**9. Future directions**

*Pain Management - Practices, Novel Therapies and Bioactives*

Cupping therapy is generally considered as a safe treatment with minor side-effects and complications [23, 65]. However, the safety of cupping therapy is under-reported. Most of the studies which were conducted primarily addressed its efficacy but only a few studies reported its complications. Generally, the complications can be divided into preventable and non-preventable [23]. The commonly recognized side-effects are erythema, edema, and ecchymosis which are directly caused by cupping. Skin burns have also been reported [65]. They may occur because of the following reasons: excessive use of alcohol, prolonged exposure to cupping therapy, sensitive skin especially in elderly people, and the use of fire [23, 65]. Separation of the epidermal layer from the dermal base of the skin may occur due to prolonged exposure of more than 20 minutes to high vacuum pressure during cupping therapy. This complication was specifically reported with pumping cupping therapy [23]. In one case report, application of cupping therapy for about 40 minutes over the lower back resulted in severe pain immediately after removal of the cups and the patient developed bullae and crusting over the application site later [66]. Change in atmospheric pressure has been reported as a risk factor for skin injury as seen in a patient who was traveling in an airplane. This resulted in multiple blisters and shades of redness, petechiae, and ecchymosis [67]. Exposure to blood-borne infections may occur if infection control measures are not followed strictly. For example, cases of factitial panniculitis and herpes simplex virus infection have been reported after cupping therapy [68, 69]. Possible complications of cupping therapy are summarized in

**8. Complications of cupping**

**228**

**Figure 2.**

*Possible complications of cupping therapy (adapted from Aboushanab* et al *[23]).*

**Figure 2**.

Cupping therapy is a complimentary type of therapy which is widely used all over the world for the treatment of chronic medical problems, especially for painrelated conditions. Although, there are several proposed theories which attempt to explain its mechanism of action in the management of chronic pain, the exact mechanism is still not clearly understood. Future research could focus on trying to find clear answers for the most likely mechanism of action and to validate the current theories in clinical trials. There is an emerging evidence of the promising benefits of cupping therapy in patients with common chronic painful conditions. However, despite the large number of clinical trials which were conducted, the evidence is still inconclusive due to major limitations. Future clinical trials of good quality are required. Such trials should ideally have a large sample size, better methodology and design, standardized treatment and reporting protocols, standardized assessment tools, and long follow-up periods.
