Chinese Cupping Notes | Remedial Therapy

Photo credit Bob Wong, The Art of Acupuncture

Traditional Chinese Cupping - Notes for Therapists from the Perspective of Remedial Massage Therapy

Chinese Cupping is about releasing myofascial tightness and removing stagnant circulation. It is a deep penetrating stretch caused by suction from partial vacuum inside a Cup placed on the body. It is not appropriate for all conditions and depending on the method of practice, can be too aggressive for fragile individuals. Other physical therapy techniques exist for releasing fascial tightness but Cupping has the advantage of deep targeted penetration not only into flesh but also into joints. The ability to rapidly remove toxic stagnation is unmatched by any other technique. My knowledge on the use of Cupping for treating internal health conditions such as influenza and digestive issues is minimal and will not be discussed here apart from describing a few signs and symptoms that indicate referral to a TCM practitioner is warranted.

Above: Lower Back Pattern

Above: Partial glutes, full back with Bladder meridian, rotator cuff, acromion. Heavy session only suitable for particularly strong individuals. Deltoids might also be included in some instances. Acromion placement particularly good for Supraspinatus impingment, shoulder arthritis and shoulders mobility generally. Typically very strong purple/black marking results on initial application.

Above: Effect from Slide Cupping along Bladder meridian either side of thoracic spine. Relatively strong "Sha" releasing heat. This case presenting with excessive lordosis through the thoracic and the vertebral extensors like steel cables. Gua Sha or Slide Cupping more effective than Static Cupping for this condition. I am sighting lower back cupping being carried out too.

Above: Strong stagnation occurring rapidly in this case where this shoulder has had two reconstructions and the client trains/works particularly heavy. First application. The response will typically fade with subsequent sessions. If practised regularly you will find that after half a dozen treatment sessions the bulk of stagnation will be removed and only faint markings will be generated by this same treatment. However, being the rotator cuff which is a very highly stressed area, it will still reflect stronger colouration than elsewhere on the back.

Above: Left and right shoulders from another hard training athlete. These cups have not necessarily been on for a long time or with greater suction applied than instances where little colouration occurs. It is about the condition of the underlying tissues affected by tightness and circulation issues. These pictures taken a long time ago prior to getting the extensive set of cups I work with now...cup selection was limited. As mentioned previously, the high degree of stagnation sighted here will gradually fade with successive sessions excepting in the presence of ongoing aggravation from injury.

Above: My present cupping set consists of 9 Size 5 cups, 27 Size 4, 36 Size 3, and a tub full of Size 2 that I have never counted. The hand pump set has been dispensed with and only do fire cupping now. Application with a hand pump is slow, the cup edges are thin and the plastic cups difficult to clean...their valves being damaged in the dishwasher. A dishwasher installed in the clinic laundry specifically for cleaning the Chinese cups Several loads go through it some days. Not all cases require cupping treatment and it may sit idle on others.

Left: Anterior Shoulder Cupping Pattern.
Long Head of Biceps origin plus anterior Delts at corner of shoulder and below. The first two of these frequently displaying very strong stagnation and highly therapeutic to reduce pain and increase range of motion.

Vacuum pressure is created by firing and heating the air prior to placement or by pumping through a one way valve or by squeezing a flexible silicone bulb. They are applied for periods as short as a mere second through to five or ten minutes and are most effective where there is general fascial tightness. A single Cup or multiple static Cups can be placed on upper and/or lower back generally, a shoulder or other joint or limb. A single Cup can be used to slide back and forth over a region of the body.

Circulation is impeded by tightness and in time becomes stagnant and I do not mean in the arteries and veins, but in the flesh of the muscle. I think of it as a toxic situation with decreased oxygen levels and increased waste matter from cells, dead cells and unused nutrients. Circulation includes not only the blood but also energy known as Chi and in Chinese medical philosophy this is most important component. Movement of the Chi leads the blood. Stagnant Chi is called Xé Chi which translates as Evil Energy.

Cupping draws the Xé Chi out of the body into the Cup. When removing Cups from the body, do not point them at anyone to avoid giving them a small dose of bad juju too. Accidentally doing so to myself one day, I can attest to the ill effects that can result.

Blood coming to the surface leaves marks that on the next day appear to be bruising but in fact no damage or contusion has been done to the body. Where there is good muscle tone, no tightness, good circulation and no stagnation, very little colouring or darkness will be apparent on the skin immediately after Cupping. Whereas, should there be chronic tightness due to injury, bad posture or overwork, etc., colouration can vary from light red to blood plum or black. The darker the marks, the more it was needed. The lymphatic system will gradually remove, process and eliminate the old blood brought to the surface over a period of several weeks.

Occasionally, where there is a chronic condition, so much blood will be drawn to the surface it oozes through the pores into the Cup. It is quite uncommon. It is not like fresh blood from a cut finger or bloody nose. It is thick and mucousy. It is old blood. It has been trapped in the muscle tissues for a long time. Traditionally, it was common practise to "bleed" the patient by intentionally cutting the skin with a razor prior to applying the Cup...effectively leeching the bad blood out of the body. Nevertheless, bringing the blood to the surface and allowing the lymphatic system to deal with it is sufficiently effective without the drama of purposefully making the patient bleed.

Assess tissue condition to determine if cupping is suitable or needed. Not all tightness responds to cupping. Heat ladden tissues (liver fire) with steel cable like quality and a gristle like tightness down on the bone with loose skin above does not respond to cupping. General fascial tightness and trigger points respond best.

As mentioned, Cupping can be an aggressive treatment that is too much for some individuals. Strong and robust men will feel tightness and pinching, experiencing pain only where Cups are placed directly on an area of extreme tightness (trigger points) and abundant amounts of stagnation are present. The pressure can be moderated for women whose flesh is softer and find it overwhelmingly painful. After a few minutes, once the Cupping has begun to release tightness and do its thing, pain levels drop dramatically. By the end of the treatment it is common they cannot be felt. A degree of euphoria may be imparted and sensations of warmth persist once the Cups are removed. The overall effect is relaxing for an individual who really needs it. However, where applied to someone who does not cope well with the intensity, they are too fragile physically or emotionally, negative results can occur such as unbearable degrees of pain and/or emotional depression.

Pain and restricted range of motion can be totally eliminated by this treatment. For example, a flight attendant that had been on sick leave for several months due to a shoulder injury that developed progressively over a long period of time and was experiencing high degrees of pain...unable to use the arm nor bear any form of massage. Gentle fascial release techniques progressed to gentle mobilisation and then conventional massage over four treatment sessions. When her condition finally allowed more intensive treatment, a standard shoulder Cupping regime was applied. All Cups except one yielded no sign of stagnation...they were not really needed. One Cup only went as black as the Ace of Spades...at the anterior deltoid and long head of biceps insertion. This one Cup totally relieved her shoulder problem, she was no longer in pain and returned to work. It is as though it sucks inflammation directly out of the joint, relieving impingement. I have seen this many times after placing Cupping on this position or directly over the Acromion.

The colour of Cupping marks indicates the degree of injury/stagnation and also internal health conditions that may warrant further TCM treatment. Light pink is the sign of no stagnation. Varying degrees of red to blood plum colour are sign of stagnant circulation. The darker the marking, the more it was needed. Black marks are sign of the highest degree of internal bruising and stagnation. Scarlet indicates a very Yang constitution and speckled red dots, Spleen fire. Individuals with either of these latter two signs should consult a TCM practitioner. Those with a Yang constitution exhibiting scarlet Cup marks will have a strong impulse to sleep mid-afternoon over the next few days or week. The colour and intensity of cup marks on successive treatments close together will reduce with each treatment as stagnation removed. There are exceptions where

Individuals with high degrees of internal dampness blister easily. The Cups becoming more uncomfortable and painful during the treatment rather than more comfortable...the blistering often preceded by sensation of itchiness. Sometimes it is only one or two small clear blisters (equivalent to 2nd degree burn) that are of little consequence. I have seen several instances of severe blistering where I had verbally checked in with their progress and they did not confess to actually being in discomfort or pain. Internal dampness can result from too much sugar in the diet and/or living in damp conditions. One reason humid Asian countries have developed cuisines heavily laced with chilli is to burn out dampness.

The first time I treated my adult son's troublesome shoulder that had undergone reconstructive surgery, he blistered badly. Yes, he had a bit of a sweet tooth and also lived in a drafty old terrace share house in Fitzroy with no heating...very damp throughout winter. I advised him that before we could do a follow-up treatment, the blistered skin will need to heal and to have a couple hot chilli dishes each week...hot enough to make him breakout in a sweat. Full intensity cupping treatment applied on his next treatment did not cause any blistering.

Before Cupping a client for the first time, I describe what they can expect to experience with a warning that should discomfort levels or itchiness increase during the course of the treatment to let me know immediately. Should I be doing a shoulder or back Cupping treatment, I will typically massage lower limbs while the Cups are at work. I maintain a closer visual inspection of the Cups these days during the course of the treatment to avoid blistering.

Assess tissue condition to determine if cupping is suitable or needed...cupping is most effective on general fascial tightness. Do not confuse tight musculature that feels like steel cables with general fascial tightness. Cable like muscles or gristle like quality down on the bone with loose flesh above is indicative of excessive heat trapped in the soft tissue. It does not respond well to Cupping. The heat can be removed and muscle tone returned to normal by dietary change in several months, TCM herbal treatment in several weeks or Gua Sha (spooning/scraping) in several minutes. This condition is often accompanied by sharp stabbing pains behind the shoulder blades that no amount of massage, stretching or joint manipulation will remove. It is most noticeable in the upperback, neck and shoulders as heat rises in the body and is generally associated with Liver fire affecting tendons.

Moderate intensity and use smaller cups for softer, weaker clients. Weak individuals with little or no general fascial tightness I would not cup at all; treatment consisting of conventional massage and more gentle fascial release techniques. Moderating intensity can be achieved when fire cupping by hesitating a second or two before applying the cup after heating. Check intensity by pulling on the cup. Should it release too easily, re-apply shortening the delay; without some suction no therapeutic benefit results. Smaller cups on upper back and shoulders, larger cups on larger muscles. Do not apply cups to damaged skin or open wounds. Do not place cups on a joint if ligamental damage is suspected or recent surgery was performed. There will be some individuals who would benefit from both Cupping and Gua Sha, but I never do both techniques on the same area of skin in one treatment.

Used correctly, traditional Chinese cupping can achieve dramatic results. Therapeutic intensity achieved in one session that may totally relieve symptoms preventing movement and ability to work which would otherwise require vast amounts of massage and physical rehab exercise beyond most people's motivation, discipline and ability. More commonly, a general benefit to a shoulder, upper or lower back condition is achieved. Supplementing massage treatment providing benefits that cannot be achieved through massage alone. Many of my clients seek cupping on a regular basis. Then again, some of my clients I would never dream of cupping. While it is extraordinarily therapeutic, it is not the treatment for all conditions.

Blistering can occur and I always tell clients to let me know if they feel any itchiness or increasing pain and discomfort. It can be a sign this is happening. The normal way of it is sensation at the cup from first administration should ease off and 5 to 10 minutes later they may not even be able to feel them in some cases. I also check in with them about half way through the cupping session questioning on how the cups feel and make a visual inspection.

It might be if they are left on for an extended period of time like 30 minutes or more, blistering might always happen but it is not only a function of time. Both suction strength and internal health condition can contribute. Internal dampness from living in damp conditions or eating too much sugar will increase the possibility of blistering.

In one instance, a recovering Coca Cola addict who had consumed 15 cans daily (he may have been understating the truth of it) and still had an enormous sweet tooth, blistered within seconds of placing the first cup. Before I could pick up the second, he began to squeal and I removed the first. Every square millimetre under that cup already had pin head sized blisters forming. It was not until two years had passed before I was able to apply cupping to him. Unfortunately he was not under the supervision of the TCM practitioner which might have otherwise accelerated his recovery.

I have also found inflammation from high intensity physical exertion can be a factor. Where broadly placed cupping results in a few little blisters typically near the middle and lower trapezius' insertion to lower half the the medial border of the scapula.

Blistering is to be avoided by giving verbal warning...do not let them tough it out if discomfort is escalating...checking in with questioning and visual inspection, and limiting duration generally. It causes discomfort for a number of days and will heal (weeks) and sign of it fades (weeks/months). It can scare off the client who will miss out on the benefits that can be gained.

Pictured above is my shoulder after two consecutive cupping sessions for acute shoulder injury that came about after heavy sessions cutting, moving and stacking timbers from trees felled in storms in 2024. It was like something tore when stretching afterwards. Subscapularis and/or the Teres muscles and insertion of these to arm. The Thai massage therapist doing a heavy overall shoulder rub down did overdo it at the insertion point. I suspect neural damage as well from one particular heavy lift several months prior that elicited a brief burning sensation may have set me up for this later catastrophe.

This cupping was sort of self applied with assistance from my wife, placement not necessarily ideal but it did the job. High degrees of stagnation and sign of inflammation from some scattered blistering. In this case the blistering was the least of my concerns and, in fact, probably had a beneficial effect reducing inflammation. It was an excruciating injury that took many months to resolve. Despite much treatment, little or no improvement in the first two months. Commencing medicinal doses of collagen supplementation (2-3 doses daily) at the two month mark made a remarkable difference. Pictured below are the signs from a third cupping session some time later indicating little or no stagnation or internal bruising remained. Regular daily use of a FIR heat treatment lamp was also key to treatment.