CLINICAL INSIGHTS, IMAGES, PROJECTS
A few reflections and considerations on the cupping demonstrations provided during the
World Golf Fitness Summit 2016.
By Marc Wahl
While honoring Traditional Chinese Medicine and all the practitioners who have nurtured cupping, acupuncture, and their traditions through the millennia, I am calling out to those very practitioners and also chiropractors, physiotherapists, golf professionals, physical trainers and the individual public to support one another in open group dialogue and further investigation of this powerful modality for specific and niche performance applications.
While cupping the body indiscriminately may or may not be successful, I believe that it is far more efficient and effective to use the FMS/TPI/SFMA system to identify and demonstrate tissue extensibility dysfunctions (TEDs) and then to specifically tailor the cupping treatment to eradicate those restrictions. Simply eradicating all restrictions even when some are not of functional detriment could actually hurt the client’s performance under some circumstances. The practitioner must ask “why” and what effect the treatment could do to the particular client.
All “cupping” is not the same. So many variables can come into play, that any combination of dry vs. wet, active vs. passive, dynamic vs. static, degree of intensity, compression by the edges of cup, as well as the size of the cup, time of dose, health of client, the permutations and therefore outcomes are virtually infinite. It’s impossible to have a conversation about “cupping” without specifying how we are using this tool.
(Access video at www.marcwahl.com)
Following are some of the topics, guidelines, considerations we discussed over the three sessions at the WGFS:
1 Don’t use on small muscle groups before competition unless the athlete can't play without intervention.
When we consider what we’re actually doing with the cupping at the level of the integumentary system, we are changing the relationships of the organelles that control proprioception, static position sense, and kinesthesia which tells us how we are moving through space. In sports with lots of gross movement, ie football, soccer, swimming and where fine motor is not as critical as golf, archery, tennis, baseball, (or any sport where there is an instrument to manipulate) the changes that we make with cupping during competition could have significant outcomes and implications. If we take the consideration of changing kinesthesia at the level of scapular stability by just one millimeter, how will that effect the entire kinetic chain, not only down the arm to the fingertips, but now down the 45 inch club and the impact of that club on the ball? These are questions that we do not have answers to at this time. Consider the example of a sobriety test where the police officer pulls someone over and has them reach out with their hand with their eyes closed and touch their nose - if they miss the mark of the fingertip to the nose, it would indicate their position sense, kinesthesia, malfunctioning due to alcohol. While this is not the same system exactly, there are some definite carryovers to the kinesthesia brought through the integumentary system. Now consider the same test done with 45-inch club, your arm and hand. Can you imagine trying to touch the ball on a tee and at over 100mph? Experience has shown me that it is very difficult for a player to receive cupping to scapular stabilization muscles and then compete at the accuracy level they had before. Conversely, challenging a player during a practice session when they realize that their target movements will be off, can increase the level of concentration and mental acuity as long as they realize the potential outcome of the cupping they receive. I have witnessed players be cupped arbitrarily, then go into a warm-up session on the range and hit the ball uncharacteristically poor, and then start questioning their setup, grip, club, shaft, loft, coach, etc. This cascade of events could have been avoided and been productive if proper warning was given.
2. What are the kinematic implications of using cupping on the decelerators of movement before competition?
Lets take a consideration of what ultimately transfers speed from one segment of the body to the next. I believe we can agree that it is deceleration. What are the components of deceleration? There are so many that it’s impossible to discuss them all in this venue, but we can probably agree again that muscle restrictions and fascia restrictions can be part of the decelerating process as we transfer speed from one segment to the next. Lets look at the lead hip on a golfer. If we take those fascial and muscular restrictions and decrease them significantly through cupping, then we will not be able to transfer the speed of the hips to the torso and up the kinetic chain. Meanwhile, the implications for training and coaching (outside of competition) show an incredible opportunity to challenge the body to work on muscular deceleration when the fascial and muscular restrictions are removed or decreased.
3. Don't use in an area unless you can answer the question “why am I doing this to this tissue?” When and where and to what degree to cup? We always need to be intentional.
As with the two points noted above, I have made and witnessed the mistakes of using cupping on small muscles before competition and seen the effects. For example, “Cupping is a valuable tool that should be used with discretion. Too much of a good thing is not always good. I was having some shoulder problems and had it cupped. My symptoms went away immediately but my ROM in my shoulder almost doubled which sounds good but for a golfer, doubling your shoulder ROM is bad due to unpredictability.” - Scott Stallings, Professional Golfer
And with the recent craze with cupping since the Olympics, I’ve seen a player (an accurate driver) have his shoulder and scapular stabilizers cupped becoming inaccurate driver of the golf ball and begin questioning his equipment, ball, loft, shaft flex, weighting… had the player known this was a possibility, he wouldn’t be looking at his equipment as the problem. Had these changes been done on off weeks or early on in the tournament week, perhaps his neurological system could have adapted to these kinesthetic proprioceptive changes. For example, lets look at what I call the “Pull-up scenario”. Let’s get away from golf for a minute. We will compare the same treatment’s effect on a shoulder press vs a pull up. A person is going to do a shoulder press in competition, let’s say they can do 50 lbs on one arm before cupping. The first thing they must do before they press the 50 lbs up is to overcome any muscular or fascial restrictions to just lift the arm itself. If the arm weights 5 lbs and they have 15 lbs of “fascial” restrictions in their muscle, fascia, and skin, then before they lift the 50 lb weight, they have to “lift” 20 lbs of restriction (the arms 5 lbs plus the 15 lbs of restrictions). If, when we cup, we can relieve 10 lbs of fascial restriction, then during the competition the person would then be able to lift 60 lbs rather than 50 lbs. Cupping in this case would help them exceed their personal best in competition and training. In the second situation, there is a pull-up competition. The personal best is 15 pull-ups. In this situation, the person lowers themself into a pull-up and the movement restrictions of the shoulder and fascial restrictions. These restrictions now store energy as the person lowers down eccentrically and now actually assists them as they return to the top position. This athlete is relying on their restrictions to meet their personal best. If we cupped the same areas on this person as in the shoulder press example, they will then not have that stored energy they relied on, and will go deeper into the full hang position but will lack the strength in that new range to return to the chin up position. The ability to get them back up relied in part on a tissue restriction, not contractile in nature, and now they are at a weak new end range they have yet to experience or train in. While the incredible opportunity to train in a new range is the holy grail of training and coaching, it would be a disaster during competition. Hence, the need to know WHEN, WHY and WHAT we are cupping. I believe this goes for all manual therapies. Cupping, needling, soft tissue work, pin and hold. Consider the philosophy behind altitude training. Train and tax the cardiopulmonary muscular systems at the high-altitude and then demand to adapt to that environment, find the edge, then compete. Knowing this about human physiology, we would have never taken a sea level athlete to the 1968 Mexico City Olympics and expected them to perform on the first day without acclimating to the environment.
4. Don't expect motion and strength gains to remain without follow up and training.
While ROM and strength gains can be astounding and dramatic initially, we can expect them to return to baseline if not nurtured 24 to 48 hours later. There is more going on than the “stretching and strength gaining” and when we look at the central mediated systems of dry needling as described by Dr. Ma in his first of three books, “Biomedical Acupuncture for Pain Management”, the body is being called to bring fresh blood and metabolism to these new “inoculated” areas of concern. These previously stagnant, “forgotten”, bottom-of-the-metabolic-concern areas now become the primary area of concern for the body and must remain at the top of the list. If we don’t continue to require and ask for more motion, more strength, and more neurological control, they will return to status quo and possibly worsen. Cupping serves by providing us with a large window of opportunity that we must take advantage of.
Over and over I hear about cupping and needling being an ancient tool, an art that has been around for 3-5 thousand years and yet we still don’t have any definitive answers and these tools are being reinvented constantly. Dogmatically following prescribed methods or certifications without the space to think creatively hampers the citizen scientist. The ability to have relationships within your clinical community where you can bounce ideas off each other is critical to develop and legitimize the many forms and uses for cupping. The citizen scientist should not to be concerned about a group’s opinion on the right or wrong way to cup, or arbitrary regulation gained by lobbying power to control a modality. It is critical for the development of systems not to have exclusive certifications that are aimed at limiting access to learning and practicing. Lets all remember that in reality people have been doing cupping without certification for thousands of years. And while I know professional tournament golf and my beliefs about how this could affect these players, I have ideas about tennis, volleyball, football, sprinting, soccer, but I don’t work with the best in the world in those sports. What would happen if we cupped a cellist or violinist from the New York Philharmonic? How would they play? Can we get 100 subjects between 40-55 and track their swings with trackman, cup their lead hips, retest and see what we get? I’ve done a few - lets do more! And there is just so much more to investigate! Can we look at kinematic sequence and wrist impact positions of pre- and post- cupped lead arm scapular stabilizers? While the changes physically and neurologically, when made on your average club golfer, may not be noticeable and may actually help them play better, what are those effects on professional golfers who make their living playing tournament golf? I believe it’s a dramatically different story.
We have so many more questions than answers. Its up to us to do the research, put down our competitive swords and pick up our cooperative pens. This is intuitive. As much as we like to classify ourselves as scientists, we do research to prove/disprove our hunches, but where do the hunches come from? Inspiration, intuition, wonder and the safety in one’s environment to fail and to be vulnerable.
A few more takeaways...
1) DO use TPI screens, FMS, SFMA, Y-balance tests, and what ever your functional tests may be to tease out tissue extensibility dysfunctions (TEDs). You can use cupping to alleviate those restrictions. The straightest line to a successful cupping treatment is to work on tissue extensibility dysfunctions. My opinion is that these screens are the most efficient way to get to that end
2) DO use cupping on small muscles and large side-on sport decelerators before training and before practice. Expect your performance to decrease as your nervous system adjusts to the new ranges and inputs in those ranges.
3) DO use cupping in conjunction with dry needling, instrument assisted soft tissue mobilization (IASTM), and all your manual techniques.
4) DO take before and after pictures (data, video) to see the dramatic changes that will occur when using cupping.
5) DO use your expertise and intuition to push this modality into popular acceptance with basis in legitimized screening, see #1.
I am looking for coaches, trainers, and manual therapists who treat the amateur golfer in order to investigate cupping via the tools we have at our disposal - 3Dassessment, force plate, video. If you have access to amateur golfers and would like to join me on this quest, please contact me.