Cupping Therapy (Hijama) in the ArabWorld

Tamer S. Aboushanab and Saud M. AlSanad

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Cupping Points Used by the Prophet Muhammad (PBUH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Wet Cupping (Wet Hijama) and the Lunar Month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Cupping Therapy Scientific Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Evidence Behind Cupping Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Cupping Therapy Claimed Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Histological Changes After Cupping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7How to Measure the Pressure Inside Cups? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Cupping Therapy Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Safety of Cupping Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9High-Quality Practice of Cupping Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Selecting Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Cupping Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13How to Perform Wet Cupping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Cupping Regulation in Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Bahrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Using Medical Simulation in Cupping Therapy Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

T. S. Aboushanab (*)MBBCh, Master of Child Health and Nutrition, Cairo, Egypte-mail: tamer.shaban@gmail.com

S. M. AlSanadComplementary and Alternative Medicine, College of Medicine, Imam Mohammad Ibn SaudIslamic University (IMSIU), Riyadh, Saudi Arabiae-mail: alsanads@gmail.com

© Springer Nature Switzerland AG 2020I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_176-1

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Cupping Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

AbstractCupping therapy (Hijama in Arabic) has been practiced for thousands of years inthe Arab World. Cupping has both a cultural and religious context which explainsits wide use, practice, and acceptance in Arab and Muslim countries. There issome evidence that suggests that cupping may be beneficial for the treatment ofpain-related diseases, such as herbes zoster, facial paralysis, and acne. There aremany types of cupping therapy such as wet, dry, flash, and massage cupping. Aclassification of cupping therapy types was developed and published as will bediscussed later. In spite of the wide safety profile of cupping, there are somereported adverse events related to cupping which can be classified into prevent-able and nonpreventable adverse events. Cupping is regulated in some Arabcountries such as the United Arab Emirates, Bahrain, and Saudi Arabia. Thereis a strong improvement in the regulation and practice of cupping therapy in theArab World. A quality model to select patient in cupping clinics is suggested.National standards for the safe use of cupping therapy equipment was developedand approved in Saudi Arabia. Using health simulation in cupping training wasalso developed and implemented in cupping therapy training in Saudi Arabia.There is a clear need for more quality well-designed large-scale clinical trials toevaluate efficacy, safety, and mechanism of action of cupping therapy.

KeywordsCupping therapy · Hijama · Arab world · Health · Prophetic medicine · Islamicmedicine

Introduction

Cupping therapy is a worldwide practice especially in the Middle East including theArab world (AlBedah et al. 2013).

Cupping or (Hijama in Arabic) is practiced by applying a cup on the selected skinpoint, and creating a sub-atmospheric pressure inside the cup either by heat or bysuction. Growing evidence suggests that wet cupping can be effective in certainconditions, especially musculoskeletal pain and migraines (Mehta and Dhapte 2015).

History

Cupping therapy was mentioned in the famous Egyptian Papyrus Ebers (1550 BC).Cupping (Hijama) was practiced by most civilizations. It was practiced and describedby Greek physicians such as Hippocrates and Galen. Unani medicine (Unani means

2 T. S. Aboushanab and S. M. AlSanad

Greek in Arabic) was an Islamic healing system based on Greek medicine theorieswhich included cupping as one of the main therapies (Qureshi et al. 2017).

Cupping is also one of the corner stones of Arab and Islamic medicine. Propheticmedicine is another term given to the health-related information from teachings, andsayings (hadiths) of the Prophet Muhammad (PBU H) (Qureshi et al. 2017). ImamAhmad recorded in his Musnad that the Prophet Muhammad (PBUH) said, “Verily,hijama (Cupping therapy) is among your best remedies.” Prophetic Medicine (Al -Tibb al-Nabawi) is one of the most famous Islamic books and was written by Ibn AlQayyim al Jawziyya. It mentioned Cupping therapy as a medical practice. Muham-mad Ibn Zakaryia Al-Razi (865–925) who was the first to differentiate smallpoxfrom measles, and was described as the father of pediatrics, benefited from Cuppingtherapy in his treatment of many diseases. Ibn Sina (Avicenna) (980–1037), theauthor of The Canon of Medicine book, reported: “Cupping can treat more than 30different diseases” (Shaban 2018).

Cupping Points Used by the Prophet Muhammad (PBUH)

These points are Cupping Points which were mentioned in the sayings of the ProphetMuhammad (PBUH) and used by cupping practitioners to treat him. These points arevery popular points to be used by cupping practitioners and also used in someclinical trials conducted in Arab World.

These points are:

A. Al-Kahil point: This is a point between the shoulders around the seventh cervicalvertebra.

B. Al-Akhdaain points: These are two points related to the right and left posteriorexternal jugular veins.

C. Yafookh point: This is located on the top and in the middle of the head.D. Kumohdwuah point: This is located at the base of the skull above the nape cavity.E. Werk point: It is located on the hip.F. Top of Foot Point: It is located on the top of the foot.

Figure 1 shows these points.

Wet Cupping (Wet Hijama) and the Lunar Month

Muslims and Arabs prefer to perform wet cupping in the second half of the lunarmonth, especially on the 17th, 19th, and 21st of every lunar month due to therecommendation of the Prophet Muhammad (PBUH). Recent research by Benliand Sunay (2017) reported significant and better results of wet cupping (wet hijama)as a treatment for migraine when performed in the second half of the lunar month.High quality and large-scale randomized clinical trials are needed to explore thisrelationship.

Cupping Therapy (Hijama) in the Arab World 3

Cupping Therapy Scientific Background

Evidence Behind Cupping Therapy

Because of the poor quality of published cupping therapy trials, the clinical evidenceof cupping therapy is still in need for more quality and large-scale trials. In asystematic review and meta-analysis by Cao et al. (2012) reported that cuppingtherapy appeared to be effective on the management of herpes zoster, facial paral-ysis, acne, and cervical spondylosis. While, Lee et al. (2010) reported that cuppingmay be effective only for reducing pain.

A systematic review conducted in 2016 reported the promising effectiveness ofwet cupping therapy (wet hijama) in management of nonspecific low back pain, neckpain, carpal tunnel syndrome, and brachialgia (Al Bedah et al. 2016a).

There is the need to conduct high-quality, large-scale, and well-designed ran-domized clinical trials to consolidate the evidence regarding the effectiveness ofcupping therapy.

Fig. 1 Cupping points used by the Prophet Muhammad (PBUH)

4 T. S. Aboushanab and S. M. AlSanad

Uses

Cupping therapy has many uses. It may be used either as a health promotionmodality or for the management of various diseases and conditions.

Cupping therapy may be used in the management of some conditions such as:

1. Nonspecific low back pain (Kim et al. 2011; AlBedah et al. 2015)2. Neck pain (Lauche et al. 2011; Cramer et al. 2011)3. Headache (Ahmed and Hssanien 2010)4. Knee osteoarthritis (Teut et al. 2012)5. Facial paralysis (Cao and Liu 2012)6. Brachialgia (Lüdtke et al. 2006)7. Carpal tunnel syndrome (Michalsen et al. 2009)8. Hypertension (Lee et al. 2010; Aleyeidi et al. 2015)9. Diabetes Mellitus (Vakilinia et al. 2016)

10. Rheumatoid arthritis (Ahmed et al. 2004)11. Asthma (Aboushanab et al. 2010; Al-Jawad et al. 2011)12. herpes zoster, acne, and cervical spondylosis (Cao et al. 2012)

Cupping therapy could be also used in the treatment of other pain relatedconditions, as an adjuvant therapy, and according to the patient’s condition anddoctor’s advice.

Mechanisms of Action

The mechanism of the action of cupping therapy has not been clear until now (Cao etal. 2012). The main proposed mechanisms of action include: effect of pressuresuction, promoting peripheral blood circulation and improving immunity (Zengand Jian-wei 2016).

The main theories that explain the mechanisms of action of cupping therapy are:release of nitric oxide theory, reflex zones theory, genetic theory, meridians systemtheory, and pain gate theory which are described in Fig. 2 (Shaban 2018).

Cupping Therapy Claimed Effects

Some of the reported cupping therapy effects are:

1. Promotion of the skin blood flow (Wei et al. 2013)2. Changing the skin biomechanical properties of rats (Norouzali et al. 2014)3. Increasing pain thresholds and producing anaerobe metabolism in the surrounded

areas (Emerich et al. 2014)

Cupping Therapy (Hijama) in the Arab World 5

Fig.2

Cup

ping

mechanism

ofactio

ntheories

6 T. S. Aboushanab and S. M. AlSanad

4. Reducing inflammation (Lin et al. 2014)5. Modulating the cellular part of immune system (Khalil et al. 2013)6. Reducing pain (Lauche et al. 2011)

Histological Changes After Cupping

Skin is the basic and outer covering layer of the human body.Skin is composed of three layers:

1. Epidermis: There are no blood vessels in this layer. It is about 1 mm in thickness.2. Dermis: it is the thickest skin layer. It is about 1.5–4 mm in thickness.3. Hypodermis: It contains subcutaneous fat and connective tissue.

Interestingly, Al-Rubaye (2012) reported that the histological changes followingwet cupping were: mild edema and longitudinal fissure as a result of cutting in theepidermis. In the dermis, histological changes were dermal edema and bleeding inthe upper and lower parts of the dermis. No cellular infiltration was noted.

Figure 3 shows the reported skin changes after cupping.

How to Measure the Pressure Inside Cups?

Pressure inside the cup can be measured by Boyle’s law according to Tham et al.(2006) which can be stated as:

P1V1 = P2V2 (P1 = Pressure before suction, V1 = Volume before suction,P2 = Pressure after suction, V2 = Volume after suction).

Furthermore, Tham et al. (2006) showed that when the cup volume was 80 ml,and the pump chamber was 41.5 ml with efficiency 60–65%. One suction =141 mbar, Two suctions = 254 mbar.

Cupping Therapy Types

A new classification of cupping therapy types was published by (Aboushanab andAlSanad 2018a). Cupping therapy types can be classified into five main categories.The first category is the technical type which includes dry, wet, massage, and flashcupping therapy. The second category is the power of suction-related type whichincludes: light, medium, strong, and pulsatile cupping therapy. The third category isthe method of suction-related type which includes: fire, manual suction, and auto-matic suction cupping therapy. The fourth category is the “Added therapy-relatedtype” which includes: Needle, moxa, herbal, magnetic, laser, electrical stimulation,water, and aquatic cupping therapy. The fifth category is the condition and area

Cupping Therapy (Hijama) in the Arab World 7

treated-related type which includes: cosmetic cupping, sports cupping, pedi cupping,facial, abdominal, female, and male cupping therapy (Aboushanab and AlSanad2018a).

Figure 4 shows the classification of cupping therapy types. While Table 1(Aboushanab and AlSanad 2018a) shows the classification and the definition ofeach type of cupping therapy.

Safety of Cupping Therapy

In spite of the wide safety profile of cupping, it has its clinical contraindications,precautions, and adverse events. Cupping is contraindicated to be performed directlyon blood vessels, lymph nodes, nerves, any skin lesion, fractures, wounds, and bodyorifices. Cupping is also contraindicated for many diseases such as hemophilia andsimilar bleeding disorders, severe diseases, emergency conditions, organ failure,using anticoagulant, anemic, and cancer patients. More studies and research areneeded to evaluate its safety. Special precautions should be undertaken in variousconditions such as diabetic patients, the elderly, patients who receive glucocorti-coids, and patient with skin grafts (Shaban 2018).

Fig. 3 Skin changes after cupping therapy

8 T. S. Aboushanab and S. M. AlSanad

Adverse Events

The majority of adverse events (AEs) related to cupping therapy were mild tomoderate in severity and reporting of them was infrequent. (Kim et al. 2013). Scarformation followed by burns (fire cupping) were the most frequently observed AEs.While, other AEs such as headache, local or whole-body itching, tiredness, dizzi-ness, anemia, bullae formation, abscess formation, skin infection, and vasovagalattack were less frequently observed (Al Bedah et al. 2016b). A new classification ofcupping therapy adverse events was published which classified AEs into preventableand nonpreventable as mentioned in Table 2 (Aboushanab and AlSanad 2018a).

Possible causes underlying preventable adverse events of cupping therapy were:

1. When performed by unqualified therapists.2. Ignoring infection control measures.3. Prolonged application of cups.4. Ignoring safety protocols.

Technical types

Dry cupping

Flash cupping

Wet cupping

Massage cupping

The power of suction related types

light cupping

Medium cupping

Strong cupping

Pulsatile cupping

Method of

suction related types

Fire cupping

Manual suction cupping

Automatic suction cupping

Added therapy related types

Needle Cupping

Moxa cupping

Herbal cupping

Magnetic cupping

laser cuppingElectrical

stimulation cupping

water cupping

Aquatic Cupping

Condition and Area treated related types

Cosmetic Cupping

Sports Cupping

Pedi cupping

Abdominal Cupping

Facial Cupping

Female cupping

Male cupping

Fig. 4 A classification of cupping therapy types

Cupping Therapy (Hijama) in the Arab World 9

Table 1 Definitions of cupping therapy types

N Cupping type Definition

1 Dry cupping Clinical types A static type of cupping therapy. Cups are appliedon selected skin points for up to 15 min

2 Wet cupping A static type of cupping. Superficial scarifications ofthe skin are performed either by surgical blade or byneedle before applying cups to collect blood

3 Massagecupping

A dynamic type of cupping therapy. Massagecupping is performed by applying selected oil to thetreatment area and applying a suitable cup by a mildto moderate suction, then, the practitioner shouldmove the cup along the treatment area

4 Flash cupping A dynamic type of cupping therapy. Several mediumto light pressure cupping are performed in a quicksuccession along the treatment area for stimulation

5 Light cupping Power ofsuction

When applying a light suction. The pressure shouldbe less than 300 mbar when the cup volume was80 ml, and the pump chamber was 41.5 ml withefficiency 60–65%

6 Mediumcupping

When applying a moderate suction. The pressureshould be between 300 and 500 mbar when the cupvolume was 80 ml, and the pump chamber was41.5 ml with efficiency 60–65%

7 Strong cupping When applying a strong suction. The pressure ismore than 500 mbar when the cup volume was80 ml, and the pump chamber was 41.5 ml withefficiency 60–65%

8 Pulsatilecupping

A continuous changing pressure is applied byspecial device

9 Fire cupping Suction method When fire is used as a method of suction

10 Manual suctioncupping

When manual suction pump, or self-suction cups areused

11 Automaticcupping

When automatic cupping devices or electricalsuction pumps are used

12 Needle cupping Added therapytypes

Acupuncture is performed then cups are appliedover the needles

13 Moxa cupping Moxa is applied first, then the cups are applied overit

14 Herbal cupping Bamboo cups are usually used. Cups are boiled in asuitable herbal tincture then applied to the skin

15 Magneticcupping

The use of magnetic probes inside the cups

16 Laser cupping The use of laser probe inside the cup

17 Electricalstimulationcupping

The cups are attached to electrical stimulationdevice. The patient receives cupping and electricalstimulation in the same time

18 Water cupping The use of warm water inside the cup

19 Aquaticcupping

Cupping is performed under water. It is acombination of aquatic therapy and cupping therapy

(continued)

10 T. S. Aboushanab and S. M. AlSanad

High-Quality Practice of Cupping Therapy

Although there are many traditional healers practicing cupping in the Arab World,there is also a high-quality standards and practice which will be the focus of this part.

Selecting Patients

Aboushanab and Alsanad suggested a quality model and created a tool to helppractitioners in selecting patients in cupping clinics. These tools were the firstversion of quality model to select patients in cupping clinics (QMSPCC-1). Theaim was enhancing and ensuring more patient safety by using QMSPCC-1. Usingthe suggested checklist tool for each patient will ensure that the clinical evaluation

Table 1 (continued)

N Cupping type Definition

20 Cosmeticcupping

Condition andarea treatedtypes

The use of cupping therapy for beauty purposes

21 Sports cupping The use of cupping therapy for the improvement ofathletes’ performance and rehabilitation

22 Pedi cupping The use of various types of cupping on foot

23 Facial cupping The use of cupping on face for beauty or therapeuticreasons

24 Abdominalcupping

The use of cupping on abdominal area for thetreatment of obesity, reducing cellulite, or treatingdigestive diseases

25 Femalecupping

The use of special cupping device for the breastenhancement

26 Male cupping The use of special cupping device (self-use) forsupport and enhancement of erection

Table 2 Preventable and nonpreventable cupping adverse events

Preventable cupping adverse event Non-preventable cupping adverse event

Scar formation Koebner phenomenon

Burn Headaches

Bullae formation Dizziness

Abscess and skin infection Tiredness

Pruritus Vasovagal attack

Anaemia Nausea

Panniculitis Insomnia

Cupping Therapy (Hijama) in the Arab World 11

and examination of each patient is complete. It can be also a method for supervisingand quality assurance of the work inside cupping clinics. The flow chart of the modelis shown in Fig. 5 and the checklist tool is shown in Fig. 6 (Aboushanab andAlSanad 2018b).

Fig. 5 Selection process flow chart (QMSPCC-1)

12 T. S. Aboushanab and S. M. AlSanad

Cupping can be performed if:

1. There are no contraindications to perform cupping.2. The vital signs are normal.3. There is a clear diagnosis of the patient’s condition.4. There are clear benefits of performing cupping in comparison with risks.5. The patient has signed the informed consent.

Cupping Session

The most common method of cupping used in Arab countries is the three stepscupping method. In the three-steps cupping therapy (Arab wet cupping), cups areapplied as a first step then removed, scarification is done as a second step then thecups are applied again as a third step. While in two steps cupping method (Asiancupping), the scarification is performed as a first step, and the cups are applied as asecond and final step. Table 3 shows a comparison between two-steps and three-steps cupping method (Shaban 2018; Khalil et al. 2018).

Fig. 6 Checklist tool (QMSPCC-1)

Cupping Therapy (Hijama) in the Arab World 13

How to Perform Wet Cupping

Following the infection control guidelines is an essential step for performing cup-ping therapy for the safety of patients. Skin disinfection is very important beforecupping. Cups should be applied on selected body areas either by pump or by fire. Inwet cupping therapy (Arab wet cupping), cups are applied as a first step, scarificationis done then the cups applied again. Skin scarification is a vital step of wet cuppingtherapy. The scarification should be superficial to facilitate healing process and toprevent possible adverse events related to cupping. The scarification should belongitudinal from above downward. The treated skin area should be cleaned bysterilized gauze. The cupped area should be disinfected again by approved skindisinfection solution. Sterilized wound dressings should be applied for 48 hours.

Follow up for these patients is very important (Aboushanab and AlSanad 2018a,b; Shaban 2018).

Figure 7 shows the steps of the wet cupping therapy technique.

Cupping Regulation in Arab World

Cupping, especially wet cupping is a widely used therapy in the Arab world but theindigenous healers are the main cupping providers which is a real challenge in manyArab countries.

There are some Arab countries beginning to face this challenge by regulatingcupping therapy practice. Cupping is regulated in some Arab countries such as SaudiArabia, United Arab Emirates, and Bahrain.

Bahrain

In Bahrain, a cupping therapy practitioner should have a bachelor’s degree in thecomplementary and alternative medicine field while a cupping therapy technicianshould have a diploma in one of the auxiliary medical professions. Both categories

Table 3 Comparison between two steps and three steps (Arabic) cupping

Two steps wet cupping Three steps wet cupping

Duration 10–15 min 5 min before scarification and 5 minafter scarification

Tools used Seven stars needle and auto-lancingdevices used more commonly thansurgical blades

Surgical blades are used morecommonly than auto-lancing devicesor seven stars needle

Culture andplace ofpractice

More commonly used in east Asiancultures like China and Korea

More commonly used in Arabiccountries

Number ofsteps

Two (scarification – applying cups) Three (applying cups – scarification –applying cups again)

14 T. S. Aboushanab and S. M. AlSanad

Fig. 7 Steps of the wet cupping therapy technique

Cupping Therapy (Hijama) in the Arab World 15

are required to attend a short practical cupping course. There were 41 licensedpractitioners by May 2019 (NHRA 2019).

Saudi Arabia

In Saudi Arabia, cupping was regulated by the National Center for Complementaryand Alternative Medicine (NCCAM) which is a part of the Ministry of Health.Currently, the only health care professionals who are permitted to have a license topractice cupping are physicians, physiotherapists, nurses and practitioners withacademic degrees in the complementary and alternative medicine field. A supposedexpansion of this regulation to include all health care professional personnel areplanned. Attending a short practical cupping course, passing all NCCAM requiredexams, and submitting free of infection certificate are essential requirements of allcupping practitioners in Saudi Arabia. Licensed cupping practitioners should onlypractice in licensed cupping clinics and use only the cupping equipment approved bythe Saudi Food and Drug Authority (SFDA). There are more than 160 licensedcupping practitioners. (Khalil et al. 2018; World Health Organization 2019).

There are 68 licensed cupping clinics in Saudi Arabia. Figure 8 represents thedistribution of these clinics across Saudi Arabia. The highest number is in Riyadh,then Jeddah, and Makkah, followed by Medina (Aboushanab et al. 2019).

22

8 86

43 2 2 2 2 2 2 1 1 1 1 1

0

5

10

15

20

25

Number of clinics

Licensed cupping clinics in Saudi Arabia

Riyadh Jeddah Mekka Medina

Dammam Taif Khober Ihsaa

Hafr Elbaten Jazan Burayeda Khamis Musheed

Kharj Ynboaa Abha Unayeza

Najran

Fig. 8 The distribution of these clinics across Saudi Arabia

16 T. S. Aboushanab and S. M. AlSanad

Using Medical Simulation in Cupping Therapy Training

Nowadays, simulation is considered a chief part of any clinical medical training. Inthe Arab world, Saudi Arabia was the first to introduce and use simulation in cuppingtherapy training. Using artificial skin for cupping training is a safe method forprolonged clinical cupping training hours especially for wet cupping therapy. Duringsimulation training, cupping trainees acquire various essential steps such as: usingsurgical blades and doing skin scarifications, using vacuum pump and applyingvarious suction degrees, and performing several types of cupping therapy.

A suggested questionnaire was developed to evaluate the cupping simulationtraining method (Aboushanab et al. 2018).

Figure 9 shows the cupping simulation model.

Cupping Standardization

Standardization of cupping therapy is an essential step to protect patients and clientsfrom any adverse events related to cupping. The Saudi Food and Drug Authority(SFDA) collaborated with the NCCAM to prepare standards for cupping therapyequipment. The standards were approved and accredited by SFDA with identifica-tion code “SFDA.MD 001:2017” and the title was “Safe Use and Handling ofCupping Devices and Their Applications.” These standards set the minimum ade-quate requirements for the safety of cupping equipment and practice (Aboushanaband AlSanad 2018c).

Fig. 9 Cupping simulation model

Cupping Therapy (Hijama) in the Arab World 17

Conclusions

Cupping therapy is practiced worldwide and, in particular, in the Arab world forthousands of years. Cupping has both a cultural and religious context which explainsits great importance, wide practice, and acceptance in Arab countries. The mechanism ofaction of cupping therapy has not been fully understood until now, but there are manytheories to explain it. Cupping may be beneficial for pain-related diseases, Herbes zoster,facial paralysis, and acne. There are 26 types of cupping which can be classified into fivecategories. Cupping is a relatively safe practice but there are some reported adverseevents related to cupping which can be classified into preventable and nonpreventableadverse events. The regulation and practice of cupping therapy has made good progressin some countries in Arab world. A quality model to select patients in cupping clinics issuggested. Cupping therapy standards for safe use of cupping equipment was developedand approved in Saudi Arabia. Using simulation in cupping training was developed andimplemented in cupping therapy training in Saudi Arabia. There is a clear need for morequality well-designed large-scale clinical trials to evaluate efficacy, safety, and mecha-nism of action of cupping therapy.

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