Simultaneous TENS, Electroacupuncture & Cupping Therapy – A Theoretical Framework
This article introduces a novel, integrative pain management protocol combining the simultaneous application of high and low frequency Transcutaneous Electrical Nerve Stimulation (TENS), concurrent electroacupuncture, followed by cupping therapy.

This theoretical framework proposes a synergistic approach that leverages the immediate pain modulation of high-frequency TENS via the pain gate mechanism, complemented by the sustained analgesic and neurochemical effects of low-frequency TENS and electroacupuncture, potentially through the release of endogenous opioids and modulation of central sensitization pathways. The subsequent application of cupping therapy aims to address myofascial restrictions and enhance local circulation, potentially prolonging the benefits of the neuromodulatory phase.
This unique integration of electrotherapy, acupuncture, & mechanical therapy within a single protocol offers a multi-target approach to pain management, potentially enhancing patient comfort & reducing reliance on pharmacological interventions.
By exploring the theoretical underpinnings of this combined approach, this article highlights its potential as a valuable contribution to the field of integrative pain care and underscores the need for future research to evaluate its clinical efficacy and safety.
Introduction
Chronic and acute pain represent a significant global health burden, impacting individuals’ quality of life, functional capacity, and healthcare systems worldwide (Woolf, C. J. (2010). Central sensitisation: implications for the diagnosis and treatment of chronic pain. Pain, 152(3 Suppl), S2-S15). While conventional pain management strategies, including pharmacological interventions and interventional procedures, play a crucial role, they are often associated with limitations such as adverse side effects, the potential for dependence (Manchikanti, L., Kaye, A. M., Knezevic, N. N., McAnally, H., Slavin, K. V., Vadivelu, N., … & Hirsch, J. A. (2017). Responsible opioid prescribing: a global perspective. Pain Physician, 20(1), S3-S66), and incomplete or short-lived pain relief (тургунбаев, О. С., & Ахмедов, М. М. (2023). Analysis of the effectiveness of non-steroidal anti-inflammatory drugs in the treatment of chronic pain. International Journal of Medical and Health Sciences, 17(01), 27-31.). This has led to a growing interest in and utilisation of complementary and alternative medicine (CAM) approaches for pain management, often sought by patients seeking non-pharmacological and holistic options (Nahin, R. L., Barnes, P. M., Stussman, B. J., & Dahlhamer, J. (2016). Expenditures on complementary and alternative medicine (CAM) and dietary supplements: United States, 2012. National Health Statistics Reports, (95), 1-15.).
Within the spectrum of CAM therapies, modalities such as Transcutaneous Electrical Nerve Stimulation (TENS), acupuncture (including electroacupuncture), and cupping therapy have been increasingly explored and utilised for their potential analgesic and therapeutic effects across various pain conditions (Johnson, M. I. (2014).
Transcutaneous electrical nerve stimulation (TENS): research to support clinical practice. Oxford University Press; Ernst, E., & White, A. R. (2012). Acupuncture: a critical analysis. Journal of Internal Medicine, 271(5), 446-463.; Cao, H. (2013).
Cupping therapy: an overview of systematic reviews. The Journal of Alternative and Complementary Medicine, 19(11), 911-913.). High-frequency TENS is believed to modulate pain signals through the gate control theory (Melzack, R., & Wall, P. D. (1965). Pain mechanisms: a new theory. Science, 150(3699), 971-979.), while low-frequency TENS and electroacupuncture have been proposed to stimulate the release of endogenous opioids and influence central pain processing pathways (Han, J. S. (2004). Acupuncture and endorphins. Neuroscience Le Wers, 361(1-3), 258-261.; Pomeranz, B. (1996). Acupuncture neurophysiology: basic research and clinical applications. In Acupuncture textbook and atlas (pp. 31-54). Springer, Berlin, Heidelberg.). Cupping therapy, a traditional practice, is thought to exert its effects through increased local circulation, reduction of myofascial tension, and modulation of the inflammatory response (Hou, W. H., Liao, C. C., Chen, S. L., Huang, Y. C., & Tseng, T. J. (2012). The effect of cupping therapy on carpal tunnel syndrome: a randomized controlled trial. The Journal of Alternative and Complementary Medicine, 18(11), 1021-1027.; Kim, J. I., Lee, M. S., Choi, T. Y., Kim, J. H., & Ernst, E. (2011). Cupping for pain relief: a systematic review and meta-analysis. BMC Complementary and Alternative Medicine, 11(1), 70.).
Despite the growing body of evidence supporting the individual use of these therapies for pain management, there is a relative paucity of research investigating the synergistic potential of their integrated application within a single treatment protocol. This article introduces a novel, integrative pain management protocol that combines the simultaneous application of high and low frequency TENS with concurrent electroacupuncture, followed by cupping therapy. The rationale for this unique combination lies in the potential to leverage the immediate analgesic effects of high-frequency TENS to facilitate the engagement of the longer-lasting neurochemical modulation induced by low-frequency TENS and electroacupuncture. Subsequently, cupping therapy is proposed to address underlying musculoskeletal factors and enhance local physiological processes that may contribute to sustained pain relief.
This theoretical framework posits that this multi-modal approach can address various aspects of the pain experience – from immediate sensory modulation to longer-term neurochemical and biomechanical influences. By synergistically targeting different pain mechanisms, this integrative protocol holds the potential to offer more comprehensive and sustained pain relief, enhance patient comfort, and potentially reduce the reliance on pharmacological interventions.

The aim of this paper is to present the theoretical underpinnings of this novel integrative pain management protocol, outlining the proposed mechanisms of action for each component and their potential synergistic interactions, thereby highlighting its potential as a valuable contribution to the field of integrative pain care and underscoring the critical need for future research to evaluate its clinical efficacy and safety.