Cupping: A purple or a blind spot?

Annie Zhang and Andrew Shubov
August 30, 2016
By Annie Zhang and Andrew Shubov
The most decorated Olympic athlete in history sparked controversy throughout the media with his use of cupping – an ancient Chinese method used to treat musculoskeletal pain and other disorders.

For those of us working in the integrative medicine field, the fact that Michael Phelps would use such a method to improve his performance was unsurprising. What concerns us is the unequivocal assertion by many mainstream medical writers that cupping is "pseudoscience" and not evidence based.

An article in The Atlantic equated displaying the effects of cupping to an invitation for "people to distrust science," and suggested "cupping has not been studied in large, controlled clinical trials." Another on Slate.com suggested that because it is difficult to perform high-quality, randomized double-blinded trials, cupping is "another expensive placebo."

On the contrary, a growing body of evidence now supports treatments formerly known as "alternative medicine," leading even the US military to employ meditation in training as well as battlefield acupuncture. An analysis of 135 randomized, controlled trials on cupping between 1992 and 2010 showed encouraging results for disorders such as shingles and neck pain. Admittedly, most of these studies are limited by a high risk of bias and the difficulty involved in blinding patients to cupping. But rather than writing it off completely, a more rational response to this data would be to design and perform higher quality studies that can more accurately assess its effectiveness.

Discounting all possibility of benefit for cupping because of a lack of "large, randomized clinical trials" represents a double standard when evaluating conventional versus "alternative" therapies. Take, for example, the American Heart Association guidelines for management of STEMIs, the most serious type of heart attacks, which contain dozens of recommendations based on one or fewer randomized trials. To quote the writers, "many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective."

Why shouldn't we apply the same logic to cupping and other non-conventional therapies?

Recent advances in our understanding of fascia, the fibrous tissue surrounding every muscle, nerve and organ, may provide new insights into the physiology of cupping and the mechanism for its potential effect. Anatomic dissection studies demonstrate the presence of connective tissue that link most muscles of the body, with implications for chronic pain syndromes, overload injuries and athletic performance.

Massage is one way to release fascial tension and adhesions to restore smooth motion of muscles and enhance local circulation, and cupping can be considered as another. Cupping can be conceptualized as a way to release fascial tension and adhesions to restore smooth motion of muscles and enhance local circulation.

For a top performing athlete, improving blood flow and restoring the smooth motion of muscles may give him the milliseconds he needs to win gold. In the case of the patient with chronic muscular pain, the same effect may provide a drug-free solution for pain. When compared with the known risks of common pain medications such as opioids and nonsteroidal anti-inflammatories, the side effects of cupping when done by a trained practitioner are minor.

In a society in the grip of a massive opioid epidemic, we as a medical establishment need to provide reasonable advice about non-drug therapies that is grounded in rational and open-minded interpretation of the available evidence and clinical experience.

The success of Michael Phelps at the Rio Olympics illuminated a blind spot in our discussion surrounding cupping and other unconventional treatments. If this can inspire a more balanced conversation about these topics, perhaps his massive showing in Rio can help leave a lasting effect at home.

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Dr. Annie Zhang, MD, is assistant clinical professor at UCLA Center for East-West Medicine and David Geffen School of Medicine at UCLA. A board-certified primary care physician, Zhang received her BA from Harvard and her MD from the David Geffen School of Medicine at UCLA. During her training, she felt limited by the lack of effective Western therapies for many common symptoms and conditions, which led her to pursue additional training in integrated medicine.

Dr. Andrew Shubov, MD, is assistant clinical professor at UCLA Center for East-West Medicine and David Geffen School of Medicine at UCLA. A board-certified primary care physician, Shubov obtained his MD from the USC Keck School of Medicine and completed his residency in Internal Medicine at Cedars-Sinai. He completed his integrative medicine fellowship at the UCLA Center for East-West Medicine. He directs his integrative therapeutic approaches to the care of chronic conditions including inflammatory bowel diseases, autoimmune disorders, heart failure and cancer.

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