What is Evidence-Based in Cupping and Fascial Science?

Cupping therapy is hot topic that's everywhere from social media to the clinic and in the athletic training room. We recently tackled this on the Rehab and Performance Lab podcast in What Is Evidence-Based in Cupping and Fascial Science? I was joined by Dr. Chris DePrato, who has spent a significant portion of his career digging into fascia and cupping

What Does the Research Say About Cupping?

The current literature on cupping is "a bit of a mixed bag". Chris suggests that the methodology in many cupping studies isn't great, citing inconsistent approaches, poorly reported details, and often a lack of strong controls and proper blinding. This makes it difficult to draw firm conclusions about its effectiveness.

Currently, the evidence for cupping starts at the basic science level, attempting to understand what's happening mechanistically. There is also emerging research on range of motion and pain. Chris referred to a systematic review that pointed to some moderate evidence for neck pain, but noted that many back pain studies, while plentiful, had poor methodology.

Importantly, there's a distinction between traditional passive cupping and the more modern approach of myofascial decompression that incorporates movement strategies.  Chris likes to refer modern cupping as cupping with movement and load. Newer research that includes movement during the cupping intervention is showing more promise, particularly for increases in range of motion. In fact, most cupping literature before 2019 focused on passive techniques, which is completely different compared to using movement while the cup is applied. There are only a few studies right now that actually look at using range of motion during the procedure, and they tend to show good outcomes for mobility impairments. One study showed that cupping with movement improved dorsiflexion range of motion.

However, when considering systematic reviews and meta-analyses, the evidence for cupping can appear poor due to historical issues with study design, such as not normalizing for pressure, time left on, or cup material. As research moves forward with better-controlled variables, more significant outcomes may be observed.

How Does Modern Cupping Work?

Modern cupping focuses on the sliding properties of the fascial system and neurophysiological effects on peripheral mechanoreceptors. As the patient moves with the cups on, it creates a shearing force that may help decrease densification and improve fascial glide.

This is different from traditional cupping, which often targeted "toxins" or "stagnation," where the color of the mark was seen as important for diagnosis. Chris indicates that modern physiology does not really support this viewpoint.

Basic science research using MRI has shown that cupping can affect tissue depth, pulling not just subcutaneous fat but also deep fascia and muscle tissue into the cup's volume. Pressures around 250 to 300 mmHg were shown to tether parvertebral muscles, and 500 mmHg could even tether the multifidus away from the spine, potentially improving slide and glide. The effects on tissue glide surfaces may last for 5 to 10 days. It is also believed that cupping, as a mechanical stimulus, applies a low load to the tissue, which over time can help facilitate the ability to add more load.

Furthermore, the neurophysiologic effects are significant, and the brain plays a powerful role in the manual therapy effect. Cupping can provide sensory input that influences pain perception and motor control.

What Are Some Best Practices for Applying Cupping?

Key takeaways regarding the application of cupping include:

• Less is often more. Consider using just one or two cups.
• For pressure, lower pressures (around 100-200 mmHg) might be sufficient if you're primarily aiming for a change in how someone feels.
• If you want to target deeper tissues, you'll likely need higher pressures (250-300 mmHg or more), but this should be anatomy-dependent. Using cupping devices with pressure gauges can help you be more objective.
• Make it active! Think of the cup as an active tool, not just a passive one. Apply cups while your clients are performing active movements, working on postural changes, or even during the initial sets of a loading exercise to potentially decrease pain and improve load capacity.
• Newer research suggests that 5-10 minutes of cupping therapy can produce greater local blood flow increases than the 15-20 minutes often used in previous practices.
• When working on swelling and lymphatic mobility, very low pressures with a cup around 75-100 mmHg would be more effective at fluid mobility than higher pressures.

Which Patients Might Benefit from Cupping?

Chris suggests that cupping therapy applications can be used for more than just pain or mobility impairments.

• The cup on the skin can enhance your patient’s neurosensory and kinesthetic awareness of different regions of the body. For example, using cups on the thoracic spine to improve awareness of thoracic rotation or on the concave portion of a scoliosis curve to improve postural awareness.
• A cup can also be used to inhibit an overactive muscle or movement pattern, such as placing a cup on the upper trapezius to inhibit excessive scapular elevation during a row or lateral raise.
• Cupping, especially when paired with movement, shows promise for individuals with mobility impairments.

When selecting patients, physical therapists and athletic trainers should identify the movement faults that are important to the individual's outcome and then the underlying impairment. Cupping, often with movement, can then be applied to see if it improves that impairment measure. Utilizing validated tests with a test-retest model can help determine the effectiveness of the intervention (think Selective Functional Movement Assessment). Palpation can help identify areas of tissue densification that might be targeted with cupping.

What About Using Cupping for Recovery?

The basic answer is that there isn't a lot of strong science directly supporting cupping for recovery. While some might anecdotally report feeling less fatigue, it's important to consider what recovery actually entails. After intense activity, the body needs to engage its own recovery mechanisms to improve. Cupping, as a mechanical stimulus, actually aims to increase load on the tissue, so using it purely for recovery might not be the most effective approach. It might come down more to a sensation of recovery rather than significant physiological changes.

Similar to other recovery modalities like recovery boots, cupping for recovery is likely more about the mental preparedness and sensation of recovery rather than significant changes in inflammatory markers. However, using cupping with effleurage at very low pressures might help mobilize fluid in cases of minor swelling, which could contribute to a feeling of recovery. Chris recommends avoiding applying numerous cups for "recovery" as this may actually cause more stress to the body.

Important Considerations for Physical Therapists and Athletic Trainers

• Cupping is an adjunct, not the whole solution. It's a tool to be used strategically and eventually weaned off as you progress towards goals of improved movement, strength, and power. Avoid patients becoming overly reliant on it.
• Approach cupping with a critical, evidence-informed lens. Be aware of the limitations in the current research and prioritize high-quality studies, especially those looking at cupping combined with movement.
• Focus on targeted application, not just covering the body in cups. Identify specific impairments and use cupping as part of a comprehensive evaluation.
• Educate patients on why you are using cupping and manage their expectations, especially regarding the visual spectacle of cup marks. The goal isn't necessarily to create dark marks.
• Consider using cupping to enhance body awareness and proprioception in patients with postural deficits or movement control issues.
• Stay updated on the latest research, as the understanding of fascia and manual therapy techniques is continually evolving.

Ultimately, our discussion on the podcast highlighted that while cupping is gaining popularity, we need to approach it with a critical, evidence-informed lens. We need more high-quality research, especially looking at cupping combined with movement. And as practitioners, we need to be thoughtful in our application, focusing on targeted impairments and using it as part of a comprehensive treatment plan like (the SFMA would be great)..

And if you want to dive deeper into this conversation, be sure to check out Rehab and Performance Lab Episode 14: What Is Evidence-Based in Cupping and Fascial Science?

You can listen to the episode at the links below. If you'd like CEUs, make sure to use the MedBridge link.

Research From the Podcast & Takeaway Resource about Cupping

Choi, T. Y., Ang, L., Ku, B., Jun, J. H., & Lee, M. S. (2021). Evidence map of cupping therapy. Journal of Clinical Medicine, 10(8), 1750. https://doi.org/10.3390/jcm10081750 

Kim, K. W., Lee, T. W., Lee, H. L., An, S. K., Park, H. S., Choi, J. W., Lee, B., & Yang, G. Y. (2020). Pressure levels in cupping therapy: A systemic review. Journal of Acupuncture Research, 37(1), 28–34. https://doi.org/10.13045/jar.2019.0033 

Pratt, R. L. (2021). Hyaluronan and the fascial frontier. International Journal of Molecular Sciences, 22(13), 6845. https://doi.org/10.3390/ijms22136845 

Spellman, J., Eldredge, R., Nelson, M., Ostrowski, J., & Concannon, J. (2022). Is myofascial decompression effective at increasing hamstring flexibility in the athletic population? A critically appraised topic. Journal of Sport Rehabilitation, 31(8), 1100–1104. https://doi.org/10.1123/jsr.2022-0013 

Tam, K. T., & Baar, K. (2025). Using load to improve tendon/ligament tissue engineering and develop novel treatments for tendinopathy. Matrix Biology, 135, 39–54. https://doi.org/10.1016/j.matbio.2024.12.001 

Wang, X., Zhang, X., Elliott, J., Liao, F., Tao, J., & Jan, Y. K. (2020). Effect of pressures and durations of cupping therapy on skin blood flow responses. Frontiers in Bioengineering and Biotechnology, 8, 608509. https://doi.org/10.3389/fbioe.2020.608509 

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.