Some thoughts on fire cupping

This article was originally published in The Journal of Chinese Medicine, from whom reprints can can be obtained:

 

Some Thoughts on Fire Cupping By Michael Pringle

Keywords: Cupping therapy, qi stagnation, blood stasis, external pathogenic factors, pain syndromes.

Abstract

This article discusses the techniques for safe and effective fire cupping as an important adjunct to acupuncture treatment, including the different applications of cups to suit the individual patient’s condition. It also covers moving cups, walking cups, water cups and emergency cupping.

Introduction

Fire cupping has a great deal to offer as an adjunct to acupuncture. It is easy, safe and normally well received by patients (as long as the practitioner is confident and explains the procedure adequately). It also offers benefits that are hard to achieve in other modalities of Chinese medicine, such as the ability to clear the channels and collaterals after long-term illness.
While in China fire cupping, the most common method of cupping, is used on probably two thirds of all patients, cupping generally appears to be underused in the West, possibly because its technicalities are not well understood.
In this article I intend to present what I feel are the important considerations for safe and effective cupping, to review the indications for cupping and to present different ways of applying cups for different situations, including emergency cupping.
I was fortunate to be rigorously schooled in cupping as an intern in the Nanjing clinic of Dr. Wang Ning Sheng who is known locally for his gentle and effective technique. Nearly every day that I was with him he would push me to use different cupping techniques on his patients.
I will limit my discussion here to fire cupping as this is the traditional method and I feel that the fire is an important transformative ingredient in cupping. I have only limited experience of cupping using mechanical suction, but for me it is just that: a mechanical procedure, which does not move the qi in the same way as fire cupping.
I hope that my experience of and enthusiasm for fire cupping will inspire more practitioners to use it.

Application

Cupping is reducing
It must first be stated that however it is applied, cupping has a reducing effect. Nevertheless there are many degrees of, and ways to apply, reduction. The main use of cupping is to reduce stagnation, either of qi or blood. If a patient has deficiency that has led to stagnation it is often difficult to tonify without first clearing the stasis. Cupping is an ideal way to clear this stasis in the midst of deficiency and make room for more qi or blood. I find moving cups or cupping of very short duration most effective in this situation.
The variables in cupping
• Number of cups.
• Degree of suction.
• Duration.
• Size of cups.
• Movement of the cups.
• Speed at which the cups are removed.

Materials

For reasons of hygiene I only use glass cups and will discuss how their effects can resemble those of bamboo cups. Bamboo is generally softer than glass and has a potentially stronger effect in facilitating the movement of blood and clearing phlegm. Chinese Herbal Medicine: Materia Medica1 states of the nature of bamboo shavings that “Its lightness can expel excess, its coolness can expel heat and its bitterness can direct downward – an admirable herb for calming the spirit and relieving constraint”. These are useful attributes for the material from which cupping tools are made.
Under the UK Code of Conduct, bamboo cups must be boiled between uses and I don’t think they will stand this treatment for long. I have gone into the attributes of bamboo because by seeing what we are missing, we can use glass cups in a particular way to achieve a similar result. I will describe this under ‘Basic Application of a Cup’.
Strength of suction – from heavy to light-heavy
The use of many cups, with a strong suction, will produce a strongly reducing effect, especially if they are left in place for a long time (e.g. 30 minutes). Heavy cupping is indicated only for those with strong and heavy bodies. For example for manual workers with serious blood and qi stagnation in their lower backs (back sprain), this type of cupping can get them back to work rapidly. Cupping may be applied while the patient is standing, with the addition of Weizhong BL-40, which is needled or bled.
However, even a single cup applied with strong suction for a long time can strongly reduce stagnation and in my experience may be used for frozen shoulder and other local bi zheng (painful obstruction) on quite frail people. One example would be the use of a single, small cup, very precisely placed on a knot of tension, to release the knot without depleting the patient. This level of precision is unnecessary on a robust person. I frequently use two or three smaller cups, as this makes it easier to tailor the strength of the effect to the patient’s needs. These cups can be applied with varying suction and removed at different times as the stagnation disperses, or in cases where the cups become uncomfortable on delicate patients.
I also use one or two cups over Zhangmen LIV-13 to release a tight diaphragm and help disperse damp-heat from the Gall Bladder and heat from the Liver.
Strong suction for a shorter period of time, 30 seconds to ten minutes, expels exterior pathogens such as wind or heat, and may have the effect of strengthening the ying (nutritive qi) and the wei (defensive qi) as long as the person’s zheng (correct) qi is already relatively strong. This is useful in averting colds and ‘flu in the early stages, and when the channels and collaterals are blocked after prolonged qi or blood stagnation due to traumatic injury, Liver qi stagnation or long-term deficiency. The ying and wei are strengthened because they are no longer obstructed by either the external pathogens (which have now been released to the exterior) or the long term stagnation and stasis (which have now been removed), so the zheng qi is then able to differentiate and propagate.
External pathogenic factors can also be successfully expelled with ‘walking cupping’ (see below). The main application of this technique is for acute wind or cold invasion with pain in the back, and it may be used even in cases of internal deficiency, because walking cups invigorate the surface. This method really comes into its own when the invasion causing the pain is relatively new and quite extreme.
Strong reduction of stagnation of qi, blood or damp, again with minimal negative impact on internal deficiency can be achieved with ‘moving cupping’ (see below).
Strength of suction – moderate
In the middle of the range is moderate suction, for example using approximately five cups on the shoulders for about five minutes. This is effective in relaxing muscle tension due to emotional stress, when the shoulders are often too tender for massage. A similar muscular tenderness may also manifest due to damp-heat or phlegm stagnation in cases of chronic fatigue syndrome. In these cases three or more treatments with cups may be needed before the stagnation begins to move.
Strength of suction – light
The lightest application would use approximately two cups on the shoulders or lower back to assist in the movement of qi while at the same time tonifying the patient with needles. This is useful in a situation where the patient is so weak that they have difficulty responding to tonification because the qi is too deficient to move and the effects of treatment cannot be maintained. Incidentally, this technique is the only one I think is overused. I have observed in China, and amongst those trained in China, that cups are habitually used on back-shu points and while this is not without merit, the standardisation of this protocol on nearly all patients should be questioned because of the variable individual response of each patient to treatment.

Bruising

The patient should be warned that cupping therapy may cause bruising for up to seven days and their consent should be obtained before beginning. Unlike normal bruising, this is not usually tender to the touch. It is rather the stagnation becoming visible on the surface. The nature of the colouration and its duration is therapeutically meaningful and this will be discussed later. If there are blisters or blood spots, the cupping has probably been too hard. It should be noted, however, that bruising may not manifest until after the first or second cupping treatment. Although one might doubt one’s diagnosis in this situation, with perseverance on the practitioner’s part the stagnation will manifest itself. It is probably a good idea not to reapply cups to the same area until the bruising has dispersed, to allow the treatment time to work.
The colour of the bruising gives a good indication of the nature of the stagnation:
• Qi stagnation bruising is generally quite a light red, or even orange if there is blood deficiency.
• Bruising in cases of long-term qi stagnation is generally brown. (This is the colour that was shown in public recently by Gwyneth Paltrow and which appeared in many newspaper photos).
• Blood stagnation bruising is generally from mid-red through to purple.
• Cold bruising is generally very blue.
As the cupping becomes effective there will be progressively less bruising which will also clear more quickly.
Additional uses of cupping
Cupping may be used to assist bleeding treatments and is applied either after needling with a bleeding needle or after seven star hammer treatments. Water cups may be used to reduce inflammation and swelling. These applications will be discussed in more detail below.
Contraindications to cupping
The British Acupuncture Council Guide to Safe Practice lists the following areas on which cupping should not be used
• On the lower back or abdomen during pregnancy.
• Directly over a recently traumatised area. (The key word here is ‘recent’. Sometimes if the bruising is not coming out and the trauma is not healing, cupping is a safe way to move the stagnation and initiate the healing process).
• Over broken or ulcerated skin (including eczema).
• Over oedematous areas. (I use ‘water cups’ over extra point Heding (M-LE-27) in cases of ‘cranes knee wind’ (swelling of the knee due to damp-heat or sometimes to cold transforming to heat). This is the only time I would cup an oedematous area, and it is adjacent to, rather than actually over the oedema).
• Over enlarged blood vessels, varicose veins, thromboses, aneurysms or advanced arteriosclerosis.
• Over needles on the thorax, although it is possible to use cups close to the spine where the musculature is thicker.
• Over the throat area.
• In cases of cardiac disease.
• Over inflamed or perforated organs.
• In cases of severe weakness or anaemia.
• In cases of susceptibility to profuse bleeding (e.g. haemophilia).
• When the patient is taking anti-coagulant medication.
• When there is very thin skin, as in some elderly patients and those on steroid medication.
• In cases of hypertension.

Practicalities and equipment

The following considerations may seem overly detailed, but in order to use cupping at different strengths and in different ways, good control over the tools is needed.

Alcohol

When I was in China there were two large jars in the store. One was marked Alcohol 60% and was used for swabbing, and the other was marked Alcohol 90% and was only used for cupping. Alcohol at a strength that allows it to burn fast and furiously is necessary for cupping. In the UK most practitioners use surgical spirit which has the disadvantage that it contains substances to discourage people from drinking it, to make it less flammable for safety reasons and to stop it being so drying to the skin (often castor oil). These not only change the way that the cupping works, but the chemical additives and resulting odours may also have a medical effect. From experimenting with several forms of alcohol I use one containing castor oil since it has the lightest and most innocuous smell.

The alcohol container

The ideal container:
• Will not break when dropped.
• Must not contain too much at a time in case it is knocked over.
• Must not deteriorate in contact with alcohol.
• Should have a wide enough mouth that the swab is not squashed on its way in or out. It also needs to have sides that slope upwards, making it easier for excess alcohol to be be squeezed off.
• I find the ideal container to be Chinese patent pill bottles.

The swab

Locking forceps should always be used (Halsted Mosquito Hemostat or Foester Sponge Forceps) in preference to normal forceps. This ensures there is no danger of dropping the swab and burning furniture or the patient. A number of practitioners seem to have been put off cupping because they were taught to hold the swab in normal forceps and had feared dropping the flaming swab ever since.
Swabs need to be wrapped tightly otherwise they can drip or squeeze alcohol out if they are accidentally knocked against the cup, which carries obvious hazards if they are alight. If traces of alcohol remain on the inside of the cup, these can run downwards when the cup is placed and burn the patient. With a tightly wrapped swab there is less likelihood of squeezing any alcohol out even if the side or the bottom of the cup is touched.
There are two ways to tightly wrap a swab. Either square or round cotton wool pads are rolled and folded in half with the cut edge in the middle of the fold. The ends are then clamped in the locking forceps with the fold about a centimetre clear. The other method is to unroll a cotton wool ball, spread it to about four centimetres in length, and then re-roll it as tightly as possible and fold and clamp as before.

Some-thoughts-on-fire-cupping-jcm-3swab

 

 

 

 

 

These methods will produce a swab that holds enough alcohol for five or six cups and can be quickly re-loaded.

The cups

To ensure that there are always enough cups, about 18 are needed in the West. Ten or 12 cups are conventionally given as sufficient, but then there is a risk of running out when treating more physically robust patients. Because the Chinese use guasha and tuina at home, their flesh tends to be softer, and in China I never saw the extreme hard stagnation that is evident here. A minimum set would be (internal diameter):
• 6 x 5cm (2”)
• 6 x 4cm (1.5”)
• 4 x 3cm (1.15”)
• 2 x 2.5cm (1”)
Quality is important in two ways. There should be no sharp mould lines and the cups must be strong enough not to shatter when they drop off (because they will).
It is important to check the quality of the cups. The round, thick, clear cups with a flattened top are good and have proved themselves by bouncing off concrete floors in China without breaking.

Oil for moving cups

Another important consideration is that that the oil used for moving cups needs to be therapeutically useful and slippery but at the same time not readily flammable. Bee Brand Massage Oil is a good example.
When testing an oil, it should be spread on good quality paper and a lighter held to it. If it lights more easily than the paper on its own then it should not be used.
The Chinese have little body hair, so they see the body hair of Europeans as a problem in cupping. Their solution is to suggest shaving. This is unacceptable to most patients, and also unnecessary. A thin smear of Aloe Vera gel creates a seal and moistens the skin without any evident changes to the therapeutic effect. It also works for dry skin without leaving a residue. Any spare gel should be wiped from around the cups so that the patient does not get cold while the cups are on.

Cleaning the cups

The British Acupuncture Council Guide to Safe Practice is clear that cups must be properly washed between use, not just wiped. This need not be onerous and should not put us off cupping. They may be removed straight into the sink and washed with Hibitane or household detergent, taken out, rinsed and dried. Then they must have the rims cleaned with an alcohol wipe, ready for reuse.

Basic Application of a Cup

Steps to successfully placing a cup:
Soak the swab and squeeze it out on the inside of the pot so that it will not drip. Holding the forceps in your dominant hand, light it with a lighter. Do not use matches, as they won’t necessarily go out when you drop them.
Hold the cup in your non-dominant hand and warm the rim with the flaming swab. Test the warmth on the inside of your other forearm to ensure the temperature is neither too hot nor too cold for your patient.
The warming of the rim is important to create the dispersing effect of bamboo. (Many books advise against this, seemingly out of fear of over heating or transferring alcohol to the rim and burning the patient. These are both legitimate worries which can be avoided if you test on your own arm).
Place the cup lightly on the place you want to apply it, then barely lift your arm and rotate your forearm. This is the secret of quick and effective application.
Waft the flame into the cup. This can be done with the cup horizontal. Remember not to touch the sides or the bottom. Patients only get burned with cups if some burning liquid is transferred to the cup and then to the person. A well squeezed and firm swab will not transfer fluid so easily if you do accidentally touch the cup.
Immediately rotate your wrist and place the cup. Then lift slightly to help the suction settle and simultaneously test the amount of suction. To achieve different degrees of suction I trained myself to always use the same speed of rotation: this way I can use different distances from the surface to alter the strength of suction. For instance, very close is strong but to get the degree of suction for ‘moving cups’ I hold the cup 7.5cm from the surface as I burn out the air.
Air is about 20% oxygen. As it is only the oxygen that burns, 20% is the most vacuum we can get. Strong cupping seems to pull most people’s flesh about one and a half centimetres into the cup, while ‘moving cups’ pull in the least amount of skin to maintain suction. Different areas and densities of flesh pull up different amounts.
Cover the patient or use a heat lamp while the cups are in place.

Removing the cups

For the greatest comfort and the best effect from the cupping, the cups should be removed as slowly as possible. The one exception to this is ‘walking cups’ when the cups are removed abruptly for a specific effect.
Slide your finger under the edge at the softest place on the skin while holding the cup down. As soon as the vacuum starts leaking out, take the cup off slowly, the slower the better.
Dr. Wang would give me a look if he heard a quick rush of air as I removed the cups. The most common complaint from patients seems to be that it is almost traumatic for them if the cups are removed too quickly, which makes them resistant to trying cups again.
After removal of the cups the patient will have slightly raised circular areas where the vacuum has pulled the skin up. It is more comfortable for the patient if this is soothed, and a good way to do this is to use gentle circular massage through a cloth.

Advanced techniques

Moving cups

Moving cups can be very gentle or strong and are a great treatment for aching lower backs or shoulders when the patient is deficient. As long as they are not left for too long, their zheng (correct) qi will not be reduced. This method is also effective for frozen or painful shoulder of recent onset.
Method: Smooth a relatively generous layer of massage oil over the area to be cupped. Apply a medium sized cup, lightly support the skin with one hand and move the cup while holding it down with the other hand. This should not hurt but it will raise an erythema.
It is very easy to lose the vacuum and the cup is then simply reapplied.

Walking cups (sometimes called flash cupping)

This technique gives strong but superficial reduction for external invasion. The first time I used it was with a computer operator who had been tense on his first day in a new job, had been placed in front of the air conditioning while only wearing a t-shirt and had ended the day in severe pain. He came for treatment early the next day and after ten minutes of moving cups was better. He wore a coat at work that day, had one more treatment that evening and then managed to move his desk.
Method: Using about four medium large cups (two each side of the spine or five, including one over the spine, if there is enough space) work over the whole back, placing the cups in very fast succession in a line across the lower back. Immediately go back to the first one, break the suction with a fast, popping wrist action, and replace it one diameter higher up the back. Break off the next one and replace, continuing until the top of the back is reached, and then work down again, the faster the better. Four or five passes is normally enough. It is useful to have a helper to hand the practitioner recharged swabs.
This is the one technique where the cup may get too hot but it will tend to be the bowl and not the rim, so the hand holding it will be able to assess the heat. Have spare cups handy and change as necessary.
Cover the patient and let them rest for fifteen minutes after cupping before they leave the clinic.

Water cups

As stated earlier, the primary application of this method is with ‘cranes knee wind’ swelling, but it can also be used to assist bleeding. In China I was taught to add a few drops of Dettol to the water. Water cupping is cooling and dispersing. I have seen this used with good effect on a patient’s gouty foot after needling.
Method: Fill a cup one third with water. Apply the flame and using a more exaggerated circular wrist action than usual, turn the cup over rapidly and place it on the patient with the water against them. To remove, pack sufficient couch paper around the cup to absorb all the water and gently release.

Cup-assisted bleeding

This is used either after a bleeding needle or after seven star hammering and is a favourite amongst a number of practitioners for frozen shoulder.
Method: Place strong cup/s over the point/s. Again pack around the cup with paper towel and use gloves while removing, as the cup can partially fill with blood.

Emergency cupping

Dr Wang insisted that I learned this so that I could cup anywhere. It has stood me in good stead with friends when they are doubled up with pain. Knowing this method means that I can always find the equipment to apply cupping in an emergency.
Method: Dr Wang’s method is safe and simple: all you need is some kind of cup. I have used mugs, jam jars, welded tube, brass ashtrays: in fact anything that is not flammable, is able to hold a vacuum and has a smooth edge can be used. It is best, however, if the item is deeper than it is wide.

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• Use a square of newspaper to provide the flame.
• This square should be slightly larger than the ‘cup’ is deep.
• Fold in an edge of the square so that the folded dimension is about 5mm shorter than the depth of the cup.
• Fold the paper lightly in half the other way, and in half again the same way.
• Do not flatten the folds.
• You now have a kind of concertina that will slip into the cup.
• Hold the cup slightly inverted above the point to be cupped.
• Hold the folded edge of the paper with two spare fingers of the hand holding the cup.
• Light the edge of the paper opposite the folded-in edge. Drop the lighter.
• Take the paper with your free hand. Tilt it to equalise the flame.
• Drop the paper into the cup, flaming end first, and immediately invert on the point. The folded-in edge is against the skin and holds the flames away from the skin by stiffening that edge. As long as there is a good seal the flame will soon asphyxiate inside the jar, creating the vacuum.
In my experience, this method is easier and quicker than wrapping coins in paper and lighting and if you don’t get a seal you can quickly remove the cup before it burns.

Afterword

For a more exhaustive discussion of cupping with many examples of suggested treatments, see Ilkay Chirali’s book on Cupping.
The principles of cupping treatment remain those of Chinese medicine. They must be based on a clear differentiation of syndromes to ensure success.
Emergency Cupping: Preparing the cup (from top to bottom)

Michael Pringle originally qualified in acupuncture at The College of Traditional Chinese Medicine in the UK in 1983. He later studied at The College of Integrated Chinese Medicine (CICM) in Reading and also went to China to consolidate his diagnostic skills. In Nanjing, Michael had tuition from Dr. Wang Ning Shen in advanced cupping techniques. He lives and works in South Devon where he also teaches cupping Contact: michael@acupuncturesouthhams.co.uk.

References
1 Bensky , D, Clavey, S, Stöger, E with Gamble, A, (2004). Chinese Herbal Medicine – Materia Medica, 3rd Edition. Eastland Press, Seattle, USA.
2 Chirali, I (1999). Traditional Chinese Medicine – Cupping Therapy. Churchill Livingstone, Edinburgh, UK.