Cupping

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1. What Cupping Is

Cupping is a manual therapy procedure in which local skin and tissue stimuli are set by negative pressure in glass, bamboo or plastic cups. A distinction is made between dry cupping (negative pressure only), wet cupping (with skin incisions) and moving cupping (massage with negative pressure). The method originates from the traditional medicine of various cultures, including Chinese, Arabic and European healing arts, and has been used for centuries to treat pain conditions, inflammations and functional disorders.

The decisive point for the evidence base is the variety of application forms and the difficulty of standardisation. Cupping is performed in different techniques, pressure intensities, application durations and body regions, which complicates the comparability of studies. In addition, a clear demarcation from placebo controls is often lacking, as the sensory stimulus (pressure, warmth, skin reddening) is difficult to simulate. The measurement of effects is usually based on subjective parameters such as pain scales or quality of life, less frequently on objective markers such as inflammatory values or mobility.

2. What the Studies Show in Detail

The key human studies and the most important reviews — by indication, with population, duration, preparation, measurement variable and result, as reported by the original studies. Numbers are stated only where the study mentions them.

Distribution of controlled human studies by indication — the numbers are not additive, as one study may be assigned to several areas:

Musculoskeletal System

A randomised controlled trial (RCT) with 98 patients (17–68 years) with non-specific chronic back pain examined the efficacy of wet cupping over three sessions at three-day intervals (day 0, 3, 6) compared with standard treatment. The effects were clear versus the control group, yet a placebo control was lacking and follow-up was limited to three months 2.

In carpal tunnel syndrome (CTS), an RCT with 52 patients (mean age 58.5 ± 8.0 years) compared a single application of wet cupping with local heat application. After seven days, pain intensity (VAS) in the cupping group decreased from 61.5 ± 20.5 mm to 24.6 ± 22.7 mm, while the control group showed only a reduction from 67.1 ± 20.2 mm to 51.7 ± 23.9 mm (group difference: -24.5 mm; 95 % CI: -36.1 to -2.9, p < 0.001). The study suggests short-term efficacy, yet long-term data and blinding are lacking 3.

Only in the secondary endpoints well-being (measured via questionnaire) and pressure pain thresholds (as a measure of pressure sensitivity) was there an advantage for cupping. The study compares cupping with an established relaxation technique and finds that it is not superior, yet well tolerated and easy to apply 5.

A pilot RCT with 32 patients (21 in the cupping group, 11 in the wait-list control) examined wet cupping in chronic non-specific low back pain (PNSLBP). Treatment was performed six times within two weeks at acupuncture points BL23, BL24 or BL25. The study suggests short-term efficacy, yet is limited by the small sample size and lack of blinding 6.

A three-arm RCT with 110 patients with chronic low back pain compared pulsating dry cupping (8 sessions) and minimal cupping (placebo-like) with a control group (paracetamol as needed). After four weeks the pulsating cupping group showed a significant pain reduction (VAS) versus the control group (difference: 21.2 mm; 95 % CI: 12.2 to 30.1, p < 0.001), while minimal cupping was also more effective than control (difference: 15.7 mm; 95 % CI: 6.9 to 24.4, p = 0.001). After 12 weeks the effect persisted for pulsating cupping (difference: 15.1 mm; 95 % CI: 3.1 to 27.1, p = 0.014). The study suggests that even minimal cupping applications may be effective in the short term, yet long-term data and a clear differentiation of mechanisms are lacking 9.

Hypothesis Some controlled studies suggest that cupping – particularly wet cupping – may be effective in the short term for chronic musculoskeletal pain. The effects are often moderate, however, and comparable to placebo or standard therapies. Heterogeneity of application protocols (frequency, duration, cupping technique) complicates a general statement. Missing: Long-term studies with standardised protocols, comparisons with established therapies (e.g. physiotherapy) and clarification of mechanisms of action.

Headache and Migraine

An observational study with 70 patients with chronic tension-type headache or migraine examined the efficacy of wet cupping. After three months headache intensity decreased by 66 % compared with baseline, and the number of headache days per month fell by an average of 12.6 days. The study suggests clinically relevant effects, yet is limited by the absence of a control group and subjective success assessment. Possible mechanisms (e.g. local improvement of circulation, anti-inflammatory action) remain speculative.

Hypothesis Cupping could represent a promising adjunctive treatment option for headache, especially when conventional approaches are insufficient. The available observational studies provide initial indications, yet RCTs with placebo control as well as standardised application protocols are lacking. Missing: Controlled studies with clear diagnostic criteria, longer follow-up periods and investigation of mechanisms of action.

Fatigue and Stress

An RCT with 141 patients (139 women, mean age 55.8 ± 9.1 years) with fibromyalgia syndrome compared cupping (five sessions over two weeks) with sham cupping and standard treatment. After 18 days the cupping group showed a significant pain reduction versus standard treatment (VAS difference: -12.4 mm; 95 % CI: -18.9 to -5.9, p < 0.001), but no difference versus sham cupping (difference: -3.0 mm; 95 % CI: -9.9 to 3.9, p = 0.396). Quality of life improved only versus standard treatment. The study provides an indication that cupping in fibromyalgia is not more effective than a placebo intervention 7.

In an RCT with 67 patients with primary insomnia cupping (four weeks) was compared with benzodiazepines and a wait-list control. Both treatment groups showed a significant reduction in the Pittsburgh Sleep Quality Index (PSQI) versus control, without differences between cupping and benzodiazepines. Imaging procedures (fMRI) indicated preclinical changes, including an increase in grey-matter volume in the right hippocampus and strengthened functional connectivity between hippocampus and prefrontal cortex. The clinical relevance of these structural and functional findings has not been examined. The study is limited by the small sample size and lack of long-term data.

Hypothesis Cupping could act beyond placebo effects in stress-associated complaints such as insomnia or fibromyalgia, possibly via modulation of the autonomic nervous system or inflammatory processes. The available controlled studies nevertheless show inconsistent results, and the effects are often not distinguishable from placebo. Missing: Studies with larger samples, longer follow-up periods and investigation of psychoneuroimmunological mechanisms.

Inflammatory Processes

An RCT with patients with chronic non-specific low back pain examined the combination of laser acupuncture and cupping (five days at points BL40 and Ashi). The combination group showed a significant reduction in pain intensity (VAS) on days 4 and 5 versus the control group (sham laser + cupping). In addition, plasma cortisol levels decreased in both groups, yet without significant group difference. The study suggests a possible additional effect of laser acupuncture during cupping, yet does not permit a statement on the effect of cupping alone. It is limited by the short treatment duration and lack of long-term data.

An observational study with 31 healthy volunteers examined the effects of wet cupping on oxidative stress. Cupping blood showed higher concentrations of malondialdehyde and nitric oxide as well as increased activity of myeloperoxidase and reduced activity of superoxide dismutase compared with venous blood. The study demonstrated differences in markers of oxidative stress in cupping blood and venous blood; removal of pro-oxidative substances from tissue was not examined. The clinical relevance of these findings has not been examined 21.

Hypothesis Cupping could act via modulation of inflammatory mediators and oxidative stress, especially in chronic pain conditions. Controlled studies with standardised biomarkers are still outstanding. Missing: Longer follow-up periods and investigation of systemic effects.

Heart and Circulation

After four weeks the cupping group showed a significant reduction in systolic blood pressure of 8.4 mmHg versus the control group (p = 0.046). After eight weeks this effect was no longer detectable.

A systematic review with meta-analysis of seven RCTs on wet cupping in hypertension found inconsistent results. Some studies showed a significant blood-pressure reduction versus antihypertensives, while others found no differences. The methodological quality of the included studies was low and heterogeneity of protocols was high. The authors conclude that no robust recommendations are possible 25.

Hypothesis Cupping could be effective in the short term for hypertension, possibly via improvement of microcirculation or modulation of the autonomic nervous system. Controlled studies with longer follow-up periods are still outstanding. Missing: RCTs with standardised protocols, larger samples and investigation of long-term effects.

Skin Disorders

A study with 34 healthy volunteers examined skin perfusion after cupping with three different cup sizes (35, 40, 45 mm diameter) and a negative pressure of 300 mmHg for five minutes. Using laser Doppler flowmetry and wavelet analysis an increase in metabolic control of skin perfusion was observed, especially with the largest cup size (45 mm). The study suggests local vascular effects, yet without clinical endpoints or long-term data 23.

Hypothesis Cupping could act in skin-associated disorders (e.g. psoriasis, urticaria) via local improvement of circulation or immunomodulation. Controlled studies in this application area are nevertheless still outstanding. Missing: RCTs with clear diagnostic criteria, standardised protocols and investigation of mechanisms of action.

Safety and Tolerability

An RCT with 50 patients (52.6 ± 10.3 years, 92 % female) with chronic neck pain compared cupping massage (five sessions over three weeks) with a wait-list control. The cupping group showed a significant reduction in pain intensity (VAS) of 14.3 mm (95 % CI: -27.7 to -1.0, p = 0.037) as well as improvements in pain on movement, functional impairment and quality of life. Adverse effects were mild and comprised transient haematomas or skin irritation. The study provides an indication of the good tolerability of cupping, yet is limited by the lack of blinding 8.

A systematic review of 11 RCTs with 498 amateur and professional athletes found no serious adverse effects of cupping. Common mild adverse effects were haematomas (up to 70 % of cases), skin irritation and transient pain. The studies reported inconsistent effects on performance parameters, yet a possible improvement in recovery and pain reduction. The methodological quality of the studies was low 10.

A study with 34 healthy participants developed and validated a sham cupping device for placebo control. The participants could not reliably distinguish between real and sham cupping, and the side effects (e.g. haematomas) were similar in both groups. The study suggests that sham cupping represents a credible placebo intervention, however data on its use in clinical studies are lacking 22.

Hypothesis Cupping shows predominantly mild and transient side effects in controlled studies. Severe complications (e.g. infections, scar formation) are rare, but can occur with improper application. Missing: Systematic surveys on side effects in large cohorts as well as standardised safety protocols for practice.

Further Investigations

A reanalysis of four RCTs with 200 patients with chronic nonspecific neck pain examined the minimal clinically important differences (MCID) and substantial clinical benefits (SCB) after cupping therapy. The MCIDs were determined as follows: -8 mm (-21 %) for VAS, -3 points (-10.2 %) for NDI, +10 points for SF-36 Bodily Pain and +5 points for SF-36 PCS. The study provides important reference values for the interpretation of clinical effects, but is limited by the heterogeneity of the included studies 1.

A systematic review of 33 studies (8 on manual therapy, 23 on dry needling, 2 on dry cupping) compared the effectiveness of various procedures for myofascial pain and trigger points. The two included studies on cupping showed short-term pain reductions, however the data were not yet sufficient for a meta-analysis. The authors conclude that the evidence for cupping within this review, which encompasses many therapy forms, is very low and further RCTs are required 24.

A systematic review with meta-analysis of six RCTs on cupping for chronic low back pain found significant improvements in pain intensity (VAS) (SMD: -0.73; 95 % CI: -1.42 to -0.04, p = 0.04) and in ODI (SMD: -3.64; 95 % CI: -5.85 to -1.42, p = 0.001). However, the methodological quality of the studies was low and heterogeneity was high. The authors emphasise the need for higher-quality studies 11.

There were no significant differences in pain intensity (VAS) or other endpoints (e.g. quality of life, psychological symptoms). The study suggests that dry cupping is not more effective than placebo, but is limited by the short follow-up period 14.

Hypothesis The evidence on cupping is heterogeneous and often of low methodological quality. While some controlled studies show short-term effects on pain, consistent long-term data and clear mechanisms of action are still lacking. Still to be clarified: High-quality RCTs with standardised protocols, placebo controls and longer follow-up periods.

Overall Picture

The available studies suggest that cupping – particularly in the wet variant – may be effective in the short term for chronic pain conditions of the musculoskeletal system (e.g. back pain, neck pain, carpal tunnel syndrome) and headaches. Some studies indicate anti-inflammatory or circulation-promoting mechanisms of action, however robust data on long-term effects and systemic impacts are lacking. The safety of cupping is well documented, with predominantly mild side effects such as haematomas or skin irritations.

The state of research is still lacking in many areas, particularly for fatigue syndromes, skin diseases, cardiovascular diseases and oncological pain. Systematic reviews frequently emphasise the methodological challenges of the primary studies, including the high heterogeneity of application protocols and the absence of placebo controls. Testable questions: High-quality RCTs with standardised protocols, longer follow-up periods and investigation of mechanisms of action at the neurobiological and immunological level.

3. How Robust the Research Is

The research on cupping comprises human studies, including controlled studies. A portion of the investigations addresses musculoskeletal pain (e.g. neck, back or knee pain), followed by safety aspects, fatigue syndromes and skin diseases. Systematic reviews and meta-analyses dominate the highly cited works, while basic studies often examine mechanistic hypotheses (e.g. circulation promotion, immunomodulation). The areas of application are broadly distributed, yet the evidence is limited or contradictory in many areas.

The methodological quality of the studies is heterogeneous. Strengths lie in the use of randomised controlled designs in a portion of the controlled studies and the focus on clinically relevant endpoints such as pain or function. Weaknesses are evident in the low placebo control, the frequently small sample size and the lack of blinding – a problem that occurs generally with manual therapies. Systematic reviews also point to publication bias, as positive results are published more frequently. The transferability of the results is often limited, as many studies were conducted in specific populations (e.g. athletes, patients with fibromyalgia).

4. What Is Frequently Claimed — and What the Data Support

5. The Most Robust Studies

Ordered by strength of evidence, not by prominence. The complete evaluation comprises significantly more studies; the most robust ones are listed here.

Controlled Studies in Humans

• 1 Clinically meaningful differences in pain, disability and quality of life for chronic nonspecific neck pain - a reanalysis of 4 randomized controlled (2013)
• 2 The effectiveness of wet-cupping for nonspecific low back pain in Iran: a randomized controlled trial (2009)
• 3 Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized controlled trial (2009)
• 4 Cupping for treating pain: a systematic review (2011)
• 5 Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain--a randomized controlled tria (2013)
• 6 Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot t (2011)
• 7 Efficacy of cupping therapy in patients with the fibromyalgia syndrome-a randomised placebo controlled trial (2016)
• 8 The Effects of Cupping Massage in Patients with Chronic Neck Pain - A Randomised Controlled Trial (2017)
• 9 Pulsatile dry cupping in chronic low back pain - a randomized three-armed controlled clinical trial (2018)
• 10 Effects of Cupping Therapy in Amateur and Professional Athletes: Systematic Review of Randomized Controlled Trials (2018)
• 11 The effect of cupping therapy for low back pain: A meta-analysis based on existing randomized controlled trials (2017)
• 12 Cupping therapy for treating knee osteoarthritis: The evidence from systematic review and meta-analysis (2017)
• 13 Evaluation of Wet Cupping Therapy: Systematic Review of Randomized Clinical Trials (2016)
• Acupoint stimulation for fibromyalgia: a systematic review of randomized controlled trials (2013)
• Non-pharmacological and pharmacological interventions relieve insomnia symptoms by modulating a shared network: A controlled longitudinal study (2019)
• Clinical Effects of Laser Acupuncture plus Chinese Cupping on the Pain and Plasma Cortisol Levels in Patients with Chronic Nonspecific Lower Back Pain (2017)
• 14 Dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with non-specific chronic low back pain: a randomised trial (2021)
• Effects of wet-cupping on blood pressure in hypertensive patients: a randomized controlled trial (2015)
• 15 The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials (2024)
• 16 Cupping for Patients With Chronic Pain: A Systematic Review and Meta-Analysis (2020)
• 17 Dry cupping in the treatment of individuals with non-specific chronic low back pain: a protocol for a placebo-controlled, randomised, double-blind stu (2019)
• 18 Dry Cupping, Ischemic Compression, or Their Combination for the Treatment of Trigger Points: A Pilot Randomized Trial (2020)
• 19 Effects of myofascial trigger point dry cupping on pain and function in patients with plantar heel pain: A randomized controlled trial (2019)
• 20 Dry cupping for plantar fasciitis: a randomized controlled trial (2017)

6. Summary

Cupping shows short-term efficacy in controlled human studies, particularly for chronic musculoskeletal pain, especially in the form of wet cupping. The safety of the procedure is well established, with predominantly mild and transient side effects such as haematomas or skin irritations. For other areas of application such as exhaustion syndromes, headaches or hypertension, further studies are still pending. The methodological quality of the studies varies considerably, with small sample sizes, lack of blinding and inadequate placebo controls frequently limiting the strength of the evidence. The heterogeneity of the application protocols (technique, pressure intensity, duration, body region) also complicates the comparability and generalisability of the results.

Hypothesis Cupping could act via local stimuli such as promotion of blood circulation, immunomodulation or modulation of the autonomic nervous system. In chronic pain conditions it could be considered as a complementary therapy option, particularly when conventional approaches are not sufficiently effective. The effects in stress-associated complaints such as insomnia or fibromyalgia could be attributable to placebo mechanisms or psychoneuroimmunological interactions. In inflammatory processes or oxidative stress, local effects could play a role; however, robust data on systemic effects are still pending. Conclusions: Cupping could be used in practice as a low-threshold, low-side-effect complement to established therapies, particularly in pain therapy. However, due to the limited evidence it should not be recommended as a sole treatment.

To improve the evidence base, controlled studies with the following characteristics are necessary: 1) Standardised protocols for application (technique, pressure intensity, duration, body region) to increase comparability. 2) Larger sample sizes and longer follow-up periods, to investigate long-term effects and clinical relevance. 3) Placebo-controlled designs with credible sham interventions, to distinguish placebo effects from specific effects. 4) Combination with objective measures such as biomarkers (e.g. inflammatory parameters, oxidative stress) or imaging procedures (e.g. fMRI), to clarify mechanisms of action. 5) Comparisons with established therapies (e.g. physiotherapy, medication), to evaluate relative efficacy. 6) Systematic recording of side effects in large cohorts, to refine safety profiles. Particularly urgent are studies on areas of application with a still growing body of research, such as headaches, skin diseases or viral infections.

7. What Remains Open

• Mechanism: How exactly does cupping work at the cellular level?
• Placebo Control: How can cupping be blinded in studies?
• Long-term Effects: Are there sustainable effects over weeks or months?