Journal of Integrative Medicine 19 (2021) 327–332

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Journal of Integrative Medicine

journal homepage: www.jcimjournal.com/jim
www.journals.elsevier.com/journal-of-integrative-medicine

Methodology

A model to standardize safety and quality of care for cupping therapy

Riska Siregar a,⇑, Aris Setyawan a,b, Syahruramdhani Syahruramdhani a,c
a
Lembaga Mitra Sehat Manfaat, Relief-Health Partnership Society, Sleman 55292, Yogyakarta Province, Indonesia
b
School of Nursing, Institute of Health Science, Surya Global Yogyakarta, Bantul 55194, Yogyakarta Province, Indonesia
c
School of Nursing, Universitas Muhammadiyah Yogyakarta, Bantul 55183, Yogyakarta Province, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Cupping therapy has historical, traditional and religious value. It is increasingly popular in the field of
Received 18 October 2020 complementary, alternative and integrative medicine. However, standards for safety and quality of ser-
Accepted 8 January 2021 vice are absent. Although it is generally considered safe, cupping therapy can cause adverse events.
Available online 2 February 2021
Most of these events are predictable and preventable. A comprehensive approach to patient eligibility
and therapist selection, along with compliance with standard operational procedures is essential to reg-
Keywords: ulate the safety of the practice. Here we discuss a model framework for standardizing safety and quality
Cupping therapy
of care. We recommend that this model be used routinely by cupping therapists and their associations on
Safety
Theoretical models
a nation-wide scale.
Practice management
Please cite this article as: Siregar R, Setyawan A, Syahruramdhani S. A model to standardize safety and
quality of care for cupping therapy. J Integr Med. 2021; 19(4): 327–332.
Ó 2021 Shanghai Changhai Hospital. Published by ELSEVIER B.V. All rights reserved.

1. Introduction would establish appropriate anatomical sites [5] and provide

guidance for cupping technique [6,7]. Infection control would
Cupping therapy has unique historical, traditional and reli- govern hand washing, use of personal protective equipment,
gious value [1], and it is increasingly popular in the field of com- instrument sterilization and waste disposal [8]. Third, the
plementary, alternative and integrative medicine. In Indonesia, suitability of cupping for a patient/client should be evaluated
many different healthcare practitioners provide cupping, includ- carefully in terms of their general health and the specific risks
ing medical doctors, nurses, physiotherapists and traditional associated with cupping. It is important to note that an
healers, with the latter still recognized as the main provider individual’s risk for various adverse events can be determined
[2]. Practitioners of traditional medicine are respected and during the initial client assessment. Finally, a well-documented
trusted by the general population, and therefore should be care- treatment report is important for promoting continuous
fully regulated. evaluation of healthcare services, and leading to safer and better
Generally considered safe, the cupping intervention (wet, dry practice [9].
and others) can lead to adverse events during or after its
application. In order to avoid adverse events, there are four
aspects of the practice that need to be carefully considered: 2. Safety and quality model
the practitioner, the practice, the patient (client) and the paper
(report). We developed a model that incorporates these components
First, each cupping practitioner should have rigorous training (practitioner, practice, patient and paper) for use in a practical set-
[3,4]. Second, the practice of cupping should be standardized and ting. The model consists of five tools: a client assessment, a cup-
include infection controls. A standard for the practice of cupping ping therapist selection criteria, an informed consent template, a
cupping therapy record and a checklist of documents.
A client arriving at a cupping clinic should be evaluated care-
fully by a therapist who is trained to take a thorough medical his-
tory. The therapist will also measure vital signs and perform other
⇑ Corresponding author. examinations based on their competency. Next, the therapist
E-mail address: riskasiregar.md@gmail.com (R. Siregar). determines whether cupping therapy is suitable for the client in

https://doi.org/10.1016/j.joim.2021.01.011
2095-4964/Ó 2021 Shanghai Changhai Hospital. Published by ELSEVIER B.V. All rights reserved.
R. Siregar, A. Setyawan and S. Syahruramdhani Journal of Integrative Medicine 19 (2021) 327–332

their current condition. This procedure is outlined in the Tool 1: A medical therapist is a doctor, nurse, midwife or physiothera-
Client Assessment (Fig. 1). pist who had been formally trained in cupping therapy. When
We propose some simple diagnostic criteria for cupping eligi- general therapists find themselves ineligible to provide cupping
bility purpose. Healthy client is one without health problem or for a client, we recommend that they refer the client to a med-
health-related limitations. Minor health issue is indicated if cli- ical therapist.
ent has mild to moderate symptom and is still able to perform A client seeking cupping should be well informed about their
daily activities without or with insignificant limitation. Major session. The type of cupping should be clearly written and agreed
health issue is indicated if client is unconscious or has marked upon. The therapist should provide a detailed explanation of the
limitation to perform daily activities. The diseases/conditions steps that follow a cupping therapy session, especially to a client
listed on medical history (Tool 1) are considered as major health who is receiving the treatment for the first time. Therapist should
issue. consider whether the client has phobia to sharp objects or blood,
Therapist selection should follow the need of client as we and they should discuss how to manage or terminate a session if
proposed in Tool 2: Cupping Therapist Selection Criteria the client becomes uncomfortable. Only when every detail has
(Fig. 2). General therapist refers to a therapist who has been been cleared, cupping can be delivered. Tool 3 (Fig. 3) provides
trained and certified by an authorized cupping training provider. guidance for this step.

Fig. 1. Tool 1: Client Assessment. ID: identity; Reg No: register number; HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome.

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R. Siregar, A. Setyawan and S. Syahruramdhani Journal of Integrative Medicine 19 (2021) 327–332

Fig. 2. Tool 2: Cupping Therapist Selection Criteria.

A Cupping Therapy Record (Tool 4) should be filled out for every other relevant information about the session in order to improve
session (Fig. 4). It is crucial to take notes on the duration of therapy, future sessions.
amount of blood evacuated, immediate adverse reaction (if any), Finally, a final check is concluded with Tool 5: Checklist of Doc-
and the management or referral. The record should also contain uments (Fig. 5). This is a most important step in regards to quality

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R. Siregar, A. Setyawan and S. Syahruramdhani Journal of Integrative Medicine 19 (2021) 327–332

Fig. 3. Tool 3: Informed Consent.

control. A supervising system should always be in place to make tice facilitates supervision and evaluation. It is important for
sure that every datum is completed and thus automate the evalu- stakeholders to work together to strengthen the whole system
ation process of cupping. of complementary, alternative and integrative medicine, and to
provide continous support and supervision for the safety of cup-
ping. Our model serves as a prototype for documenting and
3. Conclusion
delivering care, and we recommend further research to study
the feasibility of deploying such a model, and to promote better
We recommend that the cupping therapist association adopt
patient care.
this model for use on a national basis. There are four benefits
that we believe will come from the use of this approach: (1)
the careful assessment of patient eligibility would help to predict Authors’ contributions
and prevent possible adverse events; (2) following the therapist
selection rubric will ensure efficient and safe cupping; (3) fol- All authors contributed in the conception of the work. SR
lowing a formalized process will help to standardize procedures drafted the manuscript. All authors participated in the revision
and data collection; (4) standardized and well documented prac- process.

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R. Siregar, A. Setyawan and S. Syahruramdhani Journal of Integrative Medicine 19 (2021) 327–332

Fig. 4. Tool 4: Cupping Therapy Record. Reg No: register number.

Fig. 5. Checklist of Documents Cupping Therapy Record (Tool 5).

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R. Siregar, A. Setyawan and S. Syahruramdhani Journal of Integrative Medicine 19 (2021) 327–332

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cupping therapy in studies conducted in twenty one century: a review of
literature. Br J Med Med Res 2016;15(8):1–12.
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authorship, and/or publication of this article. studies conducted in Korea: a systematic review. Eur J Integr Med 2014;6
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[5] Mahmoud HS, Abou-El-Naga M, Omar NAA, El-Ghazzawy HA, Fathy YM, Nabo
Declaration of competing interest MMH, et al. Anatomical sites for practicing wet cupping therapy (Al-Hijamah):
in light of modern medicine and prophetic medicine. Altern Integr Med 2013;2
(8):1000138.
The authors declare that they have no known competing finan-
[6] El Sayed SM, Mahmoud HS, Nabo MMH. Methods of wet cupping therapy (Al-
cial interests or personal relationships that could have appeared Hijamah): in light of modern medicine and prophetic medicine. Altern Integr
to influence the work reported in this paper. Med 2013;2(3):1000111.
[7] Chen B, Li MY, Liu PD, Guo Y, Chen ZL. Alternative medicine: an update on
cupping therapy. QJM 2015;108(7):523–5.
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