  PRP therapy is currently a luxury for the peace of mind, why else would you spend $600 on something that might not work?

Questions to Consider:

Is Platelet Rich Plasma the same as blood doping and to what extent should it be regulated?

If PRP is effective in all form of wound recovery, what proofs are needed before it can be recognized as part of insurance claim?

References:

[1] Alves, Rubina, and Ramon Grimalt. “A Review of Platelet-Rich Plasma: History, Biology, Mechanism of Action, and Classification.” Skin Appendage Disorders, Karger Publishers, 6 July 2017, doi.org/10.1159/000477353.

[2] Arshdeep, Kumaran M S. Platelet-rich plasma in dermatology: Boon or a bane?. Indian J Dermatol Venereol Leprol 2014;80:5-14

[3] Marx, Robert Lee DDS. Platelet- rich Plasma Growth factor enhancement for bone grafts. Oral and Maxillofacial Surgery 1998

[4] Aghaloo, Tara L DDS. Investigation of platelet-rich plasma in rabbit cranial defects: A pilot study. Journal of Oral and Maxillofacial Surgery 2002