By Emma Van Loock Lic.Ac 2016

Chinese Cupping Therapy: Six Questions Answered...

1. Why were people talking about Cupping Therapy so much during the Rio Olympics?

Cupping exploded into public attention during the Rio 2016 Olympics as Michael Phelps, the most successfull Olympian of all time was seen with highly visible cupping marks on his shoulders and upper back, fuelling much renewed interest in the ancient technique.

2. What is cupping therapy?

Chinese cupping is first mentioned in early Chinese texts (Ma Wang Dui medical manuscripts) around 168BC, but we also find mention is various other traditional medicine systems.  Cupping involves placing a hollow vessel on the skin and creating a vaccum using fire or a vacuum pump in order to stimulate circulation to local tissue and mechanically lift the muscle and fascia with the aim of reducing pain and tension, or enhancing a traditional acupuncture treatment. It is commonly used for musculoskeletal problems and pain but traditionally has been used for a wider range of health problems for example chronic respiratory problems.  It is usually used alongside acupuncture.

3. Why is Michael Phelps using cupping?

Michael Phelps is not the first athlete to turn to cupping.  In the 2008 Beijing Olympics, swimmer Wang Qun attracted media attention having been seen sporting the tell-tale signs of cupping. Sports therapy interventions may target a number of goals including recovery, injury prevention, injury treatment, or performance enhancement.  The Olympics are the culmination of a lifetime of swimming and four years of focussed work. Michael Phelps needs to be able to perform at his best without being limited by any injuries or pain that he might be carrying, and shoulder pain in elite swimmers is extremely common.  One survey of elite swimmers found 91% had shoulder pain, 84% had positive shoulder impingement and 67% had tendinopathy of the supraspinatus.  Many turn to anti inflammatory medicine, but the usefulness of these are disputed and additionally carry risk of stomach irritation or worse. Cupping is a low risk non-invasive intervention that has been proven to improve short term pain compared with other interventions. Phelps may be using cupping to help manage short-term pain, or to aid recovery through stimulation of circulation through the tissues and muscules of the shoulder and upper back.  As a mature and ultra-succesful athelete with the weight of expectation on his shoulders, Phelps cannot afford to mess around with an intervention that may not compare favourably with another.  You can be sure that he chooses cupping because he perceives it to be a worthwhile addition to his arsenal of therapeutic techniques.

4. How does it work?

There is a saying in Traditional Chinese Medicine that when the 'qi' is obstructed there is pain, but when the 'qi' flows properly there is no pain.  Tension, trauma, inflammation, scar tissue, histological changes in the tissue structure during healing are all examples of physical causes of the obstruction of qi.  Additionally emotional stress leads to voluntary (if unintentional) tension in the body.  The simple strategy of traditional chinese medicine is to restore the correct function of qi circulation by treating the obstruction directly and addressing the cause of the obstruction. Pain is a complex experience involving inflammatory, neural or structural inputs (physical) with social and psychological influences. Cupping promotes circulation and gently lengthens the tissues by drawing them upwards into the vaccum space.  Its is thought that this improves healing and reduces pain.

5. Is there any science?

The exact mechanism of how cupping works has not been established although hypotheses exist that suggest the analegic effect may be similar to that of acupuncture eg through counter-irritation or perhaps through drawing circulation to the affected area.  Clinical studies on how this impacts recovery or pain is not yet conclusive.
However, a 2014 Systematic Review attempted to study all evidence to date on cupping therapy. The studies included both wet cupping (involves bleeding and is used in other clinics but not Belfast Community Acupuncture) and dry cupping (the type we use).
Of 55 trials identified, 16 were high enough quality to make it through to final inclusion in the study (this is good, it means they eliminated poor quality studies).
The results found overall that patients reported reduced short term pain intensity after cupping compared with conventional care, wait list, heat therapy and drugs.

6. What are the circular marks, they look painful?
The classic cupping marks are essentially caused by extravasation from the small superficial capillaries during the therapeutic process.  Although these bruises might look painful in above systematic review only 10% of patients reported mild adverse effects of bruising or mild pain at the site of cupping.  These marks are extremely common and should fade within several days.  Phelps may have been shown grimacing during a treatment but there is no need for cupping to be painful.  The strength of the vacuum may be varied to suit.  Causing a patient pain may lead to further contraction of muscles, and the British Acupuncture Council states that cupping should not be a painful procedure and to seek a licenced acupuncturist.

Listen to Emma talk about cupping on BBC Radio Ulster

Further Reading:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289625/
http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0031793

By Emma Van Loock Lic.Ac 2016

By Emma Van Loock Lic.Ac 2016

If you have suffered with pain or a lingering musculoskeletal disorder, you are not alone. Musculoskeletal conditions are the leading cause of work absenteeism in Ireland (Athritis Ireland, 2013; Health and Safety Executive, 2015) with chronic pain affecting up to one in three people (McGuire, 2011).  In the UK, 9.5 million working days were lost due to work-related musculoskeletal disorders in 2014-2015 (Health and Safety Executive, 2015).  This can have a big impact on professional and family life, mental health and general quality of life, but despite this it can take over four years to get a diagnosis, plus a further wait for treatment, despite medical consensus supporting an early intervention (Zheltoukhova et.al, 2012).
 
The health benefits of regular physical activity includes decreased risk of cardiovascular disease, diabetes, obesity, cancer and depression (World Health Organisation, 2016) and participation in sport is on the rise (Sport England, 2015; Irish Sports Council, 2011) leading to an increase in strains, sprains, and overuse injuries (Young et al., 2005).  Treatments include rest, over the counter medications or exercise therapy, and acupuncture is widely used.  Approximately 3.8 million acupuncture treatments are given in the United Kingdom each year of which 59% are due to musculoskeletal complaints such as back, shoulder, neck and knee pain (Hopton et al., 2012).
 
How Does Acupuncture Treat Musculoskeletal Injuries and Pain?
 
In Traditional Chinese Medicine it is said, “when there is free flow of Qi there is no pain, and when there is pain there is no free flow of Qi”.  ‘Qi’ may be interpreted as a metaphor used to describe many different functions, depending on the context. Mechanical trauma or overuse can lead to inflammation, bruising, scar tissue, tension or persistent abnormal pain signals leading to pain and dysfunction.  These ‘obstructions in the flow of Qi and Blood’ may be alleviated through acupuncture, moxibustion (heat), Chinese cupping therapy, electro-acupuncture and massage in order to stimulate the ‘free flow of Qi’, reduce pain and restore function.

Another Chinese concept is that of yin and yang. In a sporting context yin refers to rest and recovery, whereas yang refers to performance and competition (Reaves, 2012). Studies have demonstrated a positive effect of acupuncture on Delayed Onset Muscle Soreness (Itoh et al., 2008; Hübscher et al., 2008). Tour de France 2014 winners Team Astana employ Traditional Acupuncturist Eddie de Smedt on tour to manage stress, stomach problems, pain and recovery (Cycling News, 2014).  Acupuncture is an effective intervention for a number of sports injuries (Young et al., 2005).
 
Acupuncture may be used on its own or as an adjunct to conventional treatments.  For example, a review of all interventions for shoulder impingement found that acupuncture improved outcomes when added to exercise therapy (Dong et al., 2015).  Sustained longer term benefits of acupuncture have also been linked to improved ‘self-efficacy’ (MacPherson et al., 2015).  You can expect your traditional acupuncturist to give advice around exercise, stretching and lifestyle factors based on the traditional diagnosis (MacPherson & Thomas, 2008).
 
Where to Get Acupuncture
Private appointments are widely available at Traditional Acupuncture Clinics and fees may be covered by private health schemes. Acupuncture Foundation Professional Association registered members have undertaken training over a minimum of three years, adhere to professional guidelines and complete mandatory Continuing Professional Development training annually. 

Emma Van Loock Lic.Ac ITEC.Dip (2016)


References (click "read more")

Acupuncture and chronic pain, real or placebo?
 
Introduction
 
The traditional explanation for pain in Chinese Medicine is ‘If there is free flow, there is no pain: if there is pain, there is no free flow’.  Trauma leads to inflammation, scar tissue, bruising, restriction of circulation at local or distal tissues, taut bands of muscles, impinged nerves, trigger points etc and all of these are a disruption of the normal circulation of qi and blood.  Acupuncturists who work with patients, and patients who receive acupuncture may experience pain reduction, improved circulation, improved range of motion, improved mobility and for those of us who have had positive experiences, the proof of the pudding is in the eating.

However there are a number of questions bouncing around regarding ‘why that particular point there, instead of somewhere else?’  And ‘is it just placebo?’

A recent meta-analysis of acupuncture trials involving patients with headache and migraine, osteoarthritis and back, neck and shoulder pain. Twenty-nine trails met inclusion criteria for the study.  True acupuncture was compared with penetrated and non-pentrating sham and the authors conclude that penetrating needles appear to elicit important physiological activity and recommend that this type of sham be avoided in acupuncture studies.  (This has been a problem in previous studies attempting to demonstrate acupuncture superiority to sham-acupuncture, where the sham-acupuncture was designed to act as placebo but was in fact eliciting a physiological response).

Full text: Influence of control group on effect size in trials of acupuncture for chronic pain: a secondary analysis of an individual patient data meta-analysis. PLoS One. 2014 Apr 4;9(4):e93739). Available here

[All in the same boat: a qualitative study of patients’ attitudes and experiences in group acupuncture clinics Online First doi 10.1136/acupmed-2012-01050]

Acupuncture can relieve the pain of knee osteoarthritis and offer a low cost alternative to surgery for the condition, finds research published online in Acupuncture in Medicine.

The researchers base their findings on 90 patients with knee osteoarthritis, who were referred for group acupuncture to two knee pain clinics in St Albans, Hertfordshire, in 2008 and subsequently monitored for two years.

Fifty patients said they would be prepared to have surgery; four said they would only have the operation as a last resort; and 29 said they did not want surgery.  They were given acupuncture once a week for a month after which the frequency was reduced to a session every six weeks.

Each patient received an average of 16.5 treatments.

From the British Medical Journal.  Full article available here

In what may be the most significant research to emerge in the last five years, an international collaboration, involving some of the UK’s top acupuncture researchers, has provided definitive evidence that acupuncture is effective for chronic pain. The authors analysed raw individual patient data – an approach that allows for statistically precise results – for 17,922 participants enrolled in 29 high-quality, randomised trials of acupuncture for chronic back and neck pain, osteoarthritis, shoulder pain and chronic headache. The study, published in the prestigious Archives of Internal Medicine on September 10th, showed that for each of the four conditions, the analgesic effect of true acupuncture was slightly better than that of placebo acupuncture. However, the difference between true acupuncture and usual care alone was found to be much larger and of clinical significance. The authors hope their findings will encourage clinicians to recommend acupuncture as a safe and effective treatment and inform future clinical and policy decisions. (From www.jcm.co.uk)

Iliotibial Band Syndrome is a repetitive stress condition characterised by pain at the lateral knee and thigh.  The pain is caused by friction under the IT band leading to chronic inflammation, aggravated by exaggerated flexion and extension of the knee (such as running with speed work or hills) and the pain is relieved by rest.   Confirmation of IT band involvement is performed with palpation to the band 2-4cm proximal to the lateral joint space of the knee in the region of the acupoint GB-33. Differential diagnosis should be ruled out (eg lateral collatoral ligament sprain).  There may also be involvement of gluteal muscles (tenderness at Jian Kua) and Quadratus Lumborum.  Primary treatment involves "thread needling" of the underside of the IT band in combination with other local and distal points.  Electro-acupuncture may also be used.    This particular condition responds very well to acupuncture. Recommended treatment up to twice per week for 3 weeks then re-evaluate.

Sports Acupuncture has progressed massively in recent years with greater integration between traditional acupuncture and western anatomical understanding.  Properly licensed acupuncturists  specialising in sports acupuncture learn to integrate western anatomy for the best outcome. (Look for Lic.Ac and then evidence of ongoing sports education). Educators such as Colorado-based Whitfield Reaves have really raised the bar with their specialised knowledge and training programmes. 

Emma is a licensed acupuncturist and ITEC Sports Massage therapist and completed post-grad training in sports acupuncture with Kevin Young at CICM Reading, and is also currently continuing her studies with the sports acupuncture online programme with Whitfield Reaves online seminars.  Emma's approach is to treat sports injuries with acupuncture and integrate manual techniques as appropriate to the specific injury.