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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1674

APPLICATION OF HIJAMA (CUPPING THERAPY) IN PAIN

MANAGEMENT: A REVIEW

M.M.M. Nifras*1 and M.N.F. Rizniya2

1

Demonstrator, 2Senior Lecturer,

Institute of Indigenous Medicine, University of Colombo, Rajagiriya, Srilanka.

ABSTRACT

Hijama (Cupping therapy) is an Unani regimental mode of treatment and an ancient method which was practiced by varies communities for thousands of years. It is practicing in Sri Lanka for more than 50 years. But the research on Hijama is very poor. Therefore this review was designed to give an overview on the concept of Hijama in the aspect of Unani System of Medicine and to analyze the effectiveness of Hijama in musculoskeletal pain with scientific evidences. Definitions and Descriptions on the Concept of Hijama mentioned in the Classical Unani texts and Explanations for Mechanism of pain relieving of Hijama from authentic books were collected, along with Clinical trials or the systematic reviews on effectiveness of Hijama for pain on journal articles from 2000 – 2017 were filtered for this review. This includes all research papers in English language available in internet. There are well established theories for cupping in Unani system of medicine. The mode of pain relieving through the cupping could be compare and explained with modern theories. Even though cupping has been used to relieve number of conditions more research were reported cupping on pain. In this review 51 research studies identified on the effectiveness of wet cupping including 38 clinical trials and 13 systemic reviews. Among the clinical trials 35 are RTCs and 2 case series and one case report. Most of the RTC s concluded with positive effect in reducing musculoskeletal pain with cupping. Among the musculoskeletal conditions most trials on Low back pain (n= 13), and neck pain (n= 10) and for cervical spondylosis (n= 4). The results revealed that there were well defined theories on Hijama in classical text books. Further scientific evidences demonstrate that pain can effectively relieve with cupping therapy in musculoskeletal conditions.

*Corresponding Author M.M.M. Nifras Demonstrator,Institute of Indigenous Medicine, University of Colombo, Rajagiriya, Srilanka. Article Received on 18 March 2021, Revised on 7 April 2021, Accepted on 27 April 2021, DOI: 10.20959/wjpps20215-18992

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1675 KEYWORDS: Hijama, Unani Medicine, Musculoskeletal pain.

INTRODUCTION

Pain is often a major symptom in many medical conditions and is one of the most sited reasons for seeking medical assistance. Therefore, Pain management is considered as a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. Persistent pain may be associated with morbidity such as physical disability, depression, anxiety, and sleep disturbance. When conventional or traditional treatments are ineffective or cause morbidity, patients either have to suffer in pain or seek alternative treatment.

The majority of patients suffering from pain due to various conditions use some form of CAM (Complementary & Alternative medicine). CAM refers to therapeutic approaches that are complementary to the end goals of decreasing illness and enhancing wellness, but are alternatives to conventional medical treatment. Many different CAM modalities are used to treat pain; amongst one such example is Hijama Therapy (Cupping Therapy).

Hijama, which literally means sucking (cupping), and includes wet and dry cupping. In traditional Arabic culture, Hijama refers to wet cupping, which is specifically encouraged by the Islamic prophet Muhammad. Strong evidence suggests that Hijama can be highly effective in the treatment of pain, particularly musculoskeletal pain and headaches. Hijama is also known to be useful for a wide range of symptomatic conditions. Several studies have revealed its potential efficacy for many conditions such as pains, infections, mental disorders, high blood pressure, heart diseases and a variety of circulatory diseases and skin diseases. It is also known to remove toxins, reduce low-density lipoprotein cholesterol levels, improve blood pressure, stimulate the nervous system, and modulate the immune system.

Despite the increasing popularity, scholars have conducted very little research on Hijama. Therefore this has been designed to review the scholarly works on Hijama and critically analyze the significance of pain relieving.

Objectives

1. To give an overview on the concept of Hijama therapy in the aspect of Unani System of Medicine.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1676 2. To analyze the effectiveness of Hijama therapy in musculoskeletal pain with scientific

evidences. METHODOLOGY 2.1 Searching

Ancient Unani texts such Al Qanun FilTibb, Al Qawi 1- 4 and Shara e Asbab were used to collect data on concept of Hijama therapy in the Definitions and Descriptions on the Concept of Hijama (Types, Sites, Indications & contraindications of Hijama). Explanations for Mechanism of pain relieving & Mode of action of Hijama in pain relieving from authentic books were collected, along with Clinical trials or the systematic reviews on effectiveness of Hijama for pain on journal articles from 2000 – 2017 were filtered for this review.

2.2 Resources Required

Books, Journals and Magazines in the library/ IIM, internet facility, Newspaper articles related to traditional medicine were used to get information on Hijama and the scientific study on Cupping.

2.3 Study designs

Clinical trials or randomized controlled trials (RCT) and non-randomized clinical trials done on Hijama therapy showing the pain relieving effect in various diseases on journal articles were filtered. The journal articles from 2000 – 2017 were considered for this review. Any description on concept of Hijama therapy mentioned in the ancient text were considered and summarized. Research report was finalized to better understanding of the effectiveness of Hijama therapy in various types of pain, Specially musculoskeletal pain.

Inclusion Criteria

Any type of clinical studies including randomized controlled trials (RCTs), clinical controlled trials (CCTs), case series (CSs), and case reports (CRs) identifying the therapeutic effect of cupping therapy for pain conditions, including wet and dry type of cupping methods were included. Combined therapy with Cupping and Cupping alone were also included. Cupping therapy for pain other than musculoskeletal conditions was excluded.

2.4 Data Analysis

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1677 RESULTS

3.1 Concepts of Hijama in the aspect of Unani System of Medicine. 3.1.1 Definition of Hijama

The word Hijama comes from the root Al-hajm. Manzur writes in Lisan-ul-Arab: “And the basic meaning of the Al-hajm is to suck”.[1] As such there is no definition of Hijama in Unani classical literature. Keeping in view it‟s all aspects, Hijama can be defined as, “Hijama is a Unani regimental mode of treatment which is carried out by application of cup shaped glass or plastic vessels on the body surface, creating vacuum by heat or by special suction apparatus in order to evacuate the morbid materials, to divert the material from the diseased part, to return a displaced organ to its natural position or to encourage the blood flow to the site of Hijama”.[2]

Contrary to this well-accepted concept, Ibn Abbas Majusi in his treatise, Kamilus Sena,[3] described Hijamah under Ilaj bil Yad (surgery). Besides Hijama is discussed in the classical surgical books, as surgical procedure, like Kitab-ul-Umdah fil-Jarahat[4] written by Ibn al Quf Masihi and Kitab-ul-Tasreef[5] written by Abul Qasim Zehravi.

3.1.2 Types of Hijama

Hijama can be broadly classified into 2 types,[6]

1. Hijama-bish-shart (Wet cupping/ Cupping with scarification) 2. Hijama-bila-shart (Dry cupping/ Cupping without scarification)

3.1.3 Hijama-bish-shart & its principal advantages

Ibn Sena writes in his treatise Al-Qanun fit Tib, Hijama-bish-shart has three advantages.[7] 1. Hijama results in Istafragh (evacuation of morbid material/ humors) from the particular

organ where Hijama is done.

2. Conservation of Jawhar e Rooh (essence of the pneuma) as the latter is not evacuated with akhlat (humors) which are being evacuated.

3. Hijama does not interfere with the Aa’zay e Ra’esa(vital organs), as there is no Istafrag (evacuation) from these organs which may cause weakness.

3.1.4 Sites and Indications of Hijama-bish-shart (Wet Cupping)

In this type of Hijama, beside the application of cups, a few incisions/ scarification are made at following sites.[6]

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1678 Table 1: Sites of Hijama bish shart according to their indications.

Site Indication

Hamah/Yafukh (mid of the head) Confusional states, vertigo, Diseases of eye.

Qamhadwah (occiput) Confusional states, vertigo, Diseases of eye.

Nuqra (nape) Conjunctivitis, Otalgia

Akhda’ain (lateral sides of neck) Head tremor, Diseases of face, eyes, ears, teeth,

throat and nose

Zaqan/Ziqan (chin) Diseases of face, throat, head, mandible and

maxilla

Al-Uznain (ears) Headache and heaviness of head

Kahil (interscapular region) Asthma, dyspnea , cough, diptheria, sore throat

and shoulder pain

Mankibain/Katifain (shoulders) Palpitation, Hepatalgia and other diseases of liver

Taht al Sadyain(In between breasts) Metorrhagea or menorrhagea

RusghulYadain(ventral aspect of forearms) Chronic scabies, Pruritis, Favus and Shiqaqfilyad (cracked palm)

Naghiz (superior boarder of shoulder blade) Hepatalgia, Hepatitis and Spleenitis

Warikain (buttocks) Haemorrhoids, Haematurea, Proctitis,

Dysfunctional uterine bleeding

Qatn(lumbar region) Carbuncle, Scabies, Furuncles, Gout,

Haemorrhoids, Filiaris, Pruritis

Us’us (coccyx) Haemorrhoids, Proctitis

Maq’ad (anus) Proctitis, Haemorrhoids, Scabies

Fakhzain(thighs) Orchitis, Metritis, Furunculosis, Amenorrhea,

Gout

Rukbah (knee) Swelling of arthritis of knee

Saqain (shank) Chronic renal and uterine colic, Amenorrhea,

Epilepsy, Sciatica

Urqubain (tendanocalcaneus) Chronic renal and uterine colic, Amenorrhea,

Epilepsy, Sciatica

Ka’bain (ankles) Amenorrhea, Sciatica and Gout

Batn wa Teht us Sirah(abdomen and below navel)

Carbuncles, Furunculosis, Haemorrhoids, Gout, Filariasis

3.1.5 Hijama-bila-shart and its types

It is the type of Hijama in which only cups are applied on the body surface without any scarification.[6]

It may be divided in following types:

1. Hijama-e-Ghair-Mutaharikah (Stationary cupping) 2. Hijama-e-Mutaharikah (Gliding or moving cupping)

3.1.6 Sites of Hijama-bila-shart (Dry Cupping) and their Indication

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1679 Table 2: Sites of Hijama bila shart according to their indications.

Site Indication

Na‟f (Umbilical region) Tenesmus, Abdominal colic, Menstrual disturbances, Dysmenorrhea and Dysfunctional uterine bleeding

Lower abdomen Inguinal hernia

Loin Renal obstruction and calculus

Site of liver Hepatic problems

Site of spleen Problem of spleen

Warikain (Buttocks/hip) Sciatica

In between warikain Piles, Hydrocele, Gout

Maq‟ad (Anus) Beneficial for intestine, menstrual disturbances and piles

Medial and dorsal

aspects of thigh

Sciatica

Uzun (Ears) Fistula

3.1.7 Contraindications of Hijama

Hijama should be avoided during following circumstances,[6] - During the beginning and the end of lunar month.

- In children below age of two years and in elderly persons after sixty years. - In extremely hot or cold weather.

- In persons having viscid blood and who are obese.

- In persons whose body has become flabby due to excessive dissolution. - In people who have thin build, are pallor and are weak.

- After strenuous exercise. - After coitus.

- After Hammam.

- After heavy meals for atleast two hours.

(According to Hakim Ali Geelani, “Eating of eggs before and after Hijama should be avoided as it can result in facial palsy”.)

- In pregnant women on the lower abdomen and chest particularly in first trimester. 3.2 Pain relieving and Hijama

Cupping therapy is one of the oldest documented medical techniques.[8] The practice, which involves suctioning the skin through a cupped instrument, has apparently been used since prehistoric times to treat diseases and disorders.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1680 Cupping Therapy is effective for blood disorders such as haemophilia and hypertension, pain relief, inflammatory conditions, mental and physical relaxation, varicose veins and deep tissue massage and quotes up to 50% improvement in fertility levels.9 Even though cupping has been used to relieve number of conditions several research were reported favorable effect of cupping on pain suppression.

When wet cupping is done at diseased parts, blood circulation increases at that site. So improving local temperature. Once the local temperature is maintained the spastic condition gets rectified and the stiffness goes away or comes down.

There are clear theories that explain mechanism of relieving pain through the cupping.

Mechanism of Action of Cupping Therapy 3.2.1 Pain gate theory

This theory states that there is a gate or channel to transfer pain signals from its actual place to the brain to feel the pain. There are gates and channels that transmit the pain in our body. And when we place the vacuum cup over this channels it produces pain which interfere with the actual pain which can‟t transmit in the same gate or channel and elimination of this pain occurs.

3.2.2 Prostaglandin theory

Prostaglandins are products of inflammation in our body and they transmit pain signals to the brain. By doing cupping therapy we take these products out from the body and this kills the pain.

3.2.3 Endorphins & Encephalins production theory

These are natural components released in out body and these components are called “endogenous please substances,” which reduce the pain and enhance the mode.

3.2.4 Increasing blood circulation theory

By increasing of the blood circulation by removing the inflammatory products and toxins out by cupping therapy which will reduce inflammation and pain.

3.2.5 Nitric oxide theory

This substance is very important substance release in the body from any trauma and released also during and after cupping therapy. The functions of nitric oxide are;

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1681 - Vasodilatation, Muscle relaxation, Anti- thrombotic, Decrease inflammation and Prevent stenosis of blood vessels.

3.2.6 The energy channel theory

There are 14 channels in the Chinese medicine which can be used and there are many points on each channel. Cupping therapy can be used to stimulate acupuncture points and give the same effect as acupuncture.

3.3 Musculoskeletal pain conditions & anatomical sites to which sucking cups can be applied

Following are the anatomical sites which are used to apply cups in below mentioned musculoskeletal pain conditions to excrete pain-causing substances, prostaglandins, inflammatory mediators and cytokines.[10]

Table 3: Anatomical sites where cups should be applied for musculoskeletal pain condition.

Diseases that can be treated with Al-hijama

Anatomical sites to which sucking cups (cups of Al-hijama) can be applied

Fibromyalgia and fibrositis • 1-55 • 49-120

Cups should be put at the painful sites (in the neck or back region).

Cups should be put at the surrounding muscles.

Knee osteoarthritis • 1-55

• 9-10-11-12-13

• 53 (for right knee) or 54 (for left knee)

Knee should be surrounded by putting 6-8 cups

Back pain • 1-55

Putting cup at sites of pain Simple arthralgia, arthritis and

musculoskeletal pain

• 1-55

• 9-10-11-12-13-49-120

Sucking cups should be put upon painful joints

Pain in general • Put cups on painful points

• Encircle painful points by cups Neck pain, shoulder

pain

• 1-55

• 20-21-40-41-42

Cups should be put at the painful sites (in the neck or shoulder).

Cups should be put at the surrounding muscles (secondary source of pain)

Persistent non-specific low back pain • 1-55

• 20-21-40-41-42

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1682 shoulder).

Cups should be put at the surrounding muscles (secondary source of pain)

Figure 1: Abdominal positions. Figure 2: Back positions.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1683 3.4 Review of the scientific evidences

Table 4: Scientific evidences of reviewed articles.

S. No Conditions Title Scientific Findings Reference

1. Lower back pain Cupping for treating

pain: A systematic review

Two RCTs suggested significant pain reduction for cupping in low back pain compared with usual care.

11

2. Lower back pain Cupping Therapy

(Al-Hijama): It's Impact on Persistent Non Specific Lower Back Pain & Client Disability

Cupping therapy is effective in relieving persistent nonspecific lower back pain and client disability.

12

3. Low back pain Effects of Hijama bish

shart in Wajauz Zahr (low back pain) & Associated disability.

The study revealed that the test procedure; Hijamat bish shart has the potential in reducing Wajauz Zahr, without any adverse effectts.

13

4. Low back pain Cupping therapy

versus interferential cupping therapy.

Cupping therapy & interferential cupping therapy in addition to traditional physical therapy can be effective treatment. 14

5. Low back pain (Non specific)

The effectiveness of wet cupping for non specific low back pain in Iran.

Traditional wet

cupping care delivered in primary care setting

was safe and

acceptable to patients with non specific low back pain.

15

6. Low back pain (Non specific) The effect of moving cupping therapy on non specific low back pain.

Being a sort of

economical and

effective method

moving cupping

therapy can alleviate or even cure NLBP.

16

7. Low back pain

(Persistent, Non specific)

Evaluation of wet cupping therapy for persistent non specific low back pain.

This pilot study may provide preliminary data on effectiveness and safety of wet cupping treatment for PNSLBP.

17

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1684 cupping therapy for

low back pain.

show that cupping therapy is promising for pain control &

improvement of

quality of life.

9. Low back pain A pilot study analyzing

the effects of Chinese cupping.

Chinese cupping may

be low risk,

therapeutic treatment

for the prompt

reduction of

symptoms associated with sub acute& chronic low back pain.

19

10. Low back pain (Non specific)

Therapeutic effect of

balance cupping

therapy on

Non-specific law back pain.

Balance cupping

therapy is one of effective treatment methods for non-specific law back pain. 20 11. Back pain (Wajauz Zahr) Evaluation of efficacy of wet cupping

(Hijamat bil shurt) in cases of Back pain (Wajauz Zahr).

Hijamat bil shurt is more effective in the management of back pain.

21

12. Low back pain (NSLBP) The use of wet

cupping for persistent NSLBP. Wet cupping is potentially effective in reducing pain improving disability associated with PNSLBP at least 2 weeks after the end of the wet cupping period.

22

13. Back pain Effect of cupping

therapy in treating chronic headache and chronic back pain.

The effect of cupping therapy for chronic headache and back pain has been studied and the results revealed significant improvements in participants as a result of cupping therapy. 23 14. Sciatica Therapeutic Effectiveness of Hijama in Sciatica Pain

Present study suggests that hijama has been found to be effective in relieving pain and improving quality of life in majority of the patient‟s.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1685

15. Sciatica Treatment of Sciatica

by HIJAMA

(Regimental Therapy- Cupping)

Results suggest that by using cupping

therapy (Wet

Cupping) compared to baseline, sciatic pain was decreased more efficiently.

25

16. Sciatica Effect of cupping

therapy in Gridhrasi (Sciatica)

Hence study

concluded that Sciatic pain can be managed with CT

26

17. Sciatica Pragmatic approach

towards the role of Hijama in Irqunnasa (Sciatica).

Hijama plays a vital

role in the

management of

Irqunnasa..

27

18. Shoulder pain The effect of

traditional wet cupping on shoulder pain and neck pain.

It can be stated that Wet Cupping Therapy

has potential

therapeutic effect in nonspecific neck and upper shoulder pain.

28

19. Chronic neck pain The effectiveness of

cupping on relieving Chronic neck & Shoulder pain. In conjunction with physiological effect the subjective experience o neck &shoulder pain is reduced in intensity. 29

20. Neck pain The Effect of

Traditional Cupping on Pain and Mechanical Thresholds in Patients with Chronic Nonspecific Neck Pain. A single application of traditional cupping might be an effective treatment for improving pain,

quality of life, and hyperalgesia in CNP.

30

21. Neck pain Mode of action of

cupping- Local

metabolism & pain thresholds in neck pain patients & healthy subjects

Baseline pain

thresholds were non significantly lower in back pain patients compared to healthy controls & slightly

increased after

cupping.

31

22. Neck pain Randomized

controlled pilot study: Pain intensity &

pressure pain

thresholds in patients with neck & low back

These results suggest that Gua Sha may be an effective treatment for patients with chronic neck and low back pain

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1686 pain.

23. Neck pain The influence of

traditional cupping on body image in patients

with chronic

nonspecific neck pain

Patients with CNP experienced apparent body image, with traditional cupping therapy appeared improve.

33

24. Chronic neck pain Cupping for chronic

nonspecific neck pain.

However significant increases were found for function & quality of life in patients with chronic nonspecific neck pain.

34

25. Neck pain The influence of a

series of five dry cupping.

A series of five dry cupping treatments appeared to be effective in relieving chronic nonspecific neck pain. 35

26. Neck pain Clinically meaningful

differences in pain, disability, & quality of life for chronic nonspecific neck pain.

The results support

assumption that

patient‟s perception of treatment benefits measured by VAS in these trials might be comparable to others

in conventional

therapies.

36

27. Neck pain The effect of

traditional wet cupping on shoulder pain and neck pain.

It can be stated that Wet CT has potential therapeutic effect in nonspecific neck and upper shoulder pain.

37

28. Cervical spondylosis Clinical observation on treatment of cervical

spondylosis with

combined acupuncture & cupping therapies

Combined

acupuncture & CT is a better therapy for cervical spondylosis

with a shorter

treatment course & low relapse rate.

38

29. Cervical spondylosis Electro acupuncture

combined with wet cupping therapy.

Combined

acupuncture & cupping therapies is a better therapy for cervical spondylosis

with a shorter

treatment course & low relapse rate.

39

30. Cervical spondylosis An updated review of the efficacy of cupping

Cupping therapy

combined with other

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1687

therapy TCM treatments was

significantly superior to other treatments alone in increasing the number of cured patients with herpes zoster, facial paralysis, acne, and cervical spondylosis 31. Cervical spondylosis (Wajaur Raqaba) Management of Wajaur Raqaba (Cervical spondylosis) by Hijama bish shart.

Considerable

improvement both in disease process and quality of life was achieved.

41

32. Frozen Shoulder Frozen Shoulder - a

case study

It demonstrates that cupping therapy may effective option in the treatment of frozen shoulder along with medicines.

42

33. Brachialgiaparestheticanocturna Brachialgia

paresthetica nocturna can be relieved by wet cupping.

This study suggests short term effects of a single wet cupping therapy.

43

34. Carpal Tunnel Syndrome Effects of traditional cupping therapy in patients with carpal tunnel syndrome.

Cupping of

segmentally related shoulder zone appears to alleviate the symptoms of carpal tunnel syndrome.

44

35. Carpal Tunnel Syndrome Cupping- An effective treatment for CTS

Results show that CTS patients given cupping treatment experienced a highly significant decrease in CTS pain and other symptoms.

45

36. Rheumatoid Arthritis Immuno modulatory

effects of bloodletting cupping therapy in

patients with

rheumatoid arthritis.

The improvement rate of clinical, laboratory, cellular & immunological parameters were significantly higher with combined therapy than conventional therapy 46 37. Arthritis (Wajaul mafasil) Clinical efficacy of Hijamat in Wajaul Mafasil.

At the end of the study , it was concluded that cupping is effective

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1688 therapy for the

patients of arthritis

38. Arthritis Unani concept and

management of Waja ul mafasil (Arthritis) with special reference to Hijama therapy

Hijama has proven beneficial in the

improvement of

various signs and symptoms of arthritis.

48

39. Osteo arthritis of Knee Therapeutic

application of al hijamah (cupping therapy) in osteoarthritis of the knee. It is concluded in this observational non comparison study that Al Hijamah may be used safely and effectively in the

management of

Osteoarthritis.

49

40. Knee osteoarthritis Cupping therapy for

treating knee

osteoarthritis.

Only weak evidence can support the

hypothesis that

cupping therapy can effectively improve the treatment efficacy & physical function in patients with Knee osteoarthritis.

50

41. Knee osteoarthritis Cupping therapy for

treating knee

osteoarthritis.

Only weak evidence can support the

hypothesis that

cupping therapy can effectively improve the treatment efficacy & physical function in patients with Knee osteoarthritis.

51

42. Anterior Knee pain An investigation into

the effect of cupping therapy as a treatment for anterior knee pain.

The efficacy of the treatment of cupping therapy of anterior knee pain, wellbeing& range of motion has been researched.

52

43. General Musculoskeletal Pain The use of

Hijama(WC) in

Alternative & Complementary

Medicine.

Strong evidences suggest that Hijama can be highly effective in the treatment of pain, particularly tension headache & musculoskeletal pain.

53

44. General Musculoskeletal Pain Clinical research evidence of cupping therapy in China.

Majority of studies show potential benefit on pain conditions,

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1689 herpes zoster & other

disease. 45. General Musculoskeletal Pain Hijama (cupping) : a

review of the evidence

Two of the review found some evidences of effectiveness for cupping and pain.

55

46. General Musculoskeletal Pain Is cupping an Effective Treatment?

The effectiveness of cupping has been demonstrated only as treatment for pain &

even for this

indication doubts remain.

56

47. General Musculoskeletal Pain Cupping therapy for acute & chronic pain management.

The review suggests a potential positive short term effect of CT on reducing pain intensity.

57

48. Musculo

skeletal pain, NSLBP, Neck pain, CTS, Brachialgia

Evaluation of wet cupping therapy.

There is a promising evidence in favour of use of wet cupping

therapy for musculoskeletal pain, specially NSLBP, neck pain, CTS, Brachialgia. 58

49. General Musculoskeletal Pain Effects of cupping therapy on Range of motion, pain threshold, muscle activity of Hamstring muscle.

Those findings of this study suggested that CT has as much positive effect on flexibility, pain threshold, and muscle contraction as passive stretching.

59

50. General Musculo-skeletal Pain The effect of wet cupping on quality of life of adult patients with chronic medical conditions

There are promising effects in pouring of using wet cupping for improving healthy related quality of life of patients with chronic conditions.

60

51. Fibromyalgia Efficacy of cupping

therapy in patients with fibromyalgia syndrome

Five cupping

treatments were more effective than usual care to improve pain & quality of line in

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1690 patients diagnosed

with fibromyalgia syndrome.

3.5 Findings of reviewed papers. 3.5.1 The nature of study.

The collected literatures were categorized according to the nature of study as Systemic reviews and Clinical trials. The results were tabulated as follows.

Figure 5: The nature of study of reviewed literatures. 3.5.2 Treatment methodology

The reviewed literatures of Clinical trials were identified according to the methodology used in trials as cupping alone and Cupping combined with other therapies and medications.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1691 3.5.3 Prevalence of reviewed studies according to musculoskeletal condition

The reviewed literatures were identified and categorized according to musculoskeletal conditions and the data was tabulated according to the prevalence of condition.

Figure 7: Prevalence of musculoskeletal condition identified in reviewed literatures of clinical trials.

3.5.4 Types of Clinical trial used among reviewed literatures

This review of the effectiveness of cupping for musculoskeletal pain conditions identified 38 relevant trials, including 35 RCTs and 2 CS and 1 CR.

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1692 3.5.5 Type of cupping used in clinical trials.

The reviewed literatures of clinical trials were categorized according to the type of cupping used.

Figure 09: Type of cupping used in clinical trials. DISCUSSION

Unani system of medicine is a traditional alternative system of health and health maintenance in Asia. It observed in Sri Lanka over 50 years. Humoural imbalance is a root cause for origin and development of illness in Unani system of medicine. The principles of treatment in Unani system of medicine are Ilaj bil Thadbeer, Ila jbil Ghiza, Ilaj bil Dawa and Ilaj bil Yad. Hijamah is an important part in Ila jbil Thadbeer.[54]

There are well established theories for cupping in Unani system of medicine it describes the types of cupping, dates of lunar month when cupping should be performed, mechanism of its effect on pain and contraindications. The mode of pain relieving through the cupping could be explained with Pain gate theory, Prostaglandin theory, Endorphins and encephalin production theory, Increasing blood circulation theory and Nitric Oxide theory.

The benefits of cupping are many; on a general, systemic level cupping improves the circulation of blood and lymph. It also regulates and improves the functioning of the autonomic nervous system. Locally, the most obvious benefit of cupping is relief of pain, relaxation and increased suppleness of stiff tendons and muscles. Cupping increases the cleansing flow of lymph, while removing congested blood from the muscles. If cupping is

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1693 applied to the joints, the blood flow to the joint is increased and there's an increased secretion of synovial fluid into the joint cavity.

Avicenna in his book “Al Qanoon Fil Tibb” has mentioned Hijama as a medical pillar to management of over 37 kinds of diseases.[62] Hijama (Cupping) has been used for the prevention and cure of a wide range of conditions, such as hematological disorders, rheumatic conditions, arthritis, sciatica, back pain migraine, tension headaches, and post-herpetic pain . It can be also used for anxiety, and other physical and mental conditions. The Unani system of medicine broadly describes the Hijama as Hijama-bish-shart (Wet cupping / Cupping with scarification) and Hijama-bila-shart (Dry cupping / cupping without scarification). Further the Indications and the sites of cupping according to indications and contraindications were explained in detail.

The Chinese cupping therapy describes as adjustment of skin blood flow, make changes in biomechanical properties of the skin, increase immediate pressure pain thresholds in some areas and adjust serum P substance and quickly reduce the inflammation.

The manipulation technique and clinical application of kinetic cupping, fifteen basic manipulations of moving cupping, and 10 protocols for clinical application have been recommended in Chinese cupping theory. By the recommendation of the anatomical sites for practicing wet cupping and the safety protocols for cupping Chinese government has promulgated the national standardization of cupping therapy.[63]

A systemic review conducted by Huijuan Cao et al, reviewed 550 studies about cupping among them 70 studies on musculoskeletal pain. In this review fifty one research studies identified on the effectiveness of wet cupping for selectively musculoskeletal problems including 38 clinical trials and 13 systemic reviews. Among the clinical trials 35 are RTCs and 2 case series and one case report. Most of the RTCs concluded with positive effect in reducing musculoskeletal pain with cupping. Among the musculoskeletal conditions Low back pain, and Neck pain and for Cervical spondylosis studies are more.

Although there is no treatment option available through medicine for sciatica, the only possible intervention which can cure the condition is surgery. However, Hijama was found to be very effective in 67 percent of the patients experiencing severe sciatic pain. This might be

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www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │ 1694 due to the improved blood circulation as a result of removal of congested blood, toxic materials and inflammatory extravasations present subcutaneously at the site of pain.

The review found wet cupping to be effective for treating musculoskeletal pain. However, there were several limitations to this review; for instance, it included trials that combined wet cupping with other types of therapies, such as acupuncture and other types of cupping. Also, it pooled all the results together regardless of study design.

CONCLUSION

Reviewing the literatures on Hijama (cupping) therapy revealed that there were well defined theories on Hijama in classical text books. Further scientific evidences demonstrate that pain can effectively relieve with cupping therapy in musculoskeletal conditions.

Cupping therapy needed proper scientific interpretation and well-designed research for worldwide recognition. This will improve the benefits of cupping therapy which shows valuable effect on numerous conditions that has not treated with other methods.

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