Cupping Therapy - Part One
by Ilkay Chirali
When we look at the history of cupping therapy, we can see the enormous knowledge that
existed across vast geographical locations in the days when it was practiced. From Far Eastern
countries to the ancient Egyptians and the entire African continent; to the North and the South
Americans; the entire Northern Europeans including Russia, Poland and the Scandinavian
countries; all the Mediterranean countries including Turkey, Greece, Italy, France, as well as
England practitioners all practiced cupping in one form or other. In the UK, Dr. William Marsden,
the founder of the Royal Marsden Hospital, employed cupping therapy quite extensively at his
‘Free Hospital’ in Gray’s Inn Road during the 1830s.
In today’s modern practice, a thorough diagnosis must be made at all times before deciding on
cupping treatment. This will determine the type of cupping method (10 methods) to be used as
well as the suitability of the patient. In my book entitled “Traditional Chinese Medicine Cupping
Therapy” I mention ten cupping methods and their safe application as well as contraindications.
In my regular cupping workshops I teach the ten methods of cupping, as well as safety issues to
remember during the application (both towards the patient and the practitioner). In order to
decide the correct treatment one must pay special attention towards the patient’s present
pattern analysis.
Preparing for Cupping
Glass cupping sets come in various sizes; number 1 is the smallest size and it is mostly used to
treat facial points on adults as well as treating children under 7 years old. Number 5 is the
largest cup size and it is often used to achieve a strong cupping sensation on adult patients. The
vacuum that is required in cupping is generated by placing a flame (lit cotton wool bud) inside
the cup, thereby burning away the oxygen. The cup is then quickly placed against the patient’s
body. Cotton wool balls are prepared in advance and soaked in alcohol and kept in an air tight
jar, ready for use.
Therapies that Benefit from Cupping
Generally speaking, most of the hands-on therapeutic techniques can include cupping in their
therapy. The ultimate aim of all hands-on techniques is to use physical application in order to
stimulate the body’s natural healing mechanisms by balancing the physical, mental and
emotional energies and restore health to the individual. Apart from Chinese medicine, other
therapies such as aromatherapy, massage, chiropractic, osteopathy, kinesiology, Alexander
technique, shiatsu, reflexology, polarity and physiotherapy, can all incorporate cupping in their
main treatment model.
Ten Methods of Cupping
1. Weak /Light Cupping (Tonifying method)
2. Medium Cupping (Tonifying method)
3. Strong Cupping (Draining method)
4. Moving Cupping (Draining method)
5. Needle Cupping (Draining method)
6. Moxa /Hot Needle Cupping (Tonifying method)
7. Empty /Flash Cupping (Tonifying method)
8. Full /Bleeding Cupping (Draining method)
9. Herbal Cupping (Tonifying method)
10. Water Cupping (Even method)
1. Weak (Light) Cupping Method (tonifying)
Weak cupping is employed when Qi and Blood are sluggish, deficient (Xu) or stagnant, and a
reversal of these conditions is required. The action of weak cupping is to remove stagnation
whilst at the same time tonify the weak Qi and Blood. It is therefore termed a ‘tonifying’
method. The key factor in deciding when to apply weak cupping is the present constitution of
the patient. Pulse, tongue and observation diagnosis should all point towards a deficiency.
In practice the cups are prepared as mentioned earlier, and the skin moistened with oil. Light
the cotton wool and wait for a few seconds so that the fire is less intense. Remember, the
bigger the fire, the greater the suction! Apply the cups at the desired points until all cups are
used. When all are in place, the practitioner should take immediate notice of the suction inside
the cups. The amount of flesh drawn into the cups should be minimal and hardly raised inside
the cup. Should the initial suction be stronger than originally planned, the practitioner should
press the edge of the cup with an index finger and let some air into the cup. This action will
reduce the strength of the suction to the desired level. At no time should the patient feel an
uncomfortable sensation of pulling or pain on the treatment area. If this happens, the
practitioner should continue with the reducing technique until the patient feels comfortable.
Weak cupping is the gentlest technique out of the ten methods. This type of cupping method is
particularly suitable for debilitated adults, elderly patients and young children, especially when
under the age of seven. Light Cupping can be applied to almost anywhere on the body, but may
cause a slight reddening on the skin, rather than a deep bruise or blister. The duration of a
weak cupping application can be as long as 30 minutes.
When light cupping is performed on a hairy or a very dry skin, the suction is likely to cease
much earlier than planned. In this case, apply oil liberally and repeat the cupping procedure.
The gentle pulling action of this method stimulates the Qi movement within the meridian
system, bringing benefit to the patient and tonifying the Qi and Blood, without the risk of further
depletion of energies to the weak and frail.
2. Medium Cupping Method (tonifying)
This is the most frequently used cupping method on patients with relatively stronger
constitutions. As well as on adults, medium cupping can be safely administered to children over
the age of seven. With medium cupping the suction is firmer, but as the patient’s own energies
are also good, it will act as a tonifying method. However, there is a real danger of draining the
patient’s Qi if the cups are left on for longer than 30 minutes. Despite the medium strength
suction, prolonged application will cause Qi deficiency, thus leaving the patient lethargic after
treatment.
To achieve a medium suction, the practitioner needs to use a bigger flame than with the light
method. The practitioner also holds the cups closer to the patient. This will enable the
practitioner to apply the cups quicker and the suction will be firmer, the amount of oxygen re-
entry will be lower, thus creating a stronger vacuum. With this method, the skin is pulled well
into the cup, creating a slight redness on top of the skin inside the cup. If the cups are left on
for a long period the redness will turn to purple, indicating a ‘stronger application’. If glass cups
are used instead of the more traditional bamboo cups, the progress can be observed closely and
early adjustments can be made if desired. Medium cupping can be safely applied anywhere on
the body, including the face and abdomen. Hot or Cold Bi patterns, stress related conditions, Qi
and Blood tonification, and children’s ailments can all benefit from medium cupping.
3. Strong Cupping Method (draining)
This is one of the most draining techniques of all, (moving cupping is the other). Therefore
before deciding on using strong cupping, the practitioner must ensure the suitability of the
patient. Significant amounts of Qi and Blood are manipulated by this method, sometimes
leaving the patient tired following treatment. Pulse, tongue and observational diagnosis should
all emphasise an Excess, Full (Shi) condition (do not use in cases of False Heat patterns).
Defensive energy (Wei Qi) is greatly affected and influenced by this method. The purpose of a
strong cupping treatment is to move Qi and Blood to eliminate internal/external pathogenic
factors and stagnation from patients with relatively strong Wei Qi.
Prepare the patient and have the cups close at hand. For a strong cupping technique, a big
flame is necessary in order to achieve a strong vacuum and pulling action. For this reason, use a
large ball of cotton wool, or 2 pieces of cotton wool held together by forceps. On igniting the
cotton wool, insert the fire into the cup without delay, simultaneously turning the cup onto the
skin. A strong vacuum will be produced, giving a strong pulling sensation of the skin inside the
cup. Because of the strong nature of the pulling action, redness, and shortly after, purple-
coloured skin will quickly appear inside the cup (figure 1). It is preferable to avoid the strong
method during a patient’s first visit, and introduce the treatment using a much weaker version,
while explaining that the following cupping treatments will be slightly stronger. When using a
strong cupping method the first time, a very dark purple bruise is inevitable, and it can take up
to 15 days before diminishing completely.
Figure 1. Strong Cupping.
Cupping-time should also be short in a strong cupping treatment, certainly not more than 10
minutes during the first application. This can be increased up to 20 minutes in later applications.
Dark bruises will become much lighter and the dispersing-time of the bruise will also be much
shorter, sometimes lasting only a day or two. Following an acupuncture session, a strong
cupping treatment may cause a small amount of blood to be drawn into the cup. This is quite
normal given the strength of the suction applied by this method. Fine capillaries under the skin
can also break relatively easily with strong suction, causing deeper and longer lasting bruises.
This is also the only method of cupping that can cause blisters to form quickly. Therefore, it is
strongly advised that the practitioner should remain with the patient at all times during the
treatment, observing the progress of the suction, and if necessary, removing the cups earlier
than planned. The strong cupping method should be avoided on the face, stomach, abdomen,
and on children under the age of 14, the elderly and frail, and during the entire pregnancy
period. It is particularly beneficial in the treatment of Hot Bi and Frozen Shoulder patterns.
4. Moving Cupping - Tui Guan Fa (draining)
As mentioned earlier, moving cupping is the second most draining of all the cupping methods.
The object of this treatment technique is to apply strong cupping therapy to a much larger area
of the body. Like the strong cupping method, the patient should have a strong constitution
before moving cupping is employed. Strong energetic features are needed in order to withstand
the not so gentle pulling and moving action of the cup. Without any doubt, this is the most
painful cupping method. For this reason alone, if the patient’s energy is Empty (Xu), and
therefore weak, moving cupping can only help to diminish it further. It is mostly applied on the
Bladder channel on the back (about 1.5 and 3 inch either side to the spine), especially when
Excess Heat conditions are present, or in some neurological conditions such as paralysis or post
stroke weaknesses.
Oil the skin liberally and apply a single medium size and medium strength cup on the treatment
area. Before applying the cup, make sure the edges of the glass cups are smooth, even, and
without any chips. This is one method in which bamboo cups are of no use. The sharp edges of
the bamboo cups make it impossible to move the cup once the suction takes place. On
application of the cup, control the suction by gently moving the cup in any one direction. The
cup should move freely and without requiring a great deal of effort from the practitioner. If the
suction is strong, moving the cup will be difficult, and any attempt to move it will result in
extreme pain. Grip the cup with one hand, while supporting the skin close to the cup with the
other. Pull and slide the cup alongside the meridian using long strokes. Do not apply short, up
and down movements as this may cause unnecessary pain. If difficulty is experienced in moving
the cup, it is an indication that the suction is too strong and needs to be reduced by letting a
small amount of air into the cup. The primary objective of moving cupping is to manipulate the
Excess Qi and bring up the Heat to the surface of the skin. After only a few strokes, bruising will
appear alongside the line of movement. The more internal Heat is present, the quicker the
bruising will appear. This bruising can also be used as a diagnostic tool as far as the Qi and
Blood congestion and internal Heat are concerned; deep and darker bruising indicates a Full
(Shi) or an acute condition. Light colour bruising indicates Empty (Xue) conditions, requiring
less vigorous treatment. During the application of moving cupping, some air will almost always
escape into the cup, resulting in cessation of suction. All that is necessary is to reapply the cup
and continue with the movement. Avoid using the moving method on an open wound or lesions,
as the skin must be smooth and unbroken.
This treatment is not recommended for children under the age of 14, or for the frail and weak.
The first treatment should not exceed 5 minutes, building up to a maximum of 15 minutes per
session. For Hot skin conditions like eczema, psoriasis and acne, or painful Hot Bi syndromes,
moving cupping is greatly beneficial, though it is important to avoid direct application on
lesions. If the condition to be treated is on the hands, face or front of the body, moving cupping
can be applied on the Bladder channel on the back of the body instead. The same principle
applies with painful Bi patterns, i.e. avoid moving cupping directly on painful points, and use the
surface 1.5 to 2 cun close to the trauma for treatment.
5. Needle Cupping Method (draining)
Needle cupping is mostly used for Re (Hot) type painful Bi patterns, i.e. red and painful knee
and elbow joints, where there is a need to stop the pain and remove the excess pathogenic Heat
at the same time. The practitioner should administer the acupuncture treatment as intended
under normal circumstances, leaving the needles in place as long as necessary. One can reduce
the acupuncture treatment-time by 10-15 minutes if needle cupping is intended to follow the
acupuncture.
Following the acupuncture treatment, leave the needles in the present position and apply oil to
the skin where the acupuncture needles are situated. Choose a bamboo or large glass cup in
order to accommodate the acupuncture needle. Apply the cups over the acupuncture needles. A
medium to strong application is necessary if the treatment is over the joints, and weak to
medium cupping if the treatment is over muscular areas. Retain the cups in position for 10 to 15
minutes. Some blood may be drawn into the cup through the needles. This is normal especially
if the suction is strong.
Avoid practising needle cupping on the Back Shu points, as there is a real danger of the cup
pushing the needle deeper than originally inserted, thus causing a pneumothorax. To be on the
safe side, use short 0.5 to 1 inch needles during the treatment. This is one occasion when the
tall bamboo cups are preferable to the more round glass cups, as the height of the bamboo cups
are ideal for needle clearance, making the application much safer to administer. This method is
not recommended for children under the age of 16.
Biography
Ilkay Chirali qualified as a TCM practitioner in 1985 in Melbourne, Australia where he opened his
first clinic. He later returned to England in 1987 where he set up his own clinic in South East
London and is still practicing. He has presented numerous papers on cupping at five
international seminars and held well over 40 cupping therapy workshops as well appearing as an
‘expert’ on BBC TV and radio programmes. For details of forthcoming cupping workshops,
contact Ilkay Chirali via email: ilkayzchirali@aol.com
Cupping Therapy - Part Two
by Ilkay Chirali
6. Moxa Cupping Method (hot needle) - Ai Guan Fa (tonifying)
Moxa (Artemisia Vulgaris) is a great warming herb used by many practitioners for removing
Cold and tonifying Qi and Blood. It usually comes in two forms, the loose type and the round,
long, cigar shape. It is the latter type which is used during this treatment. Hot needle cupping is
used where Cold patterns are predominant with pain. Here, acupuncture is used to move the
channels, open the obstruction, and relieve pain. Moxa is used to heat the needle and transfer
the heat to the acupuncture point in order to warm and tonify. This method is particularly useful
in the treatment of Cold Bi patterns and arthritic joint pains.
This technique requires a great deal of care and patience. Inset a 1.5 inch long needle into the
desired acupoints, cut about 1 inch of moxa roll, and insert it on the coil of the needle. Place a
small piece of paper under the needle and on top of the skin, providing protection from ash
falling from a burning moxa. Light the moxa and wait until it burns out completely. This might
take up to 10 minutes. At this stage, when the Moxa is completely burnt out, the ash on top of
the needle is cold or just warm. The needle however, remains hot for a considerable length of
time. Without touching the needle or the ash, apply the cup over the needle (the same
therapeutic effect can be achieved if the ash is tapped-off the needle while retaining the needle
in place). When the desired cupping time is over, remove the cup gently and, before removing
the needle, shake off the ash by holding a tray under the needle and tapping gently on its base.
Hot needle cupping is especially beneficial in the treatment of Cold patterns of the Spleen and
Stomach and lower backache caused by Kidney Yang Deficiencies and Cold, i.e. bed wetting or
impotence. This method of treatment is not suitable for children under the age of 14 years.
7. Empty (Flash) Cupping Method - Shan Guan Fa (tonifying)
Empty cupping is also called flash cupping for its quickness of application. This method is
actually a medium to strong cupping method, but is applied rapidly and the cups remain in place
for a very short time, i.e. less than a minute. It is used for stimulating and moving the Qi and
Blood on the weak and frail. The rather short duration of cupping application is enough to
stimulate the Qi and Blood, but not enough to drain. It is therefore a tonifying method,
particularly when Cold or Heat is the pathogenic factor in the weak, and frail and in children
under 14 years old.
The technique is simple. Empty cupping is applied on the back of the body. Oil the area to be
cupped, place up to 12 cups near at hand, light a large cotton wool ball and apply the cups
simultaneously. Once all the cups are in place, start removing the cups without delay, beginning
with the first cup applied. When all the cups are removed, reapply them to different positions
immediately. This can be repeated for between five and ten minutes. A slight bruising will
appear all over the back, but it will fade away within a day or two. This is the favourite cupping
method for children.
8. Full (bleeding) Cupping Method - Xue Guan Fa (draining)
Also called wet cupping, this was the most favoured and practised cupping method of all by the
early practitioners. Early medical practitioners, particularly in Europe, employed the bleeding
cupping technique in order to purge foul blood from the body, which was considered the source
of disease.
Today the bleeding method is used in the treatment of a sudden increase of blood pressure, and
in the discharging of puss from boils and furuncles, which represent as an Excess, with Blood-
Heat and stagnation. From this description, it can be seen that this method will only be suitable
for adults with strong, Excess (Shi) patterns. This technique is not suitable for children or the
elderly. The empirical point to bleed is Dazhui (DU 14), located on the first thoracic vertebra.
Have the patient sit backwards on a chair, resting and supporting their head on a pillow in front
of them. Sterilise the Dazhui (DU 14) point with alcohol and make a very small incision (0,5 cm)
with a sharp razor or use a Plum-Blossom needle. Firmly tap the point for a short time to cause
bleeding (I normally use the Plum-Blossom needle). Once the point is bled, choose a large cup
size 4 or 5, and apply a strong cupping method to the point. The blood will be drawn slowly into
the cup (figure 2). If the incision made was sufficient, between 30-60 ml of blood can be
expected to be drawn into the cup. However, if the patient is taking any anticoagulant drugs,
more blood may be drawn into the cup. Removing the cup full of blood requires special attention
and care. Refrain from rushing, as it may cause the blood to spill from the cup. Within 15
minutes the bleeding will stop. Most of the blood drawn into the cup will be semi-coagulated,
and therefore, still fluid. Before removing the cup, the practitioner should wear disposable
surgical gloves on both hands, providing protection from direct contact with the blood. Ask the
patient to sit upright, place a large paper towel under the cup with one hand. While pressing the
upper edge of the cup with the other, remove the cup in an upright motion, making sure that
the mouth of the cup remains covered with the paper towel at all times during this removal
process. The cup is then cleaned by sterilizing it in Milton solution whilst the blood is disposed of
in a clinical waste container. It is not recommended to bleed more than once a month and not
more than 100ml at any one time.
Figure 2. Bleeding Cupping.
9. Herbal Cupping Method (Yao Guan Fa) (tonifying)
When employing this method, you require a few bamboo cups, a relatively deep pan, water,
metal clamps, some form of fire, and herbs in a prescription based on the patient’s treatment
plan. Put the herbs and the bamboo cups into a deep pan and cover them with water (glass
cups become too hot and are therefore not suitable for this method). Bring the water containing
the herb concoction and bamboo cups to boiling point, and simmer for 30 minutes. Prepare the
patient in the normal way, and expose the part of the body to be cupped. When practitioner and
patient are both ready, lift one cup at a time out of the pan with a metal clamp. Wait briefly to
ensure that the cup is not too hot, and then apply the cup in the normal way. Once again, extra
caution must be observed not to cause burns or blisters with hot cups or hot water dripping over
the skin. The best precaution is to try the cups on your own skin before applying them to your
patient. The herbs are soaked and absorbed by the bamboo cups, and in turn transfer their
healing properties to the patient. This method is usually employed when external pathogens
such as Cold, Damp and Wind attack the body, causing stiffness and aching of the body
particularly the neck and shoulders (common cold, asthma, and a cough). While this treatment
is not recommended for children under the age of 16 years old, it is particularly beneficial for
the elderly and the frail with Qi and Blood Xu. I personally do not practice this method often as
it requires a long period of time to prepare and administer and is therefore not very practical in
a busy clinic. Cups can be left on between 10/20 minutes. Afterwards, the bamboo cups are
infused in a herbal mix and boiled together to neutralise them.
10. Water Cupping (Shui Guan Fa) (even method)
This is one of the most least used and practised cupping methods. Firstly the practitioner needs
to be experienced and fast during the application of this particular method, and secondly, it can
be quite messy if not done correctly.
This technique involves filling a third of a glass or bamboo cup with warm water, and applying
the cupping process in a quick fashion. Whilst holding the cup close to the patient with one
hand, bring it close to the point to be cupped and insert the burning cotton wool into the cup,
then swiftly and simultaneously turn the cup onto the skin. When performed properly, no water
spillage occurs. If the application is performed in a slow motion some water spillage over the
patient is inevitable. This should however present no problems, as the water used is only warm
and will cause no harm. This method of cupping disperses the inhibited Lung-Qi, regulates the
Lung-Qi and resolves Phlegm, based upon the Lung’s influence of body fluids (Chirali 1999). It is
especially beneficial for asthma sufferers, as well as Wind-Cold or Wind-Damp rheumatic
conditions, localised swellings and pain. It is said to be particularly beneficial in the treatment of
asthmatic conditions in children when used on Feishu (UB 13). Usually a bruise does not appear
with this method.
Cupping on Children
I have treated children with acupuncture and cupping from the very first week of opening my
practice in Melbourne, Australia. However, it wasn’t until I studied paediatric acupuncture with
Julian Scott in England, who is a prominent acupuncturist and a teacher on the subject, that I
discovered the full potential of Chinese medicine in the management and treatment of children’s
diseases.
Children in general respond well and do not mind cupping therapy. They certainly prefer it to
acupuncture treatment! Children under the age of 7, require just a little extra care and patience
during treatment. At this age children are quite unpredictable, one minute appearing quite calm
and relaxed, and the next, with little warning, they can turn quite the opposite; weepy, angry
and restless. It should also be remembered that the skin of a child of this age is extremely
sensitive and vulnerable. I would certainly not recommend any method of cupping applied to
children under the age of 4 years old. It is also worth bearing in mind that some children are
petrified of fire.
Before a cupping treatment proceeds, the accompanying parent should be given a full
explanation of the cupping procedure as part of the co-operation necessary between parent and
practitioner. If necessary, apply a small cup to the inside of the parent’s arm, and let the child
touch and feel the cup. Distraction of any kind by the parent will help to relax the child, inspire
confidence and take away the child’s attention from the practitioner during the application.
Small size cups (size 1 - 2) are most suitable for children under 7 years old, also size 2 and 3
cups can be used for children under 14 years old. The golden rule to follow when treating
children under 7 years old is that the maximum treatment time allowed is just 5 minutes, and
between 7 and 14, a maximum of 10 minutes. The strength of the cups should only be empty,
weak or medium. Never use strong, moving, needle, moxa or full methods on children under the
age of 14. Children also bruise and blister easily, and a close watch is constantly needed at all
times. A gentle massage after the cupping treatment will take away the apprehension and relax
the child, and at the same time build a good rapport with the child for future treatments. In
China, cupping treatment is employed daily, and ten treatments constitute a single course. In
the West however, like acupuncture, a treatment once a week is the normal frequency.
The most common children’s ailments treated by cupping therapy include, asthma, common
cold, and digestive complaints. Usually the Back Shu points are cupped. For a more
comprehensive study on children’s treatment with Chinese medicine, see J. Scott 1991
Acupuncture in the Treatment of Children.
Biography
Ilkay Chirali qualified as a TCM practitioner in 1985 in Melbourne, Australia where he opened his
first clinic. He later returned to England in 1987 where he set up his own clinic in South East
London and is still practicing. He has presented numerous papers on cupping at five
international seminars and held well over 40 cupping therapy workshops as well appearing as an
‘expert’ on BBC TV and radio programmes. For details of forthcoming cupping workshops,
contact Ilkay Chirali via email: ilkayzchirali@aol.com
References
Chirali, I. (1999). Traditional Chinese Medicine Cupping Therapy. Edinburgh: Churchill
Livingstone
