











































MANUSCRIPT TYPE


CLINICIAN EXPERTISE COMMENTARY 

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 – June 2019 

Clinical Experts Statement: The Definition, Prescription, and 
Application of Cupping Therapy  
S. Andrew Cage, MEd, LAT, ATC1,2; Diana M. Gallegos, MS, LAT, ATC1; Brian Coulombe, DAT, LAT, ATC4; 
Brandon J Warner, MEd, LAT, ATC2,3  

1The University of Texas at Tyler, 2University of North Carolina Greensboro, Kinesiology, 3Grand Canyon University, 4Texas 
Lutheran University 

 
 
Key Phrases 
College and university patient population, therapeutic 
devices, manual techniques, cupping therapy 
 
Author Characteristics  
The first author, Andrew S. Cage, has obtained his 
International Cupping Therapy Therapist certification and is 
a member of the International Cupping Therapy Association. 
Mr. Cage also has several peer-reviewed publications as 
well as international, national, regional, and local 
presentations on the use of cupping therapy in sports 
medicine and rehabilitation. Mr. Cage has presented 
numerous times on evidence based approaches on the use of 
cupping therapy and uses cupping therapy extensively in his 
clinical practice. Further, Brandon Warner and Diana 
Gallegos, have also received certifications in cupping 
therapy and myofascial decompression and use cupping 
therapy in their clinical practice regularly. Both Mr. Warner 
and Ms. Gallegos have several peer-reviewed publications 
and presentations at the national, regional, and local levels. 
 
Correspondence 
S.  Andrew Cage, The University  of  Texas  Tyler,  11325 
Preakness Dr., Flint, TX 75762. 
E-mail: sacage@uncg.edu 
 
Full Citation 
Cage SA, Gallegos DM, Coulombe B, & Warner BJ. Clinical 
experts statement: The definition, prescription, and 
application of dry cupping therapy. Clin Pract Athl Train. 
2019;2(2): 4-11 https://doi.org/10.31622/2019/0002.2.    
 
Submitted: May 29, 2019 Accepted: June 6, 2019 
 
INTRODUCTION 

Cupping therapy is an ancient modality the use of 
which has been documented as early as 3300 
BC.1 In the past two decades, dry cupping therapy 
has grown in popularity in the United States and 
other countries where Western Medicine is the 
primary source of healthcare.1 A large amount of 
this popularity can be attributed to increased 
media interest resulting from elite level athletes 
receiving cupping therapy.2,3 Even though cupping 
therapy has gained popularity as a treatment 
device in the United States, there is still no 
consensus on the ideal parameters for applying a  

 

cupping therapy treatment to patients competing 
in amateur or professional athletics.1 The lack of 
consensus related to this medical issue can be 
attributed at least in part to a lack of high quality 
studies, lack of randomized controlled trials 
involving subjects participating in organized 
athletics, and a lack of standardized 
methodology.1,4,5 

Within the medical and healthcare field, various 
methods of creating consensus statements on best 
practices are commonly used and accepted.6-9 

These techniques have been used to publish 
consensus statements in areas including 
respiratory, urologic, and geriatric medicine.6-9 In 
instances in which there are deficiencies or 
contradictions within the current literature, the 
Delphi technique is one method of determining 
consensus that can be employed.6 Therefore, the 
purpose of this clinical expertise commentary was 
to use the Delphi technique to develop a clinical 
expertise statement on the definition and 
description of cupping therapy, as well as the  
prescription and application of dry cupping 
therapy when providing athletic training services. 
This statement was to be created with the intent of 
serving as a guide for clinicians until gaps in 
literature could be addressed. 

METHODS 
 
A review of the available literature was 
conducted using PubMed and GoogleScholar to 
locate published materials that could contribute to 
an initial list of statements to utilize in the Delphi 
process. The review focused on: description and 
definition of cupping therapy, prescription of 

https://doi.org/10.31622/2019/0002.2


Clinical Experts Statement: The Definition, Prescription, and Application of Dry Cupping Therapy  

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 – June 2019 

cupping therapy, and application of cupping 
therapy. The literature search looked for English 
language studies that had been published after 
2013. Ultimately, 31 sources were utilized in the 
creation of the literature review.1-5,10-35 

 
Upon completion of the review of literature, a 
panel of 10 athletic trainers who held a post-
professional credential in cupping therapy were 
invited to participate in a series of online surveys 
and forums. Demographic information for the 
panel of experts can be found in Table 1. 
 
Table 1. Panel demographic information 
Sex Male (N=5), 

Female (N=5) 
Age (Years) 31.3 ± 5.01 
Certified Athletic Training 
Experience (Years) 

7.0 ± 3.71 

Patients Treated Weekly 
with Cupping Therapy 

9.1 ± 4.01 

Age, Experience, and Patients Treated 
presented as means with SD. 

 
After collecting demographic information from the 
panelists, the Delphi technique was utilized in a 
similar manner to that which was performed by 
Maher et al.6 Panelists with a history of regularly 
performing formally trained cupping therapy as 
part of their daily athletic training practice were 
identified by the primary investigator and 
independently recruited to participate. Panelists 
received an electronic copy of the literature 
review, and were asked to review it for one week. 
Panelists were then surveyed on a series of 
statements regarding the definition and 
description, prescription, and application of 
cupping therapy on their patient population. 
Panelists were asked to rate each statement 
based off of whether or not they felt it warranted 
inclusion in the overarching clinical expertise 
statement (1 = Definitely do NOT include to 9 = 
Definitely include). Using the protocol outlined in 
Table 2, all statements were analyzed by the 
primary investigator to determine if they 
warranted inclusion, exclusion or modification. 
Following the first round, panelists received a 
web-based spreadsheet that outlined the results 

of the first survey. The spreadsheet also included 
areas for panelists to comment on what they felt 
should be modified in the statements that had not 
qualified for inclusion in order for them to be 
included in the final clinical expertise statement. 
After modifications were made to the 
remaining statements, the second survey was 
sent to the panelists asking them to re-rate the 
revised statements. Upon completing the second 
round of surveying, consensus was reached on all 
included statements based off each included 
statement having a median rating of 8 or higher. 
 
 

 
RESULTS 
 
Following the review of literature, 67 statements 
were developed. These statements addressed the 
definition and description of cupping therapy, 
prescription of cupping therapy (specifically, 
indications and contraindications), and the 
application of cupping therapy. All 10 panelists 
participated in the demographics survey, as well 
as the first and second round of rating statements. 
Seven out of 10 panelists provided comments and 
suggested revisions for the statements that did not 
warrant inclusion or exclusion after the first round 
of rating. Additionally, five panelists were 
contacted in a one-on-one fashion to request 
clarification on comments or to provide 
clarifications on the investigator’s remarks.  

 

Table 2. Statement inclusion key 
Statement 

Result 
Threshold Applied 

Definitely 
Include 

1. ≥ 80% of panel rated 
statement = 9 

2. Median rating of ≥ 8 
Maybe 
Include  

1. ≥ 70% of panel rated 
statement = 9 

2. Medial rating of ≥ 7 
Definitely 
exclude 

1. ≤ 80% of panel rated 
statement = 1 

2. Median rating of ≤ 2 
Review  1. Major revisions 

suggested by panelist. 
2. < 70% of panel rated 

statement = 9 



Clinical Experts Statement: The Definition, Prescription, and Application of Dry Cupping Therapy  

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 – June 2019 

 
After the rating of the original 67 statements was 
completed, 31 statements remained unmodified, 
four were excluded, and 32 were presented to 
the panel for revisions. A total of six of the 
statements regarding the description and 
definition of cupping therapy were combined into 
a single statement. Additionally, a single 
statement was created regarding mediums from 
five statements following agreement on oils were 
the preferable mediums to lotions. Statements 
regarding the number of pumps to use with plastic 
cups on experienced and inexperienced patients 
were combined into two respective statements. 
Additionally, the statement regarding the use of 
cupping therapy on the appendages of a 
pregnant patient was modified to include 
physician consent as a necessity.  
 
Of the remaining 30 statements from the first 
round of rating, eight modified statements were 
reviewed and rated in the second round. During 
this round of rating, all eight were unmodified and 
included in the final overarching statement. As all 
remaining statements had reached a consensus, it 
was concluded that there was no need to undergo 
a second round of revisions and ratings. Thus, the 
final 39 statements are presented in Table 3, 
Table 4, and Table 5 as the panel’s clinical expert 
statement on the description, prescription, and 
application of cupping therapy in athletic training.  
 
DISCUSSION 
 
The purpose of this study was to develop a clinical 
statement on the description and definition, 
prescription, and application of cupping therapy 
in athletic training. The literature review results in 
67 initial statements. Following 2 rounds of rating, 
39 statements were included in the final clinical 
expert statements. Ultimately, the goal of this 
consensus clinical expert statement was to attempt 
to reach a level of agreement based off of expert 
opinion in the absence of high-quality evidence. 
This method was chosen based off the success of 
using it in other healthcare professions to create 

consensus statements for conditions and 
interventions that did not have clearly set 
guidelines.6 The Delphi technique has been used 
by other authors to reach consensus statements on 
a variety of medical conditions.6-9 Maher6 noted 
this technique had exceptional utility when used 
for establishing guidelines for conditions that were 
not well documented in research-based literature. 
 
Upon completion of the first round of review, 
revisions were made to the statements that 
qualified for modification based off of input from 
the panelists. Revisions were made to condense 
and clarify the description and definition of 
cupping therapy, the use of cupping therapy on 
the appendages of pregnant patients, the amount 
of suction used on patients with and without 
experience with cupping therapy, and the types 
of mediums used for applying cupping therapy. 
These statements are intended to serve as a tool 
for athletic trainers looking to incorporate cupping 
therapy into their clinical practice. Through review 
of these statements, athletic trainers may be able 
to practice cupping therapy with the knowledge 
that these aspects of the practice have been 
reviewed by a clinician-driven panel. 
 
The authors encourage all athletic trainers and 
allied healthcare practitioners looking to practice 
cupping therapy to carefully review and consider 
each of these statements. The information 
contained within these statements is not inclusive of 
all individual scenarios and circumstances. 
Extenuating variables such as patient health, state 
and federal regulations, cultural beliefs, and 
patient values may affect the ability of a clinician 
to implement these statements into their practice. 
The authors strongly encourage individuals to seek 
out formal education and training in cupping 
therapy prior to administering treatments to 
patients. The statements contained within this 
document should be viewed as a resource and not 
a rigid set of guidelines for practicing cupping 
therapy. 
 



Clinical Experts Statement: The Definition, Prescription, and Application of Dry Cupping Therapy  

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 – June 2019 

 
  

Table 3. Agreed Upon Definition of Cupping Therapy1,4,5,12,17,21  
Cupping Therapy Description/Definition 

1. Cupping therapy utilizes suction from one of a variety of methods. 
2. Cups used for cupping therapy can be made of materials including plastic, glass, rubber, silicone, 

and wood. 
3. Some methods of creating suction on the tissue being treated include: pumping air from a plastic 

cup, creating an oxygen deficit in a glass cup with an open flame, and manually manipulating a 
silicone cup. 

4. Cupping therapy utilizes negative pressure to have a mechanical effect on treated tissues. 
5. Traditional cupping therapy was a commonly used technique prior to the 20th century. During the 

turn of this century, trends indicate that there was a decline in use, possibly due to the advancement 
of medical research or the ambiguity of bloodletting procedures. However, this ancient practice has 
begun to re-emerge as a viable option for orthopedic injuries. This increase may be contributed to 
the 2016 Olympics or continued research in optimizing outcomes for athletes. 

6. There is some evidence to suggest that cupping therapy can decrease musculoskeletal pain. 
7. There is some evidence to suggest that cupping therapy can increase regional and local blood flow. 

Table 4. Agreed Upon Prescription of Cupping Therapy1,2,5,13,15,22,29  
Indications 
1. Musculoskeletal pain is an indication for the use of cupping therapy. 
2. Neurological pain is an indication for the use of cupping therapy provided direction is given by the 

patient’s neurovascular specialist. 
3. Muscle tightness is an indication for the use of cupping therapy. 
4. Myofascial adhesions within a muscle are an indication for the use of cupping therapy. 
5. Subacute and chronic muscular injuries are an indication for the use of cupping therapy. 
Contraindications 
1. Open wounds are a contraindication for the use of cupping therapy. 
2. Pregnancy is a contraindication for cupping therapy over the lower back or torso. 
3. Cupping therapy treatments on the appendages of pregnant patients should be done with caution, 

and when possible with physician consent. 
4. Neurovascular compromise is a contraindication for the use of cupping therapy in the absence of 

referral by a neurovascular specialist. 
5. Cupping therapy should not be performed on a muscle that has suffered an injury within the past 24-

72 hours. 
Cupping therapy for athletic related injuries 
1. There is a need for a larger number of high-quality studies on the use of cupping therapy in athletic 

training. 
2. Several case studies have been published that suggest cupping therapy may be a viable treatment 

option for athletics related injuries. 
3. In the absence of high-quality studies specific to athletics related injuries, clinicians and educators 

must rely on studies conducted on participants from the general population. 
4. There is no time required for patients to refrain from participation in sport-related activities following 

use of cupping therapy, provided they complete an adequate dynamic warm up and are not 
experiencing soreness above patient tolerance. 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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Although the panel was able to reach consensus 
on the included statements, this study did have 
limitations. The literature review was designed to 
provide panelists with an overview of the most 
current literature. However, there was not a 
number of high-quality studies assessing the  
effects of cupping therapy. Additionally, the 
majority of these studies did not follow a 
standardized methodology that may have given 
the panel the opportunity to provide learner 
guidelines regarding the application of cupping 
therapy. Due to this limitation, the literature  

 
review was reviewed by a clinician with extensive 
experience with cupping therapy in order to 
ensure the literature review was completed in the 
most comprehensive and insightful way possible. 
Furthermore, the use of athletic trainers with their 
primary job setting as college/university may limit 
the generalizability to other job settings. Athletic 
trainers practicing in settings where the majority 
of their patients are minors may have additional 
considerations they need to make. Future research 
should incorporate panelists from other athletic 
training settings to increase the generalizability of 

Table 5. Agreed Upon Considerations of Cupping Therapy1,4,5,12,15,29 

Application 
1. When treating a minor, it is necessary to educate the patient’s parent or guardian and obtain consent 

from said guardian prior to performing cupping therapy. 
2. Cupping therapy should be performed by or under the supervision of a properly educated healthcare 

professional. 
3. Depending on the location, goal, and patient allergies, clinicians should use mediums such as coconut 

oil, grapeseed oil, and seedless massage oil to minimize patient discomfort during cupping therapy 
treatments. 

4. An area with more body hair may require the use of more oil, but may still be more difficult to 
achieve suction on. 

5. Therapeutic effects can be seen after as little as 10-minutes of treatment when using static cupping 
therapy depending on therapeutic goals. 

6. Static cupping therapy can be performed safely for up to 30-minutes depending on patient comfort 
and therapeutic goals. 

7. When using plastic pump cups with patients who have not been cupped before, starting with 1 pump 
based on patient comfort is recommended. 

8. Clinicians should use an amount of suction that does not elicit a painful response when treating patients 
who have not received cupping therapy treatments before. 

9. Depending on therapeutic goals and patient tolerance, clinicians can generally use more suction when 
treating patients who have receive cupping therapy treatments before. 

10. Clinicians can affect the amount of suction achieved during fire cupping by decreasing the amount of 
time from when the flame is removed from the cup and when the cup is placed on the intended 
treatment area. 

11. Provided a patient's soreness has not increased and patients can tolerate the amount of suction, 
clinicians can utilize cupping therapy in the presence of muscular soreness. 

Reasons to Discontinue/Adverse effects 
1. If a patient expresses discomfort during cupping therapy, the clinician should discontinue treatment. 
2. If blisters begin to form during cupping therapy, the clinician should discontinue treatment. 
3. If blisters do form during cupping therapy, standard wound care treatment is appropriate provided 

there are no signs of infection. 
4. If a patient begins to become lightheaded during cupping therapy, the clinician should discontinue 

treatment. 
5. Presence of ecchymosis related to a previous cupping therapy treatment does not disqualify a patient 

from being treated with cupping therapy again provided the patient is not experiencing soreness. 
Following treatment 

1. Patients should be instructed to hydrate properly following cupping therapy. 
2. Patients can reasonably expect to feel soreness similar to what would be expected after a deep tissue 

massage following cupping therapy. 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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these statements. A final limitation that is that the 
Delphi technique has been suggested to not meet 
the same standards as other scientific methods.6 

That being said, the controlled feedback and 
clinician input that is characteristic of this technique 
is ideally suited for creation of a consensus 
statement on a treatment technique that currently 
has gaps and contradictions within the available 
literature.  
 
CONCLUSIONS 
 
The remaining 39 statements provide an expert 
statement on the definition and description, 
prescription, and application of cupping therapy 
for athletic training clinical practice. This clinician-
driven expert statement using the Delphi 
technique provides a framework for safe and 
effective cupping therapy practices based off of 
best available evidence and clinician expertise. 
This statement is presented with the intent of 
providing direction for decision making regarding 
the prescription and application of cupping 
therapy.  
 
THE CUPPING THERAPY PANEL OF 
EXPERTS 
 
The authors would like to thank: Travis Armstrong, 
MS, LAT, ATC (Arizona Christian University, 
Glendale, AZ), Alifonzo Garcia, MS, LAT, ATC 
(Arizona Christian University, Glendale, AZ), Kerri 
Kalina, MS, LAT, ATC (University of Texas at 
Dallas, Richardson, TX), Tracy Lott, MS, LAT, ATC 
(Texas A&M University Commerce, Commerce, TX) 
Nicole Murzen, MS, ATC (Soka University of 
America, Aliso Viejo, CA), Tyler Rediger, LAT, ATC 
(University of Texas at Tyler, Tyler, TX), J.J. 
Sayson, MAT, LAT, ATC (Grand Canyon University, 
Phoenix, AZ), and Sarah Wambheim, MAT, ATC 
(University of Minnesota, Minneapolis, MN) for 
their participation in the panel.  
 
 
 
 

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