Article ID: WMC004785 ISSN 2046-1690 The value of wet cupping as a therapy in modern medicine - An Islamic Perspective Peer review status: No Corresponding Author: Ms. Marzia Ahmedi, Medical Student, St Georges Medical School - United Kingdom Submitting Author: Mr. Muhammed R Siddiqui, Registrar, Mayday Hospital, 23 Malvern Road, TN24 8HX - United Kingdom Article ID: WMC004785 Article Type: Review articles Submitted on:12-Dec-2014, 03:55:13 PM GMT Published on: 15-Dec-2014, 01:18:51 PM GMT Article URL: http://www.webmedcentral.com/article_view/4785 Subject Categories:ALTERNATIVE MEDICINE Keywords:Cupping How to cite the article:Ahmedi M, Siddiqui MR. The value of wet cupping as a therapy in modern medicine - An Islamic Perspective. WebmedCentral ALTERNATIVE MEDICINE 2014;5(12):WMC004785 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None Competing Interests: None WebmedCentral > Review articles Page 1 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM The value of wet cupping as a therapy in modern medicine - An Islamic Perspective Author(s): Ahmedi M, Siddiqui MR Abstract cup is then placed faced down flat on the skin as the heat creates suction on the skin. Suction cupping uses a suction pump to pump the air out of the cup after it is applied to the skin (Bondok 2006b). Cupping is a tradittional concept thought to help in medical conditions and has become increasingly more According to the British cupping society (BCS) the popular in certain environments. We present a review procedure of wet cupping must be carried out under on cupping with its potential applications in modern aseptic conditions and patients give consent after they medicine with a focus on the Islamic perspective of are informed of benefits and risks associated with this technique. cupping. It could be considered as a minor surgery (Younis 2013). Dr. Ahmed Younis, Senior lecturer at Introduction St. George’s Hospital, and the president of BCS, in his interview, told me he uses the ‘3 by 3 by 3 rule’ to perform wet cupping. In using ‘3 by 3 rule’ Dr Younis Cupping has become increasingly available to the uses plastic cups with suction pumps. The treatment public in the recent years. “Cupping Therapy is an surface is cleaned first then a cup is placed on the ancient medical treatment that relies upon creating a surface of the skin and vacuum is created by suction local suction to mobilise blood flow in order to promote pump, which is maintained for 3 minutes. The cup is healing” (Younis 2012). It is still practiced in rural removed and minor incisions are made using a areas as it was practiced thousands of years ago, but cupping lancet making sure some distance is left recently has been acknowledged in the western between incisions and that the cuts are made in line society. The most interesting fact is that it was with skin contours. It must be stressed that the recommended by the prophet Muhammad (Peace and incisions are only superficial and not deep. A cup is blessings of God be upon him (PBUH)) many placed again on the incised region and suction applied, thousand years ago, however, the western countries this will remove superficial blood. Again this suction is were unaware of its effects until recently (Bondok left for three minutes and the cup is then removed 2006a). gently removing the blood with tissue. This procedure is repeated three times and the blood should be Procedure removed at the end of each three minute cycle. The site of treatment is then cleaned using an antiseptic spray or cream then a medical water-proof plaster is Cupping can be wet or dry. In dry cupping cups are placed over the treatment site. The patients are placed on intact skin and the aim is to simply remove instructed not to wash the treatment site for a blood and fluid from the site of inflammation to the minimum of 24 hours due to the risk of infection. All surface of the skin. waste material including cups are put into a clinical Wet cupping, also known as bloodletting, is when an waste bag and the cupping lancet in the clinical sharps incision of about 1.5 ml deep and 1.5ml wide is made bin (Younis 2013). with a special type of lancet on the region of the skin Technique where the cup is applied. The aim is to remove superficial blood that flows into the cup which is thought to be full of toxic chemicals (Bondok 2006b). Cupping can be classified according to the type of Cupping is performed by creating a vacuum in the cup suction: light cupping, medium cupping and strong placed on the skin by either applying a heated cup on cupping. In light cupping the negative pressure is the skin which consumes the air within it (fire cupping) weak and gentle so this type of suction can be used or by using a suction pump (suction cupping). In fire for children and the elderly. Medium cupping has a cupping the practitioner may use a cup made of glass, suction which is stronger than light cupping, medium metal or wood (bamboo). The cups are then heated by pressure is used. This is the most common type of burning alcohol-soaked cotton within the cups. The cupping pressure used. Strong cupping is the firmest WebmedCentral > Review articles Page 2 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM and is unsuitable for children and elderly. good evidence base to support cupping at the moment, Muslims believe in the healing effects of cupping and Cupping is then further classified into seven categories. will continue using this method. Cupping can be used These 7 types differ as follows: Moving cupping, prophylactically to prevent disease as well as a involves applying oil on the skin and gently moving the treatment (Bondok 2006d). cup; this is similar to some massaging techniques. According to the ‘Sunnah’ (The ways of the prophet) Needle cupping is the use of acupuncture with cupping. the best days to perform cupping are the 17th,19th and Here a needle is inserted and a cup is placed over it. 21st of the Islamic month which fall on a Monday, For Hot cupping dried mugwort (artemisia vulgaris) Tuesday and Thursday. Anas bin Malik ra (May God leaves or moxa is used and is heated either on the be pleased with them) stated: ‘the Prophet (PBUH) skin directly or via a needle. In Flash cupping the cups used the treatment of cupping on both sides of his are applied to a region on the skin and is almost blessed head and shoulders and generally this immediately removed this is repeated several times in treatment was done on the 17th, 19th and 21st of the succession. Bleeding cupping is also called wet Islamic lunar month.’ (Cited from Tirmidhi by simply cupping or full cupping. This involves scarification of hijama) the skin to extract blood. Herbal cupping is when an herbal tincture is applied to the cups before suction. Bloodletting Water cupping involves filling the cup with one third full with water then applying the cups on the skin (Al-Rubaye 2012; Bondok 2006c). Bloodletting is the process of removing blood from the Cupping in Islam body. Before the advancement of science, medical practitioners believed that bloodletting had a therapeutic effect on many diseases. Bloodletting can be done by puncturing a vein or by scarification and Al-hijamah is an Arabic word for cupping which is cupping glasses. derived from the word ‘hajm’ which means ‘to suck’ (Younis 2012). In the Muslim holy book, the Quran, it There are two main types of bloodletting, general and states: “And whatsoever the messenger gives you, local. General bloodletting is when blood is taken from take it. And whatsoever he forbids, abstain”... [Qur'an] a vein (Venesection / phlebotomy) or an artery This verse tells the Muslims that they should follow the (arteriotomy) using a lancet. Many people died from ways of the prophet and the prophet Mohammed this form of bloodletting because of their weakened (PBUH) recommended cupping and advised people to state. The typical amount drained was 16-30 ounces use it. Narrated Ibn ‘Abbas: (The Prophet (PBUH) within 24 hours. Patients were bled until they fainted said), "Healing is in three things: A gulp of honey, (Turk and Allen, 1983). In the eighteenth century, cupping, and branding with fire (cauterizing). But I general bloodletting was used mainly for fevers, forbid my followers to use (cauterization) branding with inflammation and hypertension (Turk and Allen, 1983). fire” (Sahih Al-Bukhari). He also said “The best Local bloodletting is using cupping therapy or leeching medicine with which you treat yourselves is cupping, (applying bloodsucking worms or leeches to a patient’s or it is one of the best of your medicines” or “the best skin). Leeches were found to draw out blood from a treatment you can use is cupping.” The prophet particular region of the body, and were recommended (PBUH) has mentioned cupping in approximately 28 for headaches and bruises (Bondok 2006e). holy instructions (ahadith). The most striking of all is Scarification “lancing” were other names for the fact that the sayings of the great prophet bloodletting which involved making criss-cross cuts on Mohammad (PBUH) who did not have any scientific the skin to allow blood to ooze out. This was aided by background and was illiterate are in complete placing a cup over the incised region of skin, process agreement with modern scientific data. of wet cupping (Bondok 2006e). Another quote from the sayings of the messenger of History of cupping Allah (PBUH) is: “The best treatment is cupping; it removes blood, lightens back and sharpens the eyesight”. The first thing some patients say after a wet cupping treatment is that they feel light. The prophet Cupping was a common practice in ancient times; it (PBUH) during his life practiced cupping and also was first found In Ebers Papyrus, an Egyptian papyrus, strongly advised cupping to his followers although in the nineteenth century. This was one of the oldest there may not be many research studies to provide a medical textbooks which was thought to be written WebmedCentral > Review articles Page 3 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM sometime during 1550 BC. In the book, bleeding from was a way of purifying the body of harmful cupping is described as removing foreign material substances. He would only perform cupping on the from the body. Moreover, evidence of cupping was back and when the full moon was high in the sky. This found on the tomb of Tutankhamon (King Tut). This art was because he believed that at that particular time was then passed on to the Greeks and Romans; the body fluid is increased greatly or it is very active. Hippocrates [460-377 BC] and Galen [131-200 AD]. Another famous Islamic physician is Al-Razi [865-925 During the time of Hippocrates the concept of body AD], he used Dry cupping for the treatment of humours was developed. It was thought that there apoplexy and on children suffering from smallpox were four main body humours, which were: blood, above the age of five months and below fourteen phlegm, yellow bile and black bile. Health was seen as years (Bondok 2006g). a balance of these four fluids. Bloodletting was China therefore a method to bring one of these humours In traditional Chinese medicine (TCM) cupping has back into balance. Hippocrates was very much in been one of the oldest non-drug therapies in ancient favour of using wet cupping for treatment of angina, china. Cupping was used along with acupuncture and menstrual and other illnesses. Hippocrates moxibustion. ‘Qi’ is the fundamental energy of life commented on the shapes of the cup. He advised that according to the Chinese medicine and it flows in the cups should have a small diameter, cone shaped everything. The nature of ‘qi’ is warm and flowing and be light in weight (Turk and Allen, 1983). hence a disease is thought to block the flow and Hippocrates also distinguished between dry and wet becomes congested. For this reason, amongst the cupping but preferred dry cupping as it was less Chinese, cupping is thought to balance the ‘qi’. The invasive and a safer technique (Turk and Allen, 1983). cups are applied along acupuncture points (‘meridians’) Galen perceived bloodletting as one of the most and the site of pain (Ford 2013). They used horns as important methods of treatment. The only way to cups and placed them along the meridians. Chinese keeping healthy, in his opinion, was to keep the body however used fire to create suction mainly as part of clean of excess waste and toxins. Therefore tradition. However, fire is rarely used now to create abnormalities that withheld waste products within your suction because of the smoke alarms in the west. body, such as constipation or lack of menstruation, More recently dry cupping is preferred to wet cupping were the main cause of imbalance and diseases. The as it is more convenient and easier to use. It also main principle of bloodletting was seen as a way of allows more people to learn and use the technique eliminating these waste products or toxins within the safely for those individuals who can do courses as blood or diverting the blood from one part of the body stand-alone without having to learn all of TCM and to another. Galen also believed that bloodletting was a also without the worry of burning . However TCM useful method to cooling patients down during a fever practitioners in China still use the traditional method (Bondok 2006f). using round glass cups and putting fire into them via Ibn Sina [980-1037 AD] paper. Both methods are effective and safe in the hands of an experienced practitioner (Ford 2013). Ab? ?Al? al-?usayn ibn ?Abd All?h ibn S?n? also known as Avicenna in the west or simply Ibn Sina was India and Africa an Islamic philosopher and scholar, physician, Initially animal horns were used commonly for cupping psychiatrist and poet. He wrote the book ‘The canon in India and Africa. They would place the wide end of of medicine’ which was used worldwide as a medical the horn on the skin and suction was produced by text book. In his book, Ibn Sina suggested the use of strongly sucking by the mouth from the narrow end of cupping at certain times during the day and times of the horn until a vacuum was achieved then they the year as advised by the beloved prophet placed their thumb over it to close it. Cups gradually Mohammed (PBUH). He explained that the main aim changed from animal horns to cups made from mud of cupping was to draw inflammation away from deep then bamboo then glass (Younis 2013). structures in the body to the surface to take away pain England and Europe and ‘humors’ from the affected area. Ibn Sina practiced both wet and dry cupping mainly Cupping, wet cupping in particular, was also used in prophylactically in traditional medicine. He disliked England in the 1800s as it was a popular therapy. The performing wet cupping on children below the age of famous medical journal ‘The Lancet’ was named after two years and the elderly above the age of 60 years, this practice (Ullah et al., 2007). the reason for which is unknown. Avicenna had the same view as many others of his time, that cupping WebmedCentral > Review articles Page 4 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM Efficacy of cupping value was less than 0.00001 so the results were not due to chance and were statistically significant. However in another study, in Finland, which There have been many studies that have given interviewed 15 cuppers. The cuppers opinions based evidence of the effectiveness of cupping in medical on experience, were that wet cupping was in effective health problems. For example, Ahmed et al., (2011) for ‘respiratory infections, diseases of the heart, discussed the effect of wet cupping on virulent cellulitis. gastrointestinal tract, kidneys and urinary tract’ as well A 38-year male was stung by a honeybee on the as fever and diabetes (Vaskelampi and Hanninen, ‘ventral surface of the right forearm’. He was treated 1982). However this is a limited study as only 15 with antimicrobials and an antibiotic (effective against cuppers where interviewed and the findings are based many types of bacteria); however, his symptoms did solely on opinion not actual clinical trials. not improve and actually got worse. Conversely, when In a study conducted by Lauche et al. (2012) it was wet cupping was used on the site of cellulitis his concluded that just a single cupping treatment symptoms improved remarkably. He had 2 further dramatically improved neck pain at rest, with cupping sessions, which removed about 13ml of blood movement and any bodily pain associated with it. It from the infected site, and was given ‘Augmentin (1g showed a significant reduction in pain ratings based BD-oral for 5 days)’. He fully recovered and the scars on the pain diaries. As we can see according to this from the wet cupping also healed completely within study cupping has a significant effect even after one four days. This young man, unfortunately, was stung session. Furthermore, in this study participants again by a honeybee 45 days later, this time on the indicated that cupping had an immediate effect and plantar surface of his right toe. Wet cupping was participants undertaking cupping treatment showed performed at the site of the sting immediately and after better physical functioning as well which indicates a that every 12 hours so that in total he had 3 sessions higher quality of life. The study was a pilot study of 50 of cupping however this time he did not take any other patients which were assigned to treatment group or medication. The cellulitis was resolved and he had no ‘waiting list’ control group. The control group did not complications. This study suggests that wet cupping receive any treatment and study group received one can be effective for treatment of virulent cellulitis session of cupping. This study is limited by the small secondary to honeybee sting however it is only a case sample size and there is also a selection bias as the report which is based on one individual therefore more volunteers that participated in the study had a high studies are encouraged to be done. Also, it is difficult expectation of treatment so it could be that only a to replicate the study and generalise it to the wider specific group was treated hence it may not represent population. the general population (Lauche et al., 2012). Cupping has also been used to restore appetite and Another study conducted by Farhadi et al. (2009) improve digestion, remove tendency to faint and compared the efficacy of wet-cupping on nonspecific promote menstrual flow (cited by Turk and Allen, low back pain in Iran. The experimental group 1983). received wet-cupping treatment whilst the control Cao et al. (2010) identified 50 diseases that cupping group received ‘usual care’ treatment which involved a has been used for in many different studies; these combination of medication (such as NSAIDS) and diseases may have been part of clinical studies, case specific exercises recommended by the doctor. Both series or case reports. It is unknown how many of the experimental and control group did show these diseases were based on clinical studies. The improvement but the individuals in the experimental top 20 of these diseases are listed examples of which group had statistically significant lower pain, pain are pain, herpes zoster virus, cough/ asthma, acne. 12 related disability and medication use than the patients out of 20 diseases were pain related for example low in the usual care treatment. This study failed to follow back pain, fibromyalgia, generalized pain (lumbar up the patients over a long period of time thus it can sprain), infection pain (herpes zoster) and neuralgia only be said that wet-cupping has a short clinical pain (sciatica and headache). Therefore the main benefit for nonspecific lower back pain and further reason cupping was used was to relieve the pain. investigations are needed to predict the long term Respiratory diseases were common, for example the benefits of wet-cupping. The use of wet cupping in common cold and asthma. Cao et al. (2010) Iranian culture is very common as it is an Islamic conducted a meta-analysis of 8 randomised controlled country thus there is a risk of a placebo effect, this trials which showed that wet cupping was better than limits the study. There was a possibility of a biased medication for patients with herpes zoster virus. The p assessment as the patients knew their group WebmedCentral > Review articles Page 5 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM assignment due to the nature of the treatment. 18-25 years old hence there was a limited age range as well as a small sample size. Kim et al. (2011) cited that the effects of wet cupping were better when given with conventional medicine for Currently the conventional treatment for rheumatoid the treatment of pain. However they also mentioned arthritis (RA) is analgesia, NSAIDS (non-steroidal that dry cupping was better in treating low back and anti-inflammatory drugs) and DMARDS (disease cancer pain than conventional medicine. modifying anti-rheumatic drug) such as methotrexate. These conventional medicines do not cure RA and Conventional treatment for carpal tunnel syndrome cannot prevent joint destruction (cited by Ahmed et al., (CTS) is typically a wrist splint, oral anti-inflammatory 2005). Findings from Ahmed et al. (2005) showed a agents, local injection of corticosteroids and if very reduction in CRP (C-reactive protein), RF (rheumatoid severe, then surgery. However all these treatments factor) and ESR (Erythrocyte sedimentation rate) in are not completely satisfactory and therefore patients who had the combined treatment. The Michalsen et al. (2009) conducted a study to see the reductions of inflammatory markers are usually the effects of wet-cupping on CTS. Findings showed first signs of improvement. This study suggests that cupping therapy did improve symptoms more than just combined treatment with wet cupping for treatment of a simple heat patch. The disability associated with the RA was much more effective than conventional pain was relieved and neck pain was also significantly treatment alone. However this study is limited as there reduced. These positive effects however were only for were only 50 patients so it would be difficult to the short term benefits of wet cupping as it was based generalise it to a wider population. on only one cupping session. In this study, the shoulder region was cupped due to its relation to the In another study conducted by Ahmadi et al. (2008) on median nerve. In severe CTS hardening of the migraine and tension headache, the severity of the subcutis and connective tissue alterations take place headache fell from a mean of 4.27 before cupping to in the shoulder region. However, in another study it 1.46 after treatment. 95% of subjects improved after was shown that the cupping of this same region did three sessions of cupping each with a two week not improve symptoms of CTS over a long term period interval. Cupping may be effective for chronic which was cited in the study conducted by Michalsen headache as it reduces the number of days with et al. (2009). These studies suggest wet cupping may headache, the use of medication and the severity of only be effective for short term period but further the headache. This was a pre-post research design of studies are needed to investigate this. One of the 70 patients aged between 12-76 years. This study is limitations of Michalsen et al. (2009) is that because of limited as it was conducted in Iran, a culture that is the small sample size the magnitude of effect may familiar with cupping, so the results may have been have been over estimated. biased as there might have been cultural or spiritual placebo influences (Ahmadi et al., 2008). Niasari et al. (2007) cited that cupping was effective for iron overloading disorders such as polycythaemia, Ullah et al. (2008) cites in their article that cupping has hemochromatosis and porphyria cutanea tarda. Also been seen to improve fertility problems by up to 50 %. cited was the fact that individuals who had had Although cupping has been effective for many prolonged repeated bloodletting was associated with a disorders, however, many of the studies conducted did reduction of cardiovascular events. In the study not have a protocol of study that was registered in conducted by Niasari et al. (2007) it was found that authoritative organisations such as the world Health wet cupping significantly reduced Low density Organisation International Clinical Trial Registration lipoproteins (LDL) and LDL to HDL (High density Platform (WHO ICTRP) (cited by Cao et al., 2012). In lipoproteins) ratio. Overall, however, wet cupping did addition, in the studies the duration and frequency of not affect total cholesterol, triglyceride and HDL cupping therapy was unclear which also needs to be cholesterol therefore any changes in the LDL to HDL addressed. Furthermore, further studies with higher ratio must be due to changes in LDL. This study also methodological quality, study design and lager sample showed that the main effect of cupping was within one should be performed to assess the effectiveness of week after treatment and the two weeks follow up did cupping (Cao et al., 2012). not show any significant changes in lipid levels. Wet There is not any therapeutic difference between wet cupping can be used to prevent complications of and dry cupping, the preference of each is mainly atherosclerosis. However, the patients used in the culture based for example as I mentioned earlier fire study were only male so the results cannot be cupping is not used in China because of the smoke generalised to the female population. Furthermore, alarms this is a modern day adaptation to an ancient there were a total of 47 patients between the age of WebmedCentral > Review articles Page 6 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM method. In addition, in Finland the practice of cupping understood today although it is unclear where along amongst cuppers was passed down families by word the pathway cupping may act and in what ways (cited of mouth, there was no formal training undertaken by by Al-Rubaye 2012). these individuals (Vaskelampi and Hanninen 1982). Another mechanism could be by ‘Counter irritation’ Due to these personal preferences, experience and which is the process of relieving pressure from deep lack of standardised teaching methods there is bound structures in the body by irritating the superficial skin to be variability in results and for this reason one must and transferring it to another structure. This idea is be cautious about the efficacy of them. similar to the Chinese balance of ‘qi’ however in this Mechanism of action case illness is assumed to be caused by increased pressure in a specific region hence to achieve health the pressure should be relieved (cited by Al-Rubaye 2012). There are many proposed theories and ideas on how cupping therapy works but there is not a definite The removal of superficial or the ‘bad blood’ will answer yet. detoxify it. In an individual with pathology there is a build-up of metal in the blood and abnormal Anecdotally cupping is beneficial through the effects of haemoglobin when seen under the microscope. A cortisol, which reduces stress, and dopamine which study by Bilal et al. (2011) showed that the acts on the reward pathway in the brain. The composition of blood taken intravenously is much mechanism is unclear but as cupping affects these different to that from cupping. In this study initially neurotransmitters it can only be assumed that pain is venous blood was taken then afterwards the person reduced in this way. There is also the release of was cupped and the blood taken from that. The blood endogenous opioids such as endorphins which gives from cupping had reduced white and red blood cells, euphoria so this may make you feel better. Conversely, haemoglobin, haematocrit, mean cell haemoglobin where along the pain pathways cupping works, concentration, platelet count, monocytes, granulocytes, whether it is lower down in the spinal cord or higher up cholesterol, LDL, HDL and triglycerides compared to in the limbic cortex, is still unknown so further venous blood. The volume of blood extracted both investigations are needed to identify this (cited by from cupping and venous blood were equal (5ml). Ahmed et al., 2005). These differences were statistically significant Moreover, as cupping blood has a different however the limitations of the study are that it had a composition of blood to venous blood (Bilal et al., 2011) small sample size of only 25 volunteers and that they there may be an effect on the haematological system. were only male thus cannot be generalised to the One idea could be that it regulates coagulation and female population (Bilal et al., 2011). anti-coagulation by reducing fibrinogen or as it Another idea that is proposed is cited by Ullah et al. reduces the haematocrit it is theorised that there is an (2007) is the ‘gate theory of pain’ which is when a increase in blood flow and oxygen to the organs sensory stimulation of the skin overwhelms the pain (Ahmadi et al., 2008). gates and reduces pain for a period of time as the Furthermore, there is an inflammation at the site of message coming from the pain is blocked by higher cupping as seen by the redness and bullae formation frequency of impulses and this leads to the closure of (Al-Rubaye 2012) this has led people assume that the pain gates. cupping may have an effect on the immune system. Another view that is rooted in the Chinese theory of One possible mechanism could be that due to this health and disease and patterns of imbalances local inflammation there are likely to be an increase in through more than 3000 years of observation which inflammatory markers such as TNF (Tumor necrotizing was their way of researching at that time is that factor) and interferon (Ahmadi et al., 2008). disease is caused by a blocked ‘qi’ (energy) and Common theory in the middle ages was based on cupping is thought to unblock this and balance it (Cited humoural pathology. This concept is based on the four by Tham et al., 2009). main humours of the body and the aim of bloodletting Some believe the build-up of toxins is the main reason by cupping is to bring one of these humours back in to for illness and so in the cupped region blood vessels balance. This is how the illness was seen in the are dilated by action of vasodilators such as ancient times when technology had not advanced. adenosine, noradrenaline and histamine which is This is a simplified theory which has been applied to known to increase the circulation of blood. This allows cupping; purely because a definite answer has not yet the elimination of toxins that are trapped in the tissues been proven. However, the pain pathways are better WebmedCentral > Review articles Page 7 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM thus makes the person feel better (Lauche et al., feet (Bondok 2006g). 2012). Loss of blood volume along with vasodilation Cups are applied to sites where there are muscles for increases the parasympathetic activity which gives you example buttocks, chest, abdomen and back (Cited by an overall relaxation of muscles which could be Al-Rubaye 2012). The site where the cups are applied associated with the after effects of cupping. Also, the differs depending on the nature of the disorder. For loss of blood is thought to increase the quality of the example for a headache and low back pain the best remaining blood hence getting an improvement of area to place the cups are between the two scapulars symptoms (Cited Vaskilampi and Hanninen 1982). opposite the T1-T3 scapular spine (Ahmadi et al., The reason that cupping works may be due to its 2008). Also the shoulder and neck region are effective physiological affect, as described above by either areas to be cupped against many diseases. However stimulating or relaxing the body by bleeding, or it may the most important cupping points are on the back on have a psychological effect as there is a close either side of the vertebral column about ‘one and a relationship with the therapist and the patient actually half finger lateral to the tips of the spine of the observes the disappearance of the illness (Vaskilampi vertebrae’. It is important to note that this area is and Hanninen, 1982). There may also be a social directly above the sympathetic ganglions which are factor involved in that individuals having cupping connected to their internal organs. It is thought that the performed have a sense of unity and may feel better cupping regions on the back mirror the internal organs as they see themselves part of a social group. and by cupping these regions any diseases in the Moreover, the therapist has a role of a talker or a internal organ can potentially be healed (Bondok listener this may also have a role in the healing 2006h). A specific area of skin is supplied by a defined process (Vaskilampi and Hanninen, 1982). sensory nerve root which is called a dermatome as there is a convergence of information in the spinal One of the controversial views amongst the literature cord from the dermatome and an internal organ, a is that cupping works entirely by a placebo effect specific area of skin represents pain from an internal (Ahmadi et al., 2008). However, Ahmadi et al., (2008) organ also known as referred pain. For this reason suggests two reasons in which it is not a placebo specific dermatomes can be cupped to improve effect. Firstly, that wet cupping therapy is an invasive symptoms of any pathology in the internal organs therapy; there is clearly a biological effect unlike most (Bondok 2006h). These views are the more modern placebos which are either a ‘sugar pill’ or ‘talk therapy’. views as opposed to Ibn Sina’s ideas however many But this may not necessarily be true as the same can positions that Ibn Sina had mentioned in his book are be said for acupuncture. Moreover, a study found that still practiced today. in more than 50 % of individuals with headache improved after the wet cupping treatment this would Side effects not have been true if it were a placebo effect (Ahmadi et al., 2008). This placebo argument will always remain until an actual mechanism is proven so it is According to the findings of the literature there have difficult to rule it out. not been many side effects associated with wet Main sites of cupping cupping. There was one case of panniculitis reported by a subject (cited by Yoo and Tusk 2004). Other side effects for wet cupping are an increased risk of infections Hepatitis B and C, HPV and HIV as in the Ibn Sina, an experienced cupper, had mentioned six ancient medicine one horn was used for many patients. main sites of cupping in his book “Kitab Al-Qanun” and Recent studies however showed that no infections what illnesses they were used for based on anecdotal were apparent when sterile methods were used evidence (Bondok 2006g). The first site is at the back (Farhadi et al., 2009). Cupping practice today is of the head, which is thought to be effective in healing commonly using sterile methods thus reducing the headaches and any disorders of the eyes. The second likelihood of unwanted side effects. position is in between the two shoulder blades for treatment of dyspnoea and asthma. The third site is at Farhadi et al. (2009) reported that the adverse effect the roots of the forearm which is for relieving pain in with wet cupping was fainting (vaso-vagal syncope) the arms. The next position is in between the kidneys but it was seen only in the younger patients. and the buttocks this is for any diseases of the Other general side effects are circular ecchymosis digestive system. The fifth position is on the flat of the lesions as cupping breaks the superficial blood hip indicated for urinary diseases. The final position is vessels in the papillary dermis (Yoo and Tusk 2004). on the calf muscle and this is for any problems of the WebmedCentral > Review articles Page 8 of 14 WMC004785 Downloaded from http://www.webmedcentral.com on 15-Dec-2014, 01:18:52 PM The immediate effects of cupping are ‘erythema, religious use are unlikely to care about doing studies swelling, bruising, bleeding and bullae formation’ due and are confident in their belief that the technique to the cutting of the skin for bloodletting. Some works. It may not become available on the NHS due to individuals had scars (6 %) whereas some had hyper lack of evidence-base medicine but anyone can try it pigmented lesions (4%). These effects were only short privately and if they find it beneficial this could term and completely healed within a maximum of 3 contribute to anecdotal evidence of efficacy. At least if weeks. Some individuals reported a slight discomfort practitioners had to belong to an organisation then a which was technique based rather than the effect of patient would have some confidence maybe in a cupping (Al-Rubaye 2012). practitioner providing a standard and safe treatment. Contraindications Conclusion Wet cupping is not recommended for all people or all The literature does show a promising future for ages. There are strict guidelines according to the cupping, however the lack of funding for further British cupping society (Younis 2013) and some investigations is a problem, and for this reason there contraindications. See table 1 below for have not been many studies. In my opinion cupping is contraindications. The therapist should not perform effective for a broad range of diseases as it is said by cupping if they do not have the knowledge about the the holy prophet (PBUH) “The best medicine with condition or ask the patients doctor for collaboration if which you treat yourselves is cupping”. Currently wet in doubt. Also wet cupping should not be performed if cupping or al-hijamah is performed in private clinics in it interferes witha patient’s medical treatment. the UK and many people have seen its benefits even when conventional medicine has failed to satisfy their Pros and Cons of Cupping health care needs. As it has a religious link people accept it more readily without question than conventional medicine but it does not mean that it Modern day medicine is evidence-based and for a does not work. At the moment it is not under the treatment to come under the National Health Service conditions that conventional medicine needs it to work (NHS) it has to have a sufficient amount of studies that for it to be accepted perhaps with more research more have proven its efficacy. Currently with cupping the people will accept it. However one can argue that as it lack of evidence is the reason it is not regulated. Wet has a religious link then it is more likely to have a cupping in particular requires only a weekend course placebo effect. Many CAM therapies have either tribal as a training to be able to practice. No specific or religious origins. The development and domination qualifications are required and anybody can practice it. of conventional medicine led to the suppression and NHS is there to safe guard people and is there to dismissal of these CAM type therapies. In my opinion, ensure a level of standard that is ‘safe’ for patients. Cupping should be used for areas in which Nevertheless, there are organisations like the BCS conventional medicine fails to treat; there should be an that have a code of ethics and strict guidelines that integrated approach. must be followed. BCS training course are for anybody One of the other reasons that there is a lacking of that has a health background for example health care incentive to evaluate and consider cupping efficacy professionals. In this way patients can be assured to and use within the NHS is money. If no one is willing some extent that they are in safe hands. to invest money to study this therapy then it will be In order to evaluate the efficacy of cupping the sham difficult to create a good evidence base. If there is no or control needs to be such that a ‘placebo’ effect is money incentive then maybe no money for studying unlikely. Since the cupping technique is distinctive it will be available. However with increasing costs In the makes it very difficult to create a valid sham. This NHS and the acceptance that there are many areas means that in a study those having a treatment would which conventional medicine cannot treat cupping may be aware of this. One problem with this is if a person become one of the therapies ‘allowed’ to slip in thinks they may get better this could in fact contribute through the back door! If one steps back from the to feeling better. Of the research that has been done evidence-based (which only NHS requires) and only short term improvement of symptoms have been experience its healing effects then that is enough for recorded. More studies need to be done to look at individuals, as it gives them the satisfaction they longer term benefits as well as finding a good sham require thus they will accept it with no need for control. However those that use cupping due to its figures. 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