application of hijama (cupping therapy) in pain …

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Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences

APPLICATION OF HIJAMA (CUPPING THERAPY) IN PAIN

MANAGEMENT: A REVIEW

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

2

1Demonstrator,

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

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 10, Issue 5, 1674-1698 Review Article ISSN 2278 – 4357


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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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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

Summary was formulated after a thorough reading of all reading materials.


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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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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

In this type of Hijama, cups are applied at following sites without scarification.[6]


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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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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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- 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

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


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shoulder).

Cups should be put at the surrounding muscles (secondary

source of pain)

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

Figure 3: Head Positions. Figure 4: Upper and Lower limb positions.


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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

8. Low back pain Effectiveness of The research results 18


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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.

24


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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

32


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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

40


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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

47


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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,

54


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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

61


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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.

Figure 6: The methodology used in trials of reviewed literatures.


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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.

Figure 8: Type of clinical trial used in reviewed literatures.


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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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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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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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