Beyond the Bruising

(This post was originally written by me for Austin Fit Magazine

I’m sure you’re seeing those perfectly round hickeys more and more. Gwyneth on the red carpet. Jen at her movie premier. Posh Spice at Heathrow. But now the guy in line in front of you at Whole Foods. And your neighbor after acupuncture. Or your triathlete friend after physical therapy. Cupping therapy is not just trendy or some ancient Chinese secret.  It’s being used more and more by therapists treating soft tissue problems for a variety of reasons and with excellent results.

In Western medicine cupping should be looked at as a therapeutic modality to treat soft tissue. It is usually used in conjunction with other modalities such as heat, acupuncture, dry needling, and especially massage. In traditional Chinese medicine (TCM), cupping has been used for thousands of years. Much like acupuncture, experiential use of cupping on patients with a variety of medical issues led to a system of integration into TCM, and today cupping is a very common part of any acupuncture session. In TCM, cupping is used to treat skin problems and musculoskeletal pain as well as digestion problems, skin conditions, anxiety, and respiratory conditions such as asthma and the common cold.

Those of us who treat predominantly orthopedic injuries appreciate cupping for its positive effects on the superficial tissues of our bodies (skin and subcutaneous fascia). In my practice, I find that most movement dysfunctions are highly correlated with negative changes in our skin and subcutaneous tissues. Chronic inflammation and edema have much the same effect on our tissues as normal aging and a decrease in physical activity. All of these can result in adhesions (or scarring) in the various layers of our fascia, a decrease in microcirculation, and an alteration in how the nerves in these tissues conduct information from our extremity to our spinal cord and brain.

Once any or all of these things happen there will be a reduction in the fluidity and efficiency of movement. We might simply see loss of range of motion or flexibility. Tissue imbalances can also create alterations in joint mechanics resulting in compensatory movement patterns. And there is often pain (sometimes significant) originating from the nerve endings caught up in these restricted tissues. Finally, because a very large portion of our body’s lymphatic system is contained directly under our skin, restrictions in the superficial fascia can seriously impede lymphatic flow and results in the accumulation of edema which will causes even further tissue dysfunction.

The principles of cupping are basically the same now as they’ve always been. A cylinder is placed over the skin forming a seal and air is pulled or drawn out. This creates suction and the skin (as much as four inches in depth) is pulled up into the cup. Immediately blood is drawn to the area and the pulling action stretches the superficial fascia. Sometimes the cups are removed quickly, sometimes they are left stationary for minutes at a time, and sometimes they are moved around over a targeted area of lubricated skin.

Cups come in a variety of shapes and sizes and can be made of different materials such as glass, plastic, or rubber.  Air can be drawn out quickly by igniting a flammable material on the inside of a glass cylinder or bulb (as seen in acupuncture practice), by manually drawing it out of a plastic or glass cup with a hand-held pump, or by mechanically drawing it out with a vacuum machine. Rubber cups are like mini plungers applied manually and typically are moved around over lubricated skin (great for home use). One cup at a time can be used, or multiple for a widespread effect. Whichever method chosen, the end result is an increase in blood flow to the area and a mobilization of the superficial fascia. There is almost always some degree of bruising from the disruption of the tiny capillaries in the skin and subcutaneous tissues.

Western physical medicine has adopted cupping based essentially on two principles: an improvement in the mechanical quality of the superficial fascia and an enhancement of the circulatory and lymphatic capability of cutaneous and subcutaneous tissues. The lifting action on the superficial tissues can have similar and sometimes more profound results compared to myofascial release techniques. There are many proposed theories regarding how myofascial manipulation can have immediate and lasting effects (too long of a discussion for this article), and those same principles apply to cupping or vacuum therapy. Furthermore, the effect that cupping has on the nervous system contributes to mechanical improvements by stimulating nerve ending that have a direct inhibitory effect on muscle tone and myofascial viscosity.

Improvements in circulation come from what you see when the skin is pulled into a hickey and results in redness or bruising. We can control the amount of suction by how much air we pull out of the cups. The more suction, the more blood that will immediately come to the area, in a sense feeding oxygen and nutrients to possibly stagnated tissues that lack efficient blood flow. The bruising is a result of micro trauma to cutaneous and subcutaneous capillaries and fascia. While this may seem a bit barbaric, the end result is that when the tissue heals we can expect a proliferation of the capillary system and a healing of the tissue in a more normal and healthy way (especially if proper exercise and nutrition advice is given to the patient). Also, this micro trauma creates a controlled and variable degree of inflammation, which is the body’s initial response to healing. The inflammatory and immune response of platelets, white blood cells, and other chemical mediators coming to the area is a good thing, again, especially if proper subsequent exercise and nutritional advice is followed by the patient. I have found that my patients bruise significantly less after just one treatment, a sign of improved tissue mobility and circulatory health.

Local areas of mild edema are treated well with cupping as the skin is lifted and the lymphatics in the subcutaneous fascia are stimulated. I explain to my patients that space is being created where there was not enough for the lymphatics to flow efficiently. Creative use of moving the cups over larger areas or by using multiple cups has a nice pumping effect on the lymphatics.

Clearly cupping shouldn’t be considered a stand-alone treatment. But when it is combined with other soft tissue and/or joint mobilization techniques and movement or postural correction exercises, cupping will greatly enhance the rehabilitation experience. The bruising is a small price to pay for healthier tissues and a more pain-free you.