Cupping Therapy Treatment on Range of Motion

Authors: ¹Rachele E. Warken, ²Erik Reid, & ³Christopher M. Harp

¹Northern Kentucky University, Highland Heights, Kentucky, USA

Corresponding Author:

Rachele Warken is an associate professor and the director of the graduate Athletic Training Program at Northern Kentucky University. She is also a certified athletic trainer. Rachele has a bachelor’s degree from Northern Kentucky University and a master’s and doctoral degree from the University of Hawaii, Manoa.

Abstract

Purpose:The purpose of this study was to assess the effects of cupping therapy and passive stretching on shoulder internal and external rotation in healthy male high school athletes. Methods: Participants included nine high school male football players recruited from a local private high school. An eight minute cupping therapy treatment was completed on one arm, while passive shoulder stretching was completed on the other. Pre and post intervention measurements were taken for shoulder internal and external rotation and analyzed. Results: Analysis revealed that shoulder internal rotation range of motion post intervention were significantly higher than at pre intervention (p = 0.003), but there was no significant difference between shoulder internal rotation between the cupping therapy group and passive stretching group (p = 0.879). Similarly, shoulder external rotation range of motion post intervention was significantly higher than at pre intervention (p=0.021), but there was no significant difference between the cupping therapy group and passive stretching group (p = 0.621). Conclusions: The results of this study conclude that a cupping therapy treatment was as effective as a passive stretching treatment at increasing shoulder internal and external rotation in healthy high school males. Application in Sports: Cupping therapy is widely used by clinicians and athletes for a variety of reasons. Although this study this study did not find that cupping therapy is superior to passive stretching in healthy high school aged males, it did demonstrate that this intervention is as effective as passive stretching and provides the clinician with an additional method of treatment.

Key Words: Passive Stretching, Myofascial Decompression, Rehabilitation

Introduction

            Injuries to the shoulder and elbow are very common among athletes, especially in sports that require forceful overhead activities. Range of motion deficits, specifically in shoulder internal and external rotation, have been linked to both shoulder and elbow injury. Previous research has indicated that athletes with a passive shoulder internal rotation deficit greater than 25° in their dominant shoulder compared to their non-dominant shoulder were at four to five times greater risk of upper extremity injury than those with less than a 25° deficit (10). Additionally, a total range of motion (shoulder internal rotation plus external rotation) of less than 160° also resulted in an increased the risk of upper extremity injury (2). As a result, clinicians and athletes consistently work to improve shoulder rotation range of motion with the goal of decreasing shoulder and elbow injuries.

            Common methods to increase shoulder rotation include passive stretching and self-stretching. These stretches place slow and controlled tension on the soft tissue and have been shown to increase range of motion, improve flexibility, reduce the risk of injury, and improve blood circulation (1). Recently, the use of cupping therapy has gained popularity, especially in the athletic population as a result of prominent athletes advocating its use. Cupping therapy is an ancient Chinese technique that utilizes either glass or plastic cups along with fire or a vacuum pump to create negative pressure, drawing the skin and underlying tissue into the cup during treatment (9). The negative pressure developed during the treatment is thought to help reduce pain and inflammation, improve blood flow, facilitate the healing process and strengthen the immune system (6 ,8, 9).

Cupping therapy or myofascial decompression as it is commonly known in Western medicine is often used in sports medicine settings to increase range of motion. It is thought that the increase in blood flow to the muscle during a cupping therapy treatment increases tissue temperature causing tissues to become more elastic, resulting in greater range of motion (3). Although commonly used, there is currently limited research demonstrating the effectiveness of cupping therapy on improving range of motion. Previous research analyzing the effectiveness of cupping therapy on improving spine range of motion found that the cupping therapy intervention increased cervical and lumbar spine flexion range of motion following treatment (7, 11, 14). When cupping therapy was applied to other areas of the body differing results were found. When a cupping therapy treatment was applied to the gastrocnemius, an increase in dorsiflexion range of motion was identified (4). When cupping therapy was applied to the hamstring muscle group, researchers found that the cupping therapy treatment provided similar improvements in range of motions as more standard methods such as passive stretching (5, 8, 12) or found no improvement in range of motion (9, 13). To our knowledge, there is no previous research available that assess the effectiveness of cupping therapy on the upper extremity. Therefore, the purpose of this study was to assess the effects of cupping therapy and passive stretching on shoulder internal and external rotation in healthy male high school athletes. It was hypothesized that cupping therapy will result in greater shoulder internal and external range of motion values than the passive stretching technique.

Methods

Study Design

            This study utilized a cross-sectional design, and all data were collected in the athletic training clinic of a local boy’s private high school. The dependent variables include internal and external shoulder range of motion. The independent variables include the treatment types (cupping therapy and passive stretching) and the time the measurements were taken (pre-intervention and post-intervention). This study was approved by University’s Institutional Review Board.

Participants

            Participants in this study included male high school football athletes recruited from a local boy’s private high school. A total of nine participants completed the study. Participant demographic information including age, height and weight are listed in Table 1. The inclusionary criteria for this study were healthy male high school athletes who were cleared for full athletic participation. The exclusionary criteria for this study included those who did not have full medical clearance for athletic participation, had shoulder surgery within the past year, or currently have shoulder pain.

INSERT Table 1. Participant demographics.

Table 1
Participant demographics (mean ± SD)
	N	Mean	±	SD
Age (yrs)	9	15.89	±	0.60
Height (in)	9	70.00	±	2.35
Weight (lbs)	9	188.89	±	39.43

Instrumentation

A standard twelve inch goniometer was used to measure internal and external rotation range of motion of the shoulder prior to and following the interventions. For the cupping therapy intervention, five plastic cups and pumping handle were used (Hansol Cupping Therapy Equipment Set, Hansol Medical Equipment, Seoul Korea).

Procedures

All testing occurred in the athletic training room at the local all boy’s private high school. Each participant (and their parent/guardian) completed the informed consent and assent forms prior to testing. During testing, age, height, weight, dominant arm, and previous shoulder injury information were collected. Each participant completed both the cupping therapy intervention and passive stretching intervention, one on each arm. The interventions were randomly assigned to each arm (dominant/non-dominant).

Prior to any intervention, passive shoulder internal and external rotation range of motion were assessed in both shoulders with a goniometer while the participant was lying supine, with their shoulder abducted to 90°,their elbow flexed to 90° and their shoulder in neutral rotation. Two measurements in each direction were taken and the values were averaged and used in the statistical analysis.

Following the pre intervention measurements, the cupping therapy intervention was performed with the patient lying prone. Lotion was applied to the posterior shoulder, scapula, and upper back to act as a lubricant for the cups. Five cups, each two inches in diameter were then applied to the muscle bellies of the posterior and lateral deltoid, infraspinatus, the middle portion of the trapezius and the rhomboid major and given three pumps each. The cups remained in place for eight minutes and then removed. Following removal of the cups, shoulder internal and external rotation range of motion was measured again with a goniometer.

Prior to the stretching intervention, the participant was asked to perform a warm-up of the arm being stretched. The warm-up consisted of passive self-stretching into flexion, extension, internal and external rotation, and completing rows with an elastic band. Following the warm-up, the researcher manually stretched the shoulder in both internal and external rotation with the participant in the supine position. The researcher held each stretch for 30 seconds, switching between stretching internal and external rotation for a total of three stretches in each direction. Following the stretching treatment, shoulder internal and external rotation range of motion were measured with a goniometer.

Statistical Analysis

A two-way analysis of variance was used to assess the differences between interventions (cupping therapy and passive stretching) and time period (pre-intervention and post-intervention) was completed for each dependent variable (shoulder internal rotation and shoulder external rotation). A priori alpha levels were set at p < 0.05 for statistical significance. All statistical analyses were performed using SPSS Version 28 (SPSS, Inc, Chicago, IL).

Results

A total of nine male high school athletes participated in this study. The demographic information is included in Table 1. The two-way analysis of variance revealed that shoulder internal rotation range of motion post intervention were significantly higher than at pre intervention (p = 0.003). There was no significant difference between shoulder internal rotation between the cupping therapy group and passive stretching group (p = 0.879), nor was there a significant interaction (F(1, 32) = 0.094, p = 0.761) (Table 2). Similarly, the two-way analysis of variance for shoulder external rotation range of motion post intervention was significantly higher than at pre intervention (p=0.021). There was no significant difference between the cupping therapy group and passive stretching group (p = 0.621), nor was there a significant interaction (F(1, 32) = 0.061, p = 0.806) (Table 3).

Table 2
Shoulder Internal Rotation Range of Motion (deg, mean ± SD)
	Pre-Intervention			Post-Intervention
Cupping Therapy	65.33	±	4.85	73.67	±	6.78
Passive Stretching	64.00	±	11.60	74.11	±	9.91

Table 3
Shoulder External Rotation Range of Motion (deg, mean ± SD)
	Pre-Intervention			Post-Intervention
Cupping Therapy	80.78	±	9.20	88.11	±	9.73
Passive Stretching	78.22	±	9.23	87.22	±	11.95

Discussion

The purpose of this study was to examine the effectiveness of a cupping therapy treatment on increasing shoulder internal and external rotation. The results of this study found that both the cupping therapy intervention and the passive stretching intervention significantly increased shoulder rotation, however there was no difference between the interventions. To our knowledge, this was the first study to examine the use of cupping therapy to increase range of motion at the shoulder. Previous authors examined different areas of the body and found differing results.

Markowski et al. (7) conducted a study analyzing the effects of cupping therapy on lumbar flexion in participants with chronic low back pain. They found that one cupping therapy treatment significantly improved lumbar flexion range of motion. This study did not include a control group, so it is not clear if a cupping therapy treatment is superior to more standard ways of increasing range of motion such as passive stretching of the low back. Similarly, a study by Yim et al. (14) examined the difference between a cupping therapy treatment and McKenzie stretching exercises on cervical spine range of motion in healthy participants. They found that that the cupping treatment increased cervical spine range of motion to greater degree than the McKenzie stretching exercises indicating that cupping therapy applied to the cervical spine region was a superior to other standard stretching techniques.

A study by Hammons and McCullough (4) examined the effects of a cupping therapy treatment on dorsiflexion range of motion in individuals with delayed onset muscle soreness (DOMS) in their gastrocnemius muscle. They found that cupping therapy significantly increased dorsiflexion range of motion in individuals with DOMS compared to a control group. Although a control group was used in this study, this group did not receive any treatment, so although cupping therapy increased dorsiflexion, it is not clear if a cupping therapy treatment is superior to other methods of increasing range of motion.

Several studies have examined the effectiveness of cupping therapy in the hamstring muscle group. Kim et al. (5) compared cupping therapy to passive stretching in the hamstring group. They found that both interventions significantly increased hamstring range of motion, however there was no difference between groups. Murray et al. (8) found that cupping therapy significantly increased hamstring range of motion, but similar to other studies, they did not use a control group so it is unclear if the increased observed following the cupping therapy treatment was superior to other methods of increasing range of motion. Warren et al. (12) conducted a study on hamstring flexibility and compared a cupping therapy treatment to a self-mobilization treatment using a foam roller, in individuals with tight hamstrings. Similar to others, they also found that both groups had significant improvements in range of motion, but the individual treatments were not significantly different.

Finally, a study by Williams et al. (13) also looked at the effect of cupping therapy compared to a control group on hamstring flexibility. The control group did not receive any treatment. Unlike other previous research, they found that a cupping therapy treatment did not increase hamstring range of motion. Similarly, a study by Schafer et al. (9) compared hamstring flexibility in a cupping therapy group, a sham group and a control group and found that none of the groups significantly increased hamstring range of motion following treatment.

Conclusion

This is the first study to specifically examine the effects of cupping therapy on increasing shoulder internal and external rotation. The results of this study found that cupping therapy increased both shoulder internal and external rotation, but was not superior to passive stretching. Cupping therapy is a common practice among clinicians and athletes and is used for a variety of reasons. This study adds to the previous literature that indicates that cupping therapy could be a useful tool, among others to increase shoulder internal and external rotation. Future research could focus on individuals with shoulder rotation deficits, functional limitations and pain. In this population, it is possible that cupping therapy could be a superior method for increasing range of motion and function as well as decreasing pain.

Applications in Sport

            Cupping therapy is widely used by clinicians and athletes for a variety of reasons. This study concludes that the use of cupping therapy is one possible method for increasing shoulder internal and external rotation. Although the results indicated that cupping therapy is not superior to passive stretching for increasing shoulder range of motion in healthy, high school aged male athletes, it is one tool that could be used. Although not analyzed in this study, cupping therapy has been shown to help with pain and inflammation. In theory, in an athlete suffering from a shoulder pain and decreased range of motion, a clinician may choose cupping therapy over passive stretching, because cupping therapy may increase shoulder range of motion, and it may also help with pain.

References

1. Bryant, J., Cooper, D. J., Peters, D. M., & Cook, M. D. (2023). The effects of static stretching intensity on range of motion and strength: A systematic review. Journal of Functional Morphology & Kinesiology, 8(2), 37.
2. Bullock, G. S., Faherty, M. S., Ledbetter, L., Thigpen, C. A., & Sell, T. C. (2018). Shoulder range of motion and baseball arm injuries: A systematic review and meta-analysis. Journal of Athletic Training, 53(12), 1190–1199. https://doi.org/10.4085/1062-6050-439-17
3. Chi, L.-M., Lin, L.-M., Chen, C.-L., Wang, S.-F., Lai, H.-L., & Peng, T.-C. (2016). The effectiveness of cupping therapy on relieving chronic neck and shoulder pain: A randomized controlled trial. Evidence-Based Complementary and Alternative Medicine : eCAM, 2016, 7358918. https://doi.org/10.1155/2016/7358918
4. Hammons, D., & McCullough, M. (2022). The effect of dry cupping on gastrocnemius muscle stiffness, range of motion and pain perception after delayed onset muscle soreness. Alternative Therapies in Health and Medicine, 28(7), 80–87.
5. Kim, J.-E., Cho, J.-E., Do, K.-S., Lim, S.-Y., Kim, H.-J., & Yim, J.-E. (2017). Effect of cupping therapy on range of motion, pain threshold, and muscle activity of the hamstring muscle compared to passive stretching. Korean Society of Physical Medicine, 12(3), 23–32. https://doi.org/10.13066/kspm.2017.12.3.23
6. Liu, W., Piao, S., Meng, X., & Wei, L. (2013). Effects of cupping on blood flow under skin of back in healthy human. World Journal of Acupuncture – Moxibustion, 23(3), 50–52. https://doi.org/10.1016/S1003-5257(13)60061-6
7. Markowski, A., Sanford, S., Pikowski, J., Fauvell, D., Cimino, D., & Caplan, S. (2014). A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. The Journal of Alternative and Complementary Medicine, 20(2), 113–117. https://doi.org/10.1089/acm.2012.0769
8. Murray, D., & Clarkson, C. (2019). Effects of moving cupping therapy on hip and knee range of movement and knee flexion power: A preliminary investigation. Journal of Manual & Manipulative Therapy, 27(5), 287–294. https://doi.org/10.1080/10669817.2019.1600892
9. Schafer, M. D., Tom, J. C., Girouard, T. J., Navalta, J. W., Turner, C. L., & Radzak, K. N. (2020). Cupping therapy does not influence healthy adult’s hamstring range of motion compared to control or sham conditions. International Journal of Exercise Science, 13(3), 216–224.
10. Shanley, E., Rauh, M. J., Michener, L. A., Ellenbecker, T. S., Garrison, J. C., & Thigpen, C. A. (2011). Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. American Journal of Sports Medicine, 39(9), 1997–2006.
11. Sya’id, A., & Fatarona, A. (2020). Cupping care effectiveness on flection range of motion. STRADA Jurnal Ilmiah Kesehatan. STRADA Jurnal Ilmiah Kesehatan, 9(2), 1539–1544.
12. Warren, A. J., LaCross, Z., Volberding, J. L., & O’Brien, M. S. (2020). Acute outcomes of myofascial decompression (cupping Therapy) compared to self-myofascial release on hamstring pathology after a single treatment. International Journal of Sports Physical Therapy, 15(4), 579–592.
13. Williams, J. G., Gard, H. I., Gregory, J. M., Gibson, A., & Austin, J. (2019). The effects of cupping on hamstring flexibility in college soccer players. Journal of Sport Rehabilitation, 28(4), 350–353. https://doi.org/10.1123/jsr.2017-0199
14. Yim, J., Park, J., Kim, H., Woo, J., Joo, S., Lee, S., & Song, J. (2017). Comparison of the effects of muscle stretching exercises and cupping therapy on pain thresholds, cervical range of motion and angle: A cross-over study. Physical Therapy Rehabilitation Science, 6(2), 83–89. https://doi.org/10.14474/ptrs.2017.6.2.83