APPLICATION OF HIJAMA (CUPPING THERAPY) IN PAIN …
Transcript of APPLICATION OF HIJAMA (CUPPING THERAPY) IN PAIN …
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1674
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1675
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1676
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1677
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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]
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1678
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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]
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1679
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1680
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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;
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1681
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
- 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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1682
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1683
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1684
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1685
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1686
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1687
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1688
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1689
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1690
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1691
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1692
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1693
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1694
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
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.
REFERENCE
1. Manzoor I. Lisan-ul-Arab, vol. 2. YNM: 790–1p.
2. Mohamed SH, et al. Al Hijamah (Cupping Therapy): A Brief Introduction with Modern
Perspective: STM Journals 2014.
3. Majusi AH. Kamil-us-Sena, vol 2. Lucknow: Matba Munshi Nawal Kishore. 1889; 503–
13, 521–2, 531–4p.
4. Masihi IQ. Kita-bul-Umda-fil- Jarahat, vol 1. New Delhi: CCRUM, Ministry of Health &
Family Welfare, Govt. of India, YNM: 194–200p.
5. Zehrawi AQ. Kitabut Tasreef. Lucknow: Nami Press Lucknow; 1908: 181–5p.
6. Mohamed SH, et al. Hijamah (cupping therapy): a noble method of treatment in Unani
medicine: Int. J.Res. Ayurveda Pharm., 2015; 6(02).
7. Ibn Sena Ibn. Al Qanoon Fil Tibb, Book I, Part IV New Delhi: Deptt of Islamic studies,
Jamia Hamdard, 1993; p 318-321
8. Kaptchuk T, et al. Consequences of cupping: J. Med., 1997; 336: 1109–1110.
9. Hennawy, M. Cupping Therapy and Infertility, 2004; 280: 1.
10. Mahmoud HS, et al. Anatomical sites for practicing wet cupping therapy (Al-Hijamah):
In light of Modern Medicine and prophetic medicine: Altern integ Med., 2013; 2: 138.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1695
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
11. Kim JI, Lee MS, Lee DH et al. Cupping for treating pain: a systematic review: Evidence
Based Complement Alternative Medicine, 2011; doi:10.1093/ecam/nep035.
12. Hanan SA, Eman SE. Cupping Therapy (Al-Hijama): It's Impact on Persistent Non
Specific Lower Back Pain & Client Disability: Life Science Journal, 2013; 10(4s).
13. Tarique M, Ansari AH, et al. Effects of Hijama bish shart in Wajauz Zahr (low back pain)
& Associated disability: Indian Journal of Traditional Knowledge, 2016; vol 15(1): 173-
176.
14. Abd El Rahim AA, Elkabalawy MA, et al. Cupping therapy versus interferential cupping
therapy on mechanical low back pain: International Journal of ChemTech Research, 2017.
15. Farhadi K, et al. The effectiveness of wet cupping for nonspecific low back pain in Iron:
A randomized control trial: Complementary therapies in medicine, 2009.
16. Yongfeng H. The effect of moving cupping therapy on nonspecific low back pain:
Chinese journal of rehabilitation medicine, 2006.
17. Kim JI, et al. Evaluation of wet cupping therapy for persistent nonspecific low back pain:
a randomized, waiting list controlled, open-label, parallel-group pilot trial: BioMed
Central, 2011.
18. Huang CY, et al. Effectiveness of cupping therapy for low back pain: a systematic review:
Acupmed, 2013.
19. Alycia M, et al. A pilot study analyzing the effects of Chinese cupping as an adjunct
treatment for patients with sub-acute low back pain on relieving pain, improving
ROM(improving function): The journal of alternative and complementary medicine,
2014.
20. Xin LB, et al. Therapeutic effect of balance cupping therapy on Non-specific law back
pain: Chinese journal of Rehabilitation theory & practice, 2008.
21. Ansari MS, et al. Evaluation of efficacy of wet cupping (Hijamat bil shurt) in cases of
Back pain (Wajauz Zahr): Hamdard Medicus, 2013.
22. Albedah A, et al. The use of wet cupping for persistent NSLBP: Randomized controlled
clinical trial: The journal of Alternative and complementary medicine, 2015.
23. Ahmed Abbas F, et al. Effect of cupping therapy in treating chronic headache and chronic
back pain: World Family Medicine Journal, 2010.
24. Bilal M, Khan RA. Therapeutic Effectiveness of Hijama in Sciatica Pain: Pharmacology
&Pharmacy, 2016; 7: 326-330.
25. Nawaz A, Iqbal A. Treatment of Sciatica by HIJAMA (Regimental Therapy- Cupping):
Journal of Pharmacy and Pharmaceutical Sciences, 2014; 2,(2).
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1696
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
26. Nandini D, Dudhamal T. Effect of cupping therapy in Gridhrasi (Sciatica): Indian Journal
of Ancient Medicine and Yoga, 2016.
27. Sheeraz M, et al. Pragmatic approach towards the role of Hijamat in Irqunnasa (Sciatica)
A review: IJCRR, 2014.
28. Arslan M, et al. The effect of traditional wet cupping on shoulder pain and neck pain: A
pilot study: Complementary Therapies in Clinical Practice, 2016; Volume 23: 30-33.
29. Chi LM, et al. The effectiveness of cupping on relieving Chronic neck & Shoulder pain. A
randomized controlled trial: Evidence-Based Complementary and Alternative Medicine,
2016; Volume 2016.
30. Roomy L, et al. The Effect of Traditional Cupping on Pain and Mechanical Thresholds in
Patients with Chronic Nonspecific Neck Pain: A Randomized Controlled Pilot Study:
Evidence Based Complementary & Alternative Medicine, 2012.
31. Emerich M, et al. Mode of action of cupping- Local metabolism & pain thresholds in
neck pain patients & healthy subjects: Complementary Therapies in Medicine, 2014; 22
(1): 148-158.
32. Lauche R. Randomized controlled pilot study: Pain intensity & pressure pain thresholds
in patients with neck & low back pain before & after traditional east asian „guasha
therapy‟: The American Journal of Chinese Medicine, 2012.
33. Lauche R. The influence of traditional cupping on body image in patients with chronic
nonspecific neck pain: Complementary Medicine Research, 2012.
34. Lauche R, Cramer H, et al. Cupping for chronic nonspecific neck pain: a 2 year follow
up: ForschKomplementmed, 2013.
35. Lauche R, et al. The influence of a series of five dry cupping treatments on pain &
mechanical thresholds in patients with chronic nonspecific neck pain- a randomized
controlled pilot study:BMC Complementary and Alternative, 2011; 11: 63.
36. Lauche R, et al. Clinically meaningful differences in pain, disability & quality of life for
chronic nonspecific neck pain- A randomized controlled trials of cupping therapy:
Complementary therapies in medicine, 2013.
37. Arslan M, et al. The effect of traditional wet cupping on shoulder pain and neck pain: A
pilot study: Complementary Therapies in Clinical Practice, 2016; , 23: 30-33.
38. Wen WX. Clinical observation on treatment of cervical spondylosis with combined
acupuncture & cupping therapies: Journal of Acupuncture &Tuina Science, 2007.
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1697
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
39. Wanx XM. Electro accupuncture combined with wet cupping therapy on 66 patients with
cervical spondylotic radiculopathy: Shanxi Journal of Traditional Chinese Medicine,
2004.
40. Cao H, et al. An updated review of the efficacy of cupping therapy: PLos One, 2012.
41. Tausif M, et al. Management of Wajaur Raqaba (Cervical spondylosis) by Hijama bish
shart (wet cupping) & Majoon e Azaraqi: A case study: Evidence Based Complementary
& Alternative Medicin,e 2016.
42. Laxmi A, et al. Frozen Shoulder - a case study: International Journal of Applied Ayurveda
Research, 2016.
43. Ludtke R, et al. Brachialgia paresthetica nocturna can be relieved by wet cupping –
results of a randomized pilot study: Complementary Therapies in Medicine, 2006; 14(4):
247-253.
44. Michalsen A, et al. Effects of traditional cupping therapy in patients with carpal tunnel
syndrome: a randomized controlled trial: J pain, 2009.
45. Roberts M. Cupping- An effective treatment for CTS: The journal of pain, 2009.
46. Ahmed SM, et al. Immunomodulatory effects of bloodletting cupping therapy in patients
with rheumatoid arthritis: The egyptician journal of immunology, 2005.
47. Anjum N, et al. Clinical efficacy of Hijamat (cupping) in WajaulMafasil (Arthritis):
Indian Journal of Traditional Knowledge, 2005; 4(4): 412-415.
48. Mohamed SH, et al. Unani concept and management of Waja ul mafasil (Arthritis) with
special reference to Hijama (cupping) therapy: Indo American journal of pharmaceutical
research, 2014.
49. Dar AK, et al. Therapeutic application of al hijamah (cupping therapy) in osteoarthritis of
the knee: International Journal of Research and Development in Pharmacy and Life
Sciences, 2015; 4,(3): 1540-1544.
50. Li JQ. Cupping therapy for treating knee osteoarthritis. A protocol for systematic review&
meta-analysis of randomized controlled trial: Complementary Therapies in Clinical
Practice, 2017.
51. Li JQ. Cupping therapy for treating knee osteoarthritis: The evidence from systematic
review &meta-analysis: Complementary Therapies in Clinical Practice, 2017.
52. Ullah K, et al. An investigation into the effect of Cupping Therapy as a treatment for
Anterior Knee Pain and its potential role in Health Promotion: The Internet Journal of
Alternative Medicine, 2007; 4(1).
www.wjpps.com │ Vol 10, Issue 5, 2021. │ ISO 9001:2015 Certified Journal │
1698
Nifras et, al. World Journal of Pharmacy and Pharmaceutical Sciences
53. MazharUddin SM, et al. The Use of Hijama (Wet Cupping) in Alternative and
Complementary Medicine: Efficacious or Perilous? Journal of Acupuncture and Meridian
Studies, 2016.
54. Cao H, et al. Clinical research evidence of cupping therapy in China: a systematic
literature review: BMC Complementary and Alternative Medicine, 2010; 10: 70.
55. Albedah A, et al. Hijama (cupping): a review of the evidence: Focus on Alternative and
Complementary Therapies, 2011; 16(1).
56. Lee MS, Kim JI, et al. Is cupping an Effective Treatment? An overview of systematic
Reviews: J Acupunct Meridian Stud., 2011; 4(1): 1−4.
57. Cao H, et al.Cupping therapy for acute & chronic pain management: a systematic review
of randomized clinical trials: Journal of Traditional Chinese Medical Sciences, 2014.
58. Al Bedah Abdullah MN, et al. Evalution of wet cupping theraphy systematic review of
randomized clinical trials: The Journal of Alternative and Complementary Medicine,
2016; 22(10).
59. Kim JE, et al. Effect of Cupping Therapy on Range of Motion, Pain Threshold, and
Muscle Activity of the Hamstring Muscle Compared to Passive Stretching: J Korean
SocPhys Med., 2017; 12(3): 23-32.
60. Al Jaouni SK, et al. The effect of wet cupping on quality of life of adult patients with
chronic medical conditions in making Abdul Aziz University Hospital: Saudi Med J.
2017; 38(1): 53–62.
61. Lauche R, et al. Efficacy of cupping therapy in patients with fibromyalgia syndrome – a
randomized placebo controlled trial: Scientific reports, 2016.
62. Verguei D, et al. Evaluation of the Effects of Traditional Cupping on the Biochemical,
Hematological and Immunological Factors of Human Venous Blood, 1981.
63. Chen B, et al. Alternative medicine: an update on cupping therapy: J Med., 2015; 108:
523–525.