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

Cupping therapy has unique historical, traditional and reli-
gious value [1], and it is increasingly popular in the field of com-
plementary, alternative and integrative medicine. In Indonesia,
many different healthcare practitioners provide cupping, includ-
ing medical doctors, nurses, physiotherapists and traditional
healers, with the latter still recognized as the main provider
[2]. Practitioners of traditional medicine are respected and
trusted by the general population, and therefore should be care-
fully regulated.
Generally considered safe, the cupping intervention (wet, dry
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:
the practitioner, the practice, the patient (client) and the paper
(report).
First, each cupping practitioner should have rigorous training
[3,4]. Second, the practice of cupping should be standardized and
include infection controls. A standard for the practice of cupping
⇑ Corresponding author.
E-mail address: riskasiregar.md@gmail.com (R. Siregar).
guidance for cupping technique [6,7]. Infection control would
govern hand washing, use of personal protective equipment,
instrument sterilization and waste disposal [8]. Third, the
suitability of cupping for a patient/client should be evaluated
carefully in terms of their general health and the specific risks
associated with cupping. It is important to note that an
individual’s risk for various adverse events can be determined
during the initial client assessment. Finally, a well-documented
treatment report is important for promoting continuous
evaluation of healthcare services, and leading to safer and better
practice [9].
2. Safety and quality model
We developed a model that incorporates these components
(practitioner, practice, patient and paper) for use in a practical set-
ting. The model consists of five tools: a client assessment, a cup-
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
examinations based on their competency. Next, the therapist
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
their current condition. This procedure is outlined in the Tool 1:
Client Assessment (Fig. 1).
We propose some simple diagnostic criteria for cupping eligi-
bility purpose. Healthy client is one without health problem or
health-related limitations. Minor health issue is indicated if cli-
ent has mild to moderate symptom and is still able to perform
daily activities without or with insignificant limitation. Major
health issue is indicated if client is unconscious or has marked
limitation to perform daily activities. The diseases/conditions
listed on medical history (Tool 1) are considered as major health
issue.
Therapist selection should follow the need of client as we
proposed in Tool 2: Cupping Therapist Selection Criteria
(Fig. 2). General therapist refers to a therapist who has been
trained and certified by an authorized cupping training provider.
Fig. 1. Tool 1: Client Assessment. ID: identity; Reg No: register number; HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome.
328
Journal of Integrative Medicine 19 (2021) 327–332
A medical therapist is a doctor, nurse, midwife or physiothera-
pist who had been formally trained in cupping therapy. When
general therapists find themselves ineligible to provide cupping
for a client, we recommend that they refer the client to a med-
ical therapist.
A client seeking cupping should be well informed about their
session. The type of cupping should be clearly written and agreed
upon. The therapist should provide a detailed explanation of the
steps that follow a cupping therapy session, especially to a client
who is receiving the treatment for the first time. Therapist should
consider whether the client has phobia to sharp objects or blood,
and they should discuss how to manage or terminate a session if
the client becomes uncomfortable. Only when every detail has
been cleared, cupping can be delivered. Tool 3 (Fig. 3) provides
guidance for this step.
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

329
R. Siregar, A. Setyawan and S. Syahruramdhani
Fig. 3. Tool 3: Informed Consent.
control. A supervising system should always be in place to make
sure that every datum is completed and thus automate the evalu-
ation process of cupping.
3. Conclusion
We recommend that the cupping therapist association adopt
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
and prevent possible adverse events; (2) following the therapist
selection rubric will ensure efficient and safe cupping; (3) fol-
lowing a formalized process will help to standardize procedures
and data collection; (4) standardized and well documented prac-
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Journal of Integrative Medicine 19 (2021) 327–332
tice facilitates supervision and evaluation. It is important for
stakeholders to work together to strengthen the whole system
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
delivering care, and we recommend further research to study
the feasibility of deploying such a model, and to promote better
patient care.
Authors’ contributions
All authors contributed in the conception of the work. SR
drafted the manuscript. All authors participated in the revision
process.
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).

331
R. Siregar, A. Setyawan and S. Syahruramdhani
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
Declaration of competing interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
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