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Journal of Bodywork & Movement Therapies (2015) xx, 1e6

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/jbmt

REVIEW

New is the well-forgotten old: The use of dry

cupping in musculoskeletal medicine
Evgeni Rozenfeld, BPT a,b, Leonid Kalichman, PT, PhD a,*

a
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of
Health Sciences at Ben-Gurion University of the Negev, Beer-Sheva, Israel
b
Department of Physical Therapy, Medical Corps, IDF, Beer-Sheva, Israel

Received 30 August 2015; received in revised form 6 October 2015; accepted 30 October 2015

KEYWORDS Summary Cupping is an ancient technique used in treating pain and various disorders.
Cupping; Different techniques have been developed over time, however, applying a cup to create suc-
Musculoskeletal pain; tion over a painful area, is common to all. Dry or fire cupping, used on the intact skin, leaves
Dry cupping bluish circular hematomas. Recently, interest in cupping has re-emerged and subsequently,
several studies have begun to investigate the mechanisms of cupping therapy. Mechanically,
cupping increases blood circulation, whereas physiologically it activates the immune system
and stimulates the mechanosensitive fibers, thus leading to a reduction in pain.
There is initial scientific evidence that dry cupping is able to reduce musculoskeletal pain.
Since cupping is an inexpensive, noninvasive and low-risk (if performed by a trained pra-
ctitioner) therapeutic modality, we believe that it should be included in the arsenal of muscu-
loskeletal medicine. It is essential to perform additional studies clarifying the biological
mechanism and clinical effects of cupping.
ª 2015 Elsevier Ltd. All rights reserved.

History: cupping therapy in different cultures
Cupping has been practiced in most cultures in one form or
another throughout history but the true origin of cupping
* Corresponding author. Department of Physical Therapy, Reca-
nati School for Community Health Professions, Faculty of Health
Sciences, Ben-Gurion University of the Negev, P.O.B. 653, Beer
Sheva, 84105, Israel. Tel.: þ972 52 2767050; fax: þ972 8 6477683.
E-mail addresses: kalichman@hotmail.com, kleonid@bgu.ac.il
(L. Kalichman).
therapy remains uncertain. Although it is believed that
cupping therapy dates back to as early as 3000 B.C.E., the
earliest record describing cupping as the removal of
“foreign matter” from the body was found in the Egyptian
Ebers Papyrus in 1550 B.C.E. (Nickel, 2005). Subsequently,
cupping was introduced to the Greeks and eventually
spread to many other countries in Europe and America.
Cupping was practiced by many famous physicians such as
Galen (131e200C.E.), Paracelsus (1493e1541) and
Ambroise Pare (1509e90), in addition to other practitioners
including barber surgeons and bath house attendants

http://dx.doi.org/10.1016/j.jbmt.2015.11.009
1360-8592/ª 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Rozenfeld, E., Kalichman, L., New is the well-forgotten old: The use of dry cupping in musculoskeletal
medicine, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.11.009
 + MODEL
2 E. Rozenfeld, L. Kalichman
(Chirali, 1999). Cupping was widely used into the late
1800’s by European and American physicians (Turk and
Allen, 1983). In the Soviet Union, cupping was in practice
until the late 20th century (Pokrovski, 1991).
The clinical efficacy of cupping was confirmed by a joint
research project between Chinese and Russian acupunc-
turists (Chirali, 1999). Since 1999, cupping has been
accepted as an official therapeutic practice in Chinese
hospitals. A Korean survey in 2006 showed that 93.5% of
6708 oriental physicians used cupping treatments in their
clinical fields (Han et al., 2006).
Although cupping is practiced in Eastern and Western
cultures, the theories and basis for its application differ.
Eastern medicine believes that diseases are caused by
stagnant or blocked Qi, the life force; cupping is able to
unblock and correct imbalances in the flow of Qi, thereby,
leading to a greater well-being (Tham et al., 2006). Galen’s
teachings regarding four basic body fluids (humors) were
used as a theoretical background for cupping. Greek phy-
sicians believed that the cupping drew pathogenic features
to the surface, thus, facilitating their elimination (Kose
et al., 2006). Medieval European practitioners used
cupping as a means of expelling evil spirits.
In 1920, Epstein proposed a “counter-irritation” expla-
nation, referring to cupping as a process of transferring
discomfort and pain from one site to another thereby curing
the original site (Epstein, 1920). A psychosomatic theory
advocated by several researchers hypothesized that the
therapeutic effect of cupping could be attributed purely to
a placebo effect (Kouskoukis and Leider, 1983; Yoo and
Tausk, 2004).
Although cupping was used to treat pain and a variety of
other complaints for thousands of years, it nearly dis-
appeared from the therapeutic spectrum of Western med-
icine during the late 20th century. Nevertheless, during the
past few years, interest in cupping has increased and new
clinical trials suggest that cupping may be effective in
managing painful conditions (Farhadi et al., 2009; Kim
et al., 2011; Lüdtke et al., 2006).
Numerous investigations and review papers have begun
studying wet cupping (that including small incisions made
on the skin to cause bleeding). This method is invasive and
cannot be performed by most practitioners who deal with
musculoskeletal disorders (physical therapists, osteopaths,
massage therapists, etc.). Our review concentrates on dry
cupping, a noninvasive procedure, that if found effective
can be easily included in the arsenal of therapies focusing
on musculoskeletal disorders.
Methods of cupping
Cupping is traditionally performed by using a small round
cup made of thick glass with a rolled rim to ensure uni-
form and air-tight contact with the skin in order to pre-
serve a vacuum effect (Kravetz, 2004). Cups are also made
of bamboo, earthenware and other materials. Negative
pressure is created by heating the air within the cup, then
allowing it to cool and contract while in contact with the
skin. The air is heated either by swabbing the interior of
the cup with alcohol then setting it aflame or by igniting
an alcohol-soaked cotton ball or other flammable
Please cite this article in press as: Rozenfeld, E., Kalichman, L., New is the well-forgotten old: The use of dry cupping in musculoskeletal
medicine, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.11.009
materials held inside the cup (Kravetz, 2004; King and
Davis, 1983; Kouskoukis and Leider, 1983; Look and
Look, 1997). Just before the flame is extinguished, the
mouth of the cup is positioned firmly against the skin at
the desired location. The suctioning effect produced by
the vacuum anchors the cup onto the skin, drawing it
upwards into the cup. Today, cupping is frequently carried
out using plastic cups and a manual hand-pump to create
the vacuum. To cover a wider area, lubricants can also be
used to move the cup around once placed on the skin
(Turk and Allen, 1983).
The most common sites of application are the back,
chest, abdomen and buttock e areas of abundant muscle
(Yoo and Tausk, 2004). Traditionally, cupping is performed
in sets of four, six or 10. The cups are typically left in place
for 5e20 min or more. The longer a cup is left on the skin,
the more of a circular mark is created (Kouskoukis and
Leider, 1983).
The after-effects of cupping include erythema, edema,
and ecchymosis in a characteristic circular arrangement.
These bruises may take several days to several weeks to
diminish (Yoo and Tausk, 2004; Manber and Kanzler, 1996).
Cupping has unique morphologic features. Family physi-
cians and dermatologists should be made aware of this
technique as it is becoming more and more widespread.
Mechanical effects of cupping
Tham et al. (2006) demonstrated in a soft tissue model that
the soft tissue directly under the rim of the cup com-
presses, while the periphery tenses. The tensile stresses
appear to be greater in the bulb-shaped region under the
center of the cup, extending down to the muscle layer.
However, these forces reach their maximum on a very small
area of the skin layer near to and just inside the cup’s rim.
This is probably caused by the stretching of the skin and the
underlying soft tissue layers when drawn into the cup by
the applied vacuum.
The cups typically used for cupping, range in diameter
from approximately 38 mme50 mm. Tham et al. (2006)
observed that maximum stress was found in a larger cup
and minimum stress in a smaller cup, located along the
axis passing through the center of the cup. Therefore, it
may be assumed that a small cup will not be able to exert
the force required to make any difference. For constant
vacuum pressure, a larger cup is able to exert a higher
stress at the interface between the fat and muscle layers.
These results are consistent with the experimental data
reported by Hendriks et al. (2006) in a study describing
the mechanical behavior of the skin using different
diameter suction devices. Hendriks’s data clearly show
that increasing the diameter of the suction device leads to
larger skin-surface displacements, resulting in a corre-
spondingly larger uplift and resulting stress at the un-
derlying tissue layers.
The larger compressive stresses were found associated
with a sharper cup rim which caused more pain and
discomfort to the patient (Kravetz, 2004). It was therefore,
recommended that cups with more rounded rims should be
used (Kravetz, 2004). This rounded rim is commonly
referred to as a rolled rim or rolled edge.
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The use of dry cupping in musculoskeletal medicine
Zhao et al. (2009) studied the effects of time and
negative pressure on the cupping mark color. Cupping was
performed on 12 sites on the back of a healthy subject.
Thirty-four persons were included and the amount of time
the cup was in place was recorded. The cupping mark color
at each site was assessed 24 h after the procedure using a
cupping mark color atlas as a reference. The amount of
time the cup was in place, either 10 min, >30 min,
>20 min, had a statistically significant effect on the
cupping mark color. The effect of 700 hPa, >600 hPa,
>500, hPa, >400 hPa pressure on the cupping mark
color was also significant. The application for 10 min and a
pressure of 400 hPa, produced a marked ecchymosis on
the cupping site, which became darker and darker along
with increased stimulation intensity.
Huber et al. (2011) compared four methods of producing
a vacuum: a 2 cm lighter flame, a 4 cm lighter flame, an
alcohol flame and mechanical suction with a balloon. They
found that all methods yielded consistent pressures, how-
ever, large differences in magnitude were observed be-
tween methods (mean pressures 200  30 hPa with a 2 cm
lighter flame; 310  30 hPa with a 4 cm lighter flame;
560  30 hPa with an alcohol flame; and 270  16 hPa
with a balloon). Mechanical suction with a balloon showed
the best reproducibility.
Physiological effects of cupping
There are various hypotheses, both traditional and scien-
tific, that have endeavored to explain the effects of
cupping. Nevertheless, there is still no reliable scientific
data clarifying the exact mechanism which can determine
the therapeutic effect of cupping.
One theory inferred by several authors is that cupping
increases the circulation surrounding the treated area, thus
enabling toxins trapped deep in the soft tissue layers to rise
to the body surface (Kouskoukis and Leider, 1983; Look and
Look, 1997; Yoo and Tausk, 2004). The consequences of the
cupping treatment are a direct result of the stress devel-
oped within the skin layers (Tham et al., 2006). The skin has
a very rich blood supply (Gawkrodger, 2002) and the ar-
teries in the subcutaneous tissue layer branch upwards into
the dermal layer to form a superficial network, very close
to the skin’s surface (at the papillary-reticular dermal
boundary). The existence of high tensile stresses inside the
cup is believed to cause a severe dilation of the capillaries,
leading to rupture (Tham et al., 2006; Zhao et al., 2009).
The tensile stresses also cause ecchymosis produced by the
escape of blood into the tissues after the rupture of the
blood vessels.
In traditional Chinese medicine (TCM), the principles of
acupuncture and acupressure are very similar to that of
cupping therapy. For this reason, TCM practitioners will
occasionally apply cupping to acupoints. Of all the hy-
potheses suggested to-date attempting to explain the pain-
relief effects of acupuncture analgesia in scientific terms,
the most comprehensive is the neural mechanism theory
(Pomeranz, 2001) which states that acupuncture analgesia
is prompted by the stimulation of the small diameter nerves
in muscles, which then send impulses to the spinal cord.
The three neural centers e spinal cord, mid-brain and
Please cite this article in press as: Rozenfeld, E., Kalichman, L., New is the well-forgotten old: The use of dry cupping in musculoskeletal
medicine, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.11.009
3
pituitary e are subsequently activated, releasing chemical
transmitters, such as monoamines and endorphins, thus
blocking the pain messages. In addition, Schulte demon-
strated that acupressure and acupuncture analgesia can
elicit the release of morphine-like substances (endorphins),
serotonin or cortisol which can lead to pain relief in addi-
tion to changing the physiological state of the individual
(Schulte, 1996). It was found that acupressure and
acupuncture work by stimulating or activating: 1. vaso-
constriction and dilation; 2. a neurotransmitter release; 3.
enkephalin secretion; 4. the immune system and 5. the pain
gates (according to the gate control theory) in the central
nervous system which interpret pain sensation (Anon, 1998;
Schulte, 1996). TCM, including acupressure and acupunc-
ture, have proven useful in pain management (Schulte,
1996; Cadwell, 1998; Hinze, 1988). The effect of dry
cupping apparently can be explained by activation of the
same pathways.
It has been proposed that cupping can affect the im-
mune system in two ways: by irritating the immune system
thus causing local inflammation, which subsequently acti-
vates the complement system and increasing the level of
the tumor necrotizing factor (TNF) and interferon; or by
increasing the lymph flow (Ahmadi et al., 2008).
Cupping is a form of treatment by which somatic struc-
tures such as skin, subcutaneous tissue, fascia, etc. are
favorably influenced by manipulation. Cupping has been
hypothesized to improve performance at all neuro-
physiological levels (spinal cord, changes of milieu, envi-
ronment and performance of the nociceptor) (Musial et al.,
2013). It is likely that this manipulation of the skin and
deeper tissue layers will stimulate the inhibitory receptive
fields of cortically projecting multi receptive dorsal horn
neurons or provoke diffuse noxious inhibitory controls (Le
Bars, 2002; Ji and Woolf, 2001; Woolf and Salter, 2000).
Deep relaxation, induced by cupping is an additional
desirable effect, probably contributing to the general
reduction of stress and directly affecting the motivational-
affective pain processing network (Musial et al., 2013).
By generating a vacuum, cupping causes local edema,
ecchymosis or minor bleeding from the capillary vessels
(Tham et al., 2006; Zhao et al., 2009), therefore, it is
logical to assume that the effect of cupping is, in some way,
similar to autohemotherapy (Klemparskaya et al., 1986)
(subcutaneous reinjection of freshly drawn autologous
blood).
Treatment for musculoskeletal pain
Cupping is used for neuralgia or myopathy, headaches,
stomach aches, insect bites, infections, etc., but one of the
main complaints treated by cupping is pain, primarily
musculoskeletal pain. According to a Korean survey,
cupping is primarily used by physicians for treating
musculoskeletal diseases (96%). The most frequently
applied points are the neck and shoulders (94%) (Lee et al.,
2008). Recent studies examining the efficacy of cupping
treatment for various musculoskeletal disorders showed
good results (Lauche et al., 2011; Cramer et al., 2011; Kim
et al., 2012; Markowski et al., 2014; Teut et al., 2012),
 + MODEL
4 E. Rozenfeld, L. Kalichman
however, there are only a few randomized controlled trials
regarding dry cupping.
Three studies investigated the influence of cupping on
neck pain (Lauche et al., 2011; Kim et al., 2012; Cramer
et al., 2011). Lauche et al. (2011) examined a series of
five cupping treatments and their influence on pain and
mechanical thresholds in patients with chronic neck pain.
Fifty patients were recruited and randomized into a
treatment group and waiting-list controls. Patients in the
treatment group received a series of five cupping treat-
ments over a two week period; the control group did not.
After two weeks, patients in the treatment group had
significantly less pain and had attained better results on the
Short Form Health Survey (SF-36) subscales for bodily pain
than patients in the waiting-list group.
In a study investigating the effect of pulsating cupping
on chronic neck pain compared to standard medical care,
Cramer et al. (2011) recruited 50 patients with chronic
nonspecific neck pain who were subsequently randomized
into treatment and control groups. The treatment group
received five pneumatic pulsation treatments employing a
mechanical device over a period of two weeks while the
controls continued with self-directed standard medical
care. After the intervention, significant decrease in pain
intensity, functional disability (neck disability index e NDI),
and physical quality of life (SF-36) were observed in both
groups. No significant differences were found between
groups for pain at motion and pressure pain threshold.
According to this study, it appears that pulsating cupping is
a safe and effective method in relieving pain and improving
function and quality of life in patients with chronic neck
pain.
Kim et al. (2012) performed a randomized controlled
pilot trial to evaluate the effectiveness of cupping therapy
for neck pain in video display terminal workers. Forty
workers with moderate to severe neck pain were randomly
allocated into one of two interventions: six sessions of wet
and dry cupping or heat pad application. Both groups
received treatments three times a week over a two week
period. The symptoms related to work were evaluated at
several points during a 7-week period. The participants
were offered an exercise program during the participation
period as well. Cupping was found more effective than a
heating pad in improving pain (numeric pain rating scale-
NPRS), NDI and discomfort (measure yourself medical
outcome profile 2-MYMOP score) at two evaluation points (3
and 7 weeks). Significant improvement in the EuroQoL
health index (EQ-5D) was observed at seven weeks in both
groups. The researchers found that two weeks of cupping
therapy and an exercise program may be effective in
reducing pain and improving neck function.
Markowski et al. (2014) evaluated the effect of cupping
on pain, tenderness to palpation and range of motion of
patients with sub-acute or chronic low back pain. Twenty-
one patients who had reported back pain for at least
eight weeks volunteered to participate in the study. Four
glass cups were applied and pressurized over the lower
erector spinae muscles. A significant improvement in post-
treatment pain scores was found (evaluated by visual
analog scale) in the straight leg raising test, lumbar flexion
range of motion and pain pressure threshold at all four
investigated points.
Please cite this article in press as: Rozenfeld, E., Kalichman, L., New is the well-forgotten old: The use of dry cupping in musculoskeletal
medicine, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.11.009
Pulsatile dry cupping was examined on patients with
osteoarthritis of the knee and found to relieve symptoms of
knee osteoarthritis compared to no intervention. The re-
searchers concluded that further studies comparing
cupping with active treatments are needed (Teut et al.,
2012).
We found no studies on no-effect of negative effect of
dry cupping. It is possible that this is due to a publication
bias effect, where only positive results are published.
Complications of cupping
Cupping is considered a safe therapy with minor side ef-
fects such as erythema, edema, and ecchymosis which are
a directly caused by cupping. Because cupping encourages
blood flow to the cupped region (hyperemia), the patient
may feel warmer and/or hotter as a result of vasodilatation
taking place. Slight sweating may occur.
There a few contraindications for cupping such as
pregnancy or menstruation, cancer (metastatic) and bone
fracture. Also, cupping cannot be applied to a site of deep
vein thrombosis, arteries or areas where a pulse can be felt,
i.e. an area where the dermis or flesh is injured or
compromised as in sunburn, abrasion, rash or contusion
(Chirali, 1999). Some complications may ensue due to a
long duration of cupping therapy (more than 20 min) or a
high vacuum pressure which may cause separation of the
epidermal layer from the dermal base of skin.
In a case report by Ling and Wang, a man who had
received cupping therapy while aboard his private airplane,
presented to the emergency department with tingling and a
painful sensation felt on his back. Multiple blisters within
circular marks of differing sizes and varying shades of
redness, petechiae, and ecchymosis were found. Upon
further observation, it was deduced that these symptoms
were a result of changes in atmospheric pressure related to
the unexpected descent of the plane which had increased
the negative pressure in the cups (Lin et al., 2009).
In another case report, a woman reported that cupping
had been performed on her lower back two weeks previ-
ously in order to relieve her back pain. However, the cup
was held on her skin for over 40 min. She experienced
intense pain soon after the procedure. Bullae and crusting
subsequently developed over the area within the ensuing
week (Tuncez et al., 2006).
Another complication that can occur due to cupping is a
skin burn. Despite several documented single case reports
of burn injuries caused by cupping (Iblher and Stark, 2007;
Kose et al., 2006; Sagi et al., 1988), no systematic reviews
of this complication have been published.
According to Zhao et al. (2014), burn injuries occurring
during cupping therapy are usually a result of one of the
following: 1) the practitioner uses an excessive amount of
alcohol to moisten the inner surface of the cupping vessel
(this is the most common reason for patients presenting to
the author’s department with burns); 2) the container
holding the alcohol was accidently knocked over during
cupping therapy; 3) the materials used to start the fire
needed to produce a vacuum effect, caused the burn
injury. Practitioners usually use a piece of paper or cotton
soaked with alcohol to heat the air before an application. In
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The use of dry cupping in musculoskeletal medicine
some cases, a hasty practitioner applies the cupping vessel
to the treatment site before the alcohol has burned away
which subsequently results in a burn; 4) therapy may
continue for too long (i.e., more than 30 min) or the skin is
very sensitive to heat (e.g., in some older people the skin is
thin and vulnerable, while in some children the skin is too
tender to tolerate the hot cups). Treatment, complications
and residual effects of burns sustained from cupping do not
differ from other burns.
Additional complications may occur as a result of
contamination. Nowadays, cups are made of glass or plas-
tic. While cupping, blood may be drawn into cups. Small
amounts of blood or fluid may express into the cups and
may or may not be related to excessive suction force, skin
fragility or hydration. Blood-borne pathogens may not be
visible to the naked eye and therefore, there may be a risk
of transfer of these pathogens (Nielsen et al., 2012).
Although a Medline and Chinese language database
search revealed no reported cases of blood-borne pathogen
transmission through cupping devices, disease transmission
may be unidentified because the possibility has not been
considered. When cupping, blood or body fluids may
contaminate the cup and the skin area. The re-use of
contaminated cups without decontamination can expose
other patients to blood-borne pathogens.
Complications as well as transmission of infection have
been documented as originating from cupping. Factitial
panniculitis and herpes simplex virus have been reported
secondary to cupping demonstrating that transmission of
blood-borne pathogens can occur (Lee et al., 1995; Jung
et al., 2011). As a result of this report, there is a need
for caution in removing cups containing blood or body fluids
with respect to the potential for splash or aerosol formation
upon the release of suction. Cups used for dry cupping
should be cleaned, washed (immediately after use) and
disinfected with a high level, registered hospital-grade
disinfectant before reuse or disposal (Nielsen et al., 2012).
There is a greater risk for epidermal separation when
using pumping cupping rather than a vacuum caused by a
flame; on the other hand the risk for acquiring a burn is
much greater during the second method. Taking into
consideration all the aforementioned data, we recommend
that cupping therapy be performed by practitioners with
training in the art of cupping. The training should include
the intensive practice of cupping application, as well as
information on contraindications and precautions.
Conclusions
The existence of high tensile stress inside the cup causes
severe capillary dilation leading to its rupture. Capillary
rupture, the cause of ecchymosis, typically remains after
cupping therapy. In a larger cup, the stress forces are
greater than in a smaller cup; therefore in order to achieve
maximal results, the largest cup possible should be used.
The physiological effect of cupping expressed in the
activation of the immune system by causing local inflam-
mation and activation of the complement system, also af-
fects the thymus and increases the lymph flow. Cupping
also stimulates the mechanosensitive Ab fibers which
reduce nociceptive input. More intense stimulation
Please cite this article in press as: Rozenfeld, E., Kalichman, L., New is the well-forgotten old: The use of dry cupping in musculoskeletal
medicine, Journal of Bodywork & Movement Therapies (2015), http://dx.doi.org/10.1016/j.jbmt.2015.11.009
5
activates the C and Ad fibers in the affected areas, thereby
raising the inhibitory receptive fields of cortically projec-
ting and provoking diffuse noxious inhibitory controls. In
addition, cupping probably strongly impacts relaxation and
may serve as a social, comforting interaction. Further in-
vestigations of these mechanisms of action are necessary.
As was found in several studies (Cramer et al., 2011;
Hong et al., 2006; Lauche et al., 2011, 2012), cupping
application seems to be effective in treating various
musculoskeletal pain conditions. However, further studies
are necessary to confirm these results and evaluate the
effectiveness of cupping compared to standard treatments.
Studies investigating the effects of repeated interventions
in different intervals and long-term observations are
needed as well.
Complications of cupping are rare and in most cases
result from the therapist’s incompetence (Cao et al., 2012,
2010; Cramer et al., 2011; Kim et al., 2011; Teut et al.,
2012). On the other hand, some complications can be
serious, such as a skin burn and contamination (Iblher and
Stark, 2007), we, therefore suggest that cupping be
employed only by practitioners who have undergone spe-
cific, supervised training.
The results of reviewed studies and patients’ experi-
ences with cupping therapy support the assumption that
cupping is a safe and effective treatment for musculo-
skeletal pain conditions and can be used as a therapeutic
technique in musculoskeletal medicine.
Financial sources
None.
Conflicts of interests
None.
Acknowledgments
The authors thank Mrs Phyllis Curchack Kornspan for her
editorial services.
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