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