Journal of Complementary and Alternative Medical Research

4(3): 1-13, 2017; Article no.JOCAMR.39269 ISSN: 2456-6276

Cupping Therapy (Al-Hijamah) Points: A Powerful Standardization Tool for Cupping Procedures?

Naseem Akhtar Qureshi1*, Osama A. Alkhamees2 and Saud M. Alsanad2

1Ministry of Health, Riyadh, Saudi Arabia. 2College of , Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.

Authors’ contributions

This work was carried out in collaboration between all authors. Authors NAQ, OAA and SMA designed the study and wrote the protocol. Author NAQ wrote the first draft of the manuscript. Authors OAA and SMA managed the analyses of the study. Authors NAQ and SMA managed the literature searches. Author NAQ revised the paper a number of times before and after submission. All authors read and approved the final manuscript.

Article Information

DOI: 10.9734/JOCAMR/2017/39269 Editor(s): (1) Sachin Kumar Jain, College of Pharmacy, IPS Academy, India. Reviewers: (1) Pedro Gomez Piqueras, University Castilla La Mancha, Spain. (2) Vinay Jagga, Rehabilitation College, India. (3) Izharul Hasan, India. Complete Peer review History: http://www.sciencedomain.org/review-history/22944

Received 8th January 2018 th Review Article Accepted 30 January 2018 Published 1st February 2018

ABSTRACT

Background: Cupping (Al-Hijamah) therapy is a traditional complementary and practice used in diverse diseases with the variable outcome since ancient times. The precise selection of cupping points is a core component of techniques and one of the important determinant factors concerning the outcome of a disease and safety of the patient. Objective: The aim of this narrative overview is to critically describe various cupping points and their tentative selection criteria that help cupping practitioners in applying cups accurately on the afflicted surface. Methods: Electronic searches of certain databases and scientific publishing websites were made using Boolean Operators and keywords, and based on exclusion/inclusion criteria and consensus 40 full pertinent English articles of the last five years (2013-2017) were included by two independent reviewers.

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*Corresponding author: E-mail: [email protected];

Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269

Results: The theme of cupping points is complex controversial and often puzzling, and connected to a variety of determining tentative criteria and factors and have their prime roots in Prophetic Islamic medicine and , Traditional Chinese medicine (TCM) and Modern medicine. Conclusion: The cupping (Al-Hijamah) therapy techniques with precise selection of cupping points on the afflicted skin surface (i.e., sites of pain) tend to produce good therapeutic response without any major adverse events in patients with specific diseases. This study calls for further research in order to uniformly define and classify cupping therapy points concerning individual specific diseases, prevention of diseases and promotion of health at global level.

Keywords: Al-Hijamah; cupping therapy; cupping points; ; Chinese traditional medicine; modern medicine; adverse events.

1. INTRODUCTION crusted lesions, lipoma, keloid scar (local events), and headaches, Cupping therapy (Al-Hijamah) is a traditional dizziness, tiredness, including iron practice used in diverse diseases since ancient deficiency, nausea, sleep disturbances, times. Evidently cupping therapy is reported to vasovagal attack, herpes viral infection, cardiac be used first in Egyptian culture (1550 BC), hypertrophy, and pruritis (systemic events) [3, Chinese society and then spread to Greek 10-17]. Notably, standardization of cupping culture, Middle East and now across the world techniques is reported to reduce the aforesaid [1], i.e., including countries of seven continents. events [18]. In addition, several research Since primeval days, there have been methods including sham cupping devices and progressive advancements in cupping therapy designs developed and used for rigor and better (dry and wet cupping and combined cupping quality studies on cupping therapy around the when cupping is combined with or world [19]. Furthermore, innumerable cupping other forms of therapies); cups and cupping sets treatment centers are developed to streamline tremendously improved, indications and the clinical practice of cupping therapy around contraindications identified, classification, the world. Cupping training methods including policies, safety protocols and antiseptic and simulation using manikin [20], and efficacy sterilization guidelines developed with evaluation tools were developed for capacity standardized techniques and safe practices [2-5], building and demonstrating its effectiveness, and mechanisms of action and effects explored [6,7], also mitigating professionals’ false beliefs against and efficacy studies concerning various diseases Hijamah therapy, respectively [21,22,23]. using rigor and better quality designs such as case controlled studies, randomized clinical Clinical wisdom suggests that selecting cupping trials, systematic reviews and meta-analysis points (certain acupoints and points across were conducted with good outcomes [3,8]. meridians) locations precisely for a given disease Hijamah therapy (cupping) is reported to rarely is vital for achieving good recovery among cause some local and systemic adverse effects patients with different diseases. In other words, of mild to moderate severity often attributed to selection of precise cupping points, standardized untrained and incompetent practitioners, infection cupping therapy techniques, and good outcomes control laxity and risky operation sites (critical concerning various diseases are inherently anatomical sites) such as cupping around nose connected. Notably cups usually applied to and nasal sinuses, near jugular veins and skin certain acupuncture points and site of pain and overlying thyroid glands and others, details pathology along meridian points. Furthermore available in subsequent section [3,9]. These selection of precise cupping points by cupping adverse effects are hyperemia, circular practitioners will differ according to a particular erythema, edema, and ecchymosis, minor burns, body system and its diseases’ paraphernalia. localized infection, pruritis and Consequently cupping practitioners need to have hyperpigmentation, abscess (lumber and cervical in-depth knowledge of anatomical cupping epidural) and bullae development, factitial points, their underlying philosophical, theoretical, panniculitis (inflammation of subcutaneous fat), biological and psycho-sociocultural paradigms cutaneous mycobacterium infection, bleeding, and outcomes related to several disease Köebner phenomenon (Cupping-induced conditions and selection of precise cupping Localized ), scar formation, atrophic or points [6,24]. To our knowledge, there is no

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published literature on anatomical sites for points used in cupping therapy are located at cupping points in Saudi Arabia after year 2013 head and neck region, back, front chest, [24]. The objective of this study is to overview abdomen, anterior, posterior and sides of trunk, qualitatively the pertinent literature with a special front of upper arms, front, back and sides of both focus on cupping therapy (Al-Hijamah) points legs, and feet but overall cupping points most used in the management of many medical frequently used are located on dorsal side of the conditions. The significance of this pilot research body [3,24]. There is converging evidence that calling for an universal acceptable system of cupping therapy is used in a variety of diseases cupping points is that cupping practitioners within with variable outcomes [3,24-27], and and outside Saudi Arabia may have knowledge inconsistent recovery could be attributable to a concerning cupping point locations derived from number of factors including an improper selection different traditional medical systems, which need of cupping points. Therefore selection of cupping to be used accurately in various diseases point locations concerning a medical condition by resulting in further standardization of cupping a trained experienced professional is highly techniques associated with better outcome and important for reducing adverse events and good quality of life. increasing efficacy of cupping therapy. Besides precise selection of cupping point, quality of 2. METHODS cupping sets and aseptic procedures are equally important tools to achieve good results in a 2.1 Search disease. To be concise but unambiguous, cupping point locations on the body surface Boolean operators were used to search specific (hence cupping is a skin surface therapy) mainly data on cupping therapy points. Electronic connected to TCM meridian acupoint system, searches of three databases and three open and assimilated over decades and corresponding access scientific publishing houses (Google important medical conditions especially Scholar, PubMed, OvidSP and Dovepress.com, presenting with pains are given in order of Hindawi.com and Sciencdomain.org) using importance in the adapted Table 1[24, 28]. keywords such as cupping therapy points OR However, the cupping points with numbers Cupping points OR Hijamah points OR Chinese localized on the body surface (back and front) Cupping points OR Acupoints OR Traditional regarding a particular disease needs scientific cupping points OR Islamic Cupping points OR research to provide evidence-based data to Cupping points OR Modern Cupping support its comprehensiveness and points AND Cupping procedures OR Cupping standardization because this system from Arab case reports OR Cupping observational studies traditional practitioners and healers is outdated OR Cupping RCTs OR Cupping systematic as impressed by modern cupping therapists, reviews were conducted for retrieving articles though these points may be derived or copied published in English literature. A large number of from TCM or Traditional Korean or another articles (n=5759) were retrieved. Two authors system. The moot idea is if a cupping point (NAQ and SMS) independently reviewed the number from traditional healers matches with available data for extracting pertinent articles. Chinese meridian acupoint number with a Consequently, unrelated articles (n=2075), Chinese prefix is not the reliable point for inaccessible papers (n=1102), no abstract Chinese or cupping (Al-Hijamah) therapy? available (n=142), and duplications (n=2375) Most researchers will agree on this point were excluded. The remaining were 65, which positively if traditional healers point matches with were screened further, and those full English acupoints. This is our pure presumption but we articles (n=40) which mainly focused on cupping lack the evidence, and researchers should bridge (Hijamah) therapy points along with scientific this important knowledge gap by conducting relevance of the last five years (2013-2017) were pertinent studies. However, some anatomical selected by two independent reviewers. cupping point sites without numbering concerning a number of diseases are described 3. RESULTS elsewhere [3]. In this review 20 case reports and case series reported cupping points in the

following way; back (n=12), back combined with 3.1 Cupping Points other areas such as abdomen, chest, shoulder, forearm, sternum, (n=5), posterior cervical area There are a large number of cupping points (n=3), no report of cupping points (n=3) and reported in the pertinent literature. Most cupping other areas [3] without specifying any points or

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following any system including TCM acupoints, from disease to disease and certain methods or Prophetic medicine, modern anatomical system rules need to define the precise selection of and traditional points. There are several cupping points and current overview attempted to nomenclatures of cupping points without any do so. The first criterion is that cupping points substantial evidence and hence cupping points may be one or more but select the least number system remains a challenging grey area. In a of points, may range from 1 to five from the randomized controlled trial (RCT) dry cupping above mentioned CPs. Furthermore select the was reported to apply on P6 acupoint on the most frequently used points in most diseases, wrist for managing postoperative nausea and which are beneficial to many patients concerning vomiting with success in patients who underwent cupping practice. Another important criterion for laparoscopic cholecystectomy [29]. In another selecting cupping points is the most painful RCT, patients were relieved of shoulder and locations on body surface concerning a disease neck pain when cupping therapy used SI 15, GB under consideration, matching with 21, and LI 15 acupuncture points [30]. There is recommended cupping points. The head region probably no clear universal classification of must be the last option for selecting cupping cupping points and their origin concerning point. Notably the site of cupping (front or back of cupping therapy, and Chinese researchers the body) will decide about the types of cupping, especially use different meridian acupoints with and use of two respiratory windows (back) specific names and numbers in Chinese cupping located in the interscapular region in most [30]. It is beyond this paper to include a full systemic diseases. Notably, opposite points to spectrum of diseases, adverse effects, efficacy the selected cupping points on the skin for a and outcome studies and all cupping points disease should be given equal importance for system in the given Table 1 and for more details cupping therapy but this is more fitting to see these sources [3,24,26,28,31]. Notably acupoints often selected in acupuncture therapy. cupping therapy has evident role in promotion of Furthermore, cups should not be placed on any health and prevention of diseases [1, 24, 32] and skin disease/or lesion, i.e., eczema or psoriasis notably cups are applied on healthy skin surface. and directly over varicose veins which are not With special reference to interscapular region only the contraindications of cupping therapy but points including Kahel (Fig. 2) which are used posit a potential risk of rupturing veins and frequently in most systemic diseases but not all, consequently bleeding. There are other areas this area is characterized by five features; brown where cupping points also should not be selected adipose tissue, direct proximity to sympathetic and cupping is not done on those locations ganglia, passage of the thoracic duct, two mentioned in the subsequent section. important acupuncture meridians, and closeness Conversely, cupping points include pathological to the main vessel divisions carrying blood from sites based on more than a dozen mechanisms the and the brain. The interscapular from which a high degree of clearance of blood application of wet cupping (Hijamah) therapy and interstitial spaces is required [24]. discharges waste products, stimulates the body's Furthermore, the third important criterion for metabolism, increases immunity, and regulates selecting cupping points is related to the blood biochemistry reflecting its therapeutic mechanism of cupping actions and effects and effects [24,28,33]. The Kahel area covers the therapeutic value, which are comprehensively largest skin surface on the back between the two described elsewhere [3,6,24,]. Briefly, the scapulars and may include these points (# 1, 55, proposed mechanisms underlying Hijamah 45, 46, 48 and others with different Chinese include pain-gate theory, diffuse noxious cupping points). inhibitory controls (DNIC) and reflex zone theory, and accordingly pain is reduced through 3.2 Tentative Criteria for Selecting CPs competitive inhibition either at peripheral (pain gait theory) or central (DNIC) levels, Arguably, there is no need to select and use all biomechanical properties of the skin cupping points especially taken from Chinese (neovascularization and microtrauma) are meridian system (acupoints) which are favorably changed and transformed, and fresh thousands in numbers (maybe the key points on blood circulation (with oxygenation) is increased the main meridians =365, extra-meridian points considerably to the diseased area by cupping more than =1000); however, according to (Hijamah) therapy [6,24,34]. In other words, traditional healers most frequently used CPs are Hijamah tends to increase pain threshold and 55(1-55) on the back and 43 on the front (141- consequently pain is reduced and not perceived 143) [28]. Notably cupping therapy points differ by the patient. From TCM perspective, illnesses

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are triggered when the life force of body in terms The overall selection of cupping points may of “chi” or “” is disturbed or stagnated include local and adjacent points, distal and attributable to medical disease or trauma, proximal points, clustering points and their infections, stress, anxiety and other factors. combinations. However, when it is necessary According to Chinese theory, cupping therapy extreme precautions should be taken in applying (and also acupuncture modality) that impact cups on anatomical critical sites. channels brings back equilibrium, and thus patient condition including pain improves. 3.3 Other Salient Features of Cupping Another hypothesis- nitric oxide theory- explains Therapy Points cupping effects in terms of muscle relaxation, changes in local tissue structures (microtrauma Dry cupping (without puncturing/scarification), and inflammation) and increase in oxygenated wet-cupping (with scarification) and other forms blood circulation, anticoagulation effect and anti- of cupping including combined with other inflammatory responses. Activation of immune therapies like acupuncture are used in various system theory by cupping explains ailments across different parts of the world physiologically its immunological effects, [2,8,24]. These conditions typically include many hormonal adjustments and clearance of chronic diseases which are associated with proinflammatory cytokines especially in those moderate to severe pain. In specific terms, health conditions linked with immunological variable numbers of cups but often not more than disturbances [6,7]. According to blood five in a given session are used on precisely detoxification theory, cupping (Hijamah) helps to selected points on ill or surrounding body surface release and removes wastes and heavy at a time for a variable time, usually 5 to 20 metals from the body [6,35] attributed to minutes. Conversely cups are applied often on enhanced excretory functions of the dermis, the back involving healthy skin surface in the removal of congestion, tissue adhesions being prevention of diseases and promotion of health broken and restoration of homeostasis [26]. such as in athletes for enhancing their Assumingly these theories mostly work in performance. There is no fixed number of tandem in producing cupping effects in the body. sessions, fixed number of cups, and fixed time In context to cupping points, reflex zone theory is schedule for a session. Notably cupping therapy important but other theories too because it might be given lifelong in chronic diseases with guides practitioners to put cups on distant points monthly interval or so. Later on, these cupping which are painful but may be away from the points might be changed depending on the diseased organs [36]. Overall selection of outcome of disease or recovery rate, for cupping points in a particular medical condition is example, if the outcome is poor or recovery is governed by a number of criteria linked with very slow. Accordingly number of cupping disease type, its severity and nature, most sessions and the interval between them may also painful sites, areas surrounding disease site, vary for a particular disease as there are no disease site itself, most safe sites, most scientific rules concerning these items of cupping frequently used points linked with good efficacy therapy. Cupping sessions can be repeated in such as Kahel, critical anatomical sites, and case of relapse of the disease. Overall aforesaid underlying mechanisms of action and effects of cupping technique components may vary based cupping [3,6,24]. It is advisable not to apply cups on clinical condition of an individual patient. to critical anatomical sites such as skin overlying Notably, wet cupping (Al-Hijamah) is preferred carpal tunnel (a potential possibility to injure compared to other forms of cupping therapy, nerves and veins), axilla skin (may injure brachial based on severity and nature of disease such as plexus), over nasal sinuses (dangerous area may infections or non-communicable disease and transfer infection to intracranial structures), skin painless or painful condition [2,8, 24, 25, 37]. It is in front of ears (may injure 7th cranial nerve), skin wise to know that dry cupping has been used overlying thyroid gland (may injure underlying successfully in many conditions including great vessels and veins), and potentially musculoskeletal conditions associated with pain dangerous triangle of face (may transmit and plantar fasciitis [38,39] and this mode of infection to dural sinuses to intracranial cupping is going to survive in future. Wet cupping structures causing thrombosis and death) and therapy is widely used in Arabic and Islamic skin overlying superficial neck veins and arteries countries whereas dry cupping is the commonest (may rupture them and cause hemorrhage) [24]. type of therapy in the Western landscape.

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Table 1. Cupping points (CPs) with a specific site on the body surface concerning diseases presenting mainly with pain [adapted from 24, 28]

Diseases/illnesses Main symptoms# Mostly used CPs for Less frequently used Remarks first 1 session** CPs Headache Pain in head or neck 1, 55, 2, 3 ------Various headaches identified. Each CP has a specific anatomical area on skin surface. Migraine Throbbing headache& visual 1, 55, 2, 3, 106 ------Plus cupping at area of pain disturbance Backache 1, 55 ------Plus cupping on both sides of the spine and places of pain Neck & shoulder pain Neck & shoulder Pain 1, 55, 40, 20, 21 ------Plus places of pain Knee pain Pain 1, 55, 11, 12, 13 ------53,54 points plus cupping around the knee Rheumatism Pain in joints 1, 55 Plus all areas of pain Rheumatoid Arthritis Pain and swelling in joints 1, 55, 120, 49, 36 ------Plus cupping on all large and small joints Muscle spasm Pain and difficult movements ----- Multiple cupping sessions around the affected muscle Gout Swollen joints with pain 1, 55, 28, 29, 30 31, 121 Plus cupping on pain points. Pain due to excess uric acid Varicocele Pain in the scrotum 1, 55, 6, 11, 12, 13, 28, 29, 30, 31, 125, Enlarged venous plexus in the scrotum. 126 Skin diseases Itching and pain 1, 55, 49, 120, 129, 6, 7, 8, 11 Plus cupping on the affected areas (excluding eczema& psoriasis) Sores (skin wounds) Pain 1, 55, 129, 120 ----- Do not confuse with sores in mouth and on genitals Cellulite Pain, redness of skin ------Daily massage cupping over affected area. Diseases of the eyes Pain & secretion of tears 1, 55, 36, 101, 104 105, 9, 10, 34, 35 CP above the eyebrows and on the hair line Heart disease Angina pain 1, 55, 19, 119, 7 8, 46, 46, 47, 133 &134 Includes multiple disease & symptoms, same CP are used Peripheral circulatory Pain while walking 1, 55, 11 ----- Plus DC on both sides of the spine from the dis. top to bottom. Menstruation Pain and irregular menses 1, 55 ----- Plus DC on 125, 126, 137, 138, 139, 140, 141, problems 142, 143

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Diseases/illnesses Main symptoms# Mostly used CPs for Less frequently used Remarks first 1 session** CPs Ear, nose, &throat Pain, nausea and dizziness, 1, 55, 20, 21, 41, 42, 120, 49, 114, 43, 44 Also include tonsils, oral cavity and teeth Kidney disease Renal pain & bleeding 1, 55, 9, 10, 41 42 Plus DC on CPs 137,140 Neuritis (peripheral) Inflammation of nerves 1, 55, 110, 111, 112 113&114 Plus cupping on the affected areas Sciatic pain Neural pain from the buttock 1, 55, 11, 12, 26,27 51,52 Plus at places of pain on the right/left leg (right & left) down to legs muscles, its beginning and end points Abdominal pain Vague Pain 1, 55, 7, 8 DC on 137, 138, 139, Plus DC* on the back opposite to the pain 140 Gastric ulcers Epigastric pain 1, 55, 7, 8, 50 41, 42, 137 to 140 In one session, three to five CPs are used Gastritis Upper abdominal pain, 1, 55, and 121 ------Bloating and anorexia due to inflammation of nausea, vomiting stomach lining and gall bladder Pain in right upper quadrant 1, 55, 6, 48, 41 42, 46, 51, 122, 123, Plus 5 cups on the right, outer leg. Nausea disease of the abdomen &124 and vomiting other symptoms Irritable bowel Cramps, diarrhea & 1, 55, 6, 48, 7 8, 14, 15, 16, 17, 18, Plus DC on 137. Each CP has a specific syndrome constipation 45, 46 anatomical area on skin surface. *DC=dry cupping, ** Mentioning these skin surface points does not mean that we support traditional points and ignore other cupping point systems, #Main symptoms in addition to diagnostic tests must guide a practitioner to reach a diagnosis which is a crucial step for the selection of final CPs. CPs matching these numbers may have their origin in different traditional systems including Chinese meridian system and Prophetic medicine and other systems but need scientific studies for evidence based data to support or refute them.

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Fig. 1. Cupping points (Sunnah points) adapted from [28]

Fig. 2. The anatomical features of the interscapular area with blood supply used in wet- cupping adapted from [33]

3.4 Cautionary Note and Cupping Points Cupping points and cupping should never be selected and applied respectively directly on Evidently cupping therapy is absolutely or veins, nerves, arteries, open sores/wounds, relatively contraindicated in certain conditions. places of deep vein thrombosis, inflamed skin, The question arises “is there any special cupping skin lesions such as eczema or psoriasis, eyes, points considered in these conditions? The lymph nodes, body orifices such as anus, nose, straightforward answer is big no. These eye or oral cavity and varicose veins [3,40]. conditions include but possibly not limited to Cupping therapy is not without local and pregnant or menstruating women, puerperium, systemic adverse events [3,14] which are bone fractures, metastatic cancers, patients with attributed to a variety of factors including multiple organ failure (kidney, heart and liver incompetent practitioners, untrained traditional failure), hemophilia/bleeding disorders, infectious healers and quacks [3,9] and selection of wrong diseases, high fever and convulsions, medical cupping points. Overall cupping points if not and surgical emergencies, patients with selected precisely and in collaboration with pacemaker and severe cardiovascular disease, patient may contribute to the development of patients using anticoagulants, very obese or thin adverse events of cupping (Hijamah) therapy, person or emaciated patient, very recent wet delayed therapeutic response, ethical problems cupping and blood donation and severe . and additional cost burden.

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4. DISCUSSION acupoints? This amazing hypothesis-cum-idea needs scientific answers by conducting relevant Cupping (Al-Hijamah) therapy is an integral part research studies. The Kahel region includes skin of traditional complementary and alternative overlying 7th cervical vertebral spine and medicine practice since ancient times. Since then surrounding area (upper, lower, right and left there have been continuous technical lateral) and interscapular region. The Kahel developments in several aspects of cupping region used most commonly in diseases but not therapy including identification of cupping points all for therapeutic and preventive purposes [3,24] and currently this traditional modality is (especially cupping during Sunnah days, i.e., used in various diseases including low back pain 17th, 19th and 21st of the Islamic, lunar month with good outcome [3,30,40-42]. In a recent which coincide with Monday, Tuesday or study, Hijamah is reported to be cardioprotective Thursday), and very important area (but similarly as it restored sympathovagal imbalances by other points on the back) linked with safe and stimulating the peripheral nervous system [43]. suitable skin points on the back, flat area suitable However, more rigorous better quality studies are for applying cups easily, and away from critical required to provide level I and II evidence structures such as nerves, veins, and arteries. [3,30,39]. Recently Huang and colleagues (2017) This area and Sunnah days for cupping were summarized seven cupping (wet cupping, also recommended by Prophet Mohammad moving cupping, balance-cupping, cupping with (PBUH) for cupping (Al-Hijamah) therapy [24, retention) studies that reported level I and level II 28]. This Kahel area together with other cupping evidence of cupping in chronic conditions points on the back and dorsum of legs is also including low back pain and acute lumber sprain used for promotion of health in sports medicine, [44]. Although precise mechanism of action and and for enhancing athletes’ performance [32]. It effects underpinning cupping therapy and is better to use the largest cup on Kahel cupping points is not precisely known, several area/point because of multiple reasons such as hypothesis and theories have been put forward large area. The Akhdayin sites closer to jugular to explain how precise application of cupping veins are important because cupping therapy points helps cupping therapy in producing good may clear biochemical substances (and toxic outcome in various illnesses [3,6,45-51]. materials) found in high concentration in jugular veins (and interstitial spaces) during episodes of Cupping points possibly part of meridian cluster and migraine headaches [26]. When acupoints system and other traditional system practitioners apply cups on Akhdayin sites (#43 are powerful tools to standardize and modernize &44), they must take extreme precaution not to the cupping therapy (Al-Hijamah). There injure jugular veins or else never use these are twelve main meridians which are invisible critical points. However cupping on areas behind channels and present throughout the body with ears (#22&23 and #/GB20&21) is without any Qi or energy flow. Each limb is traversed by six risk as these points are away from jugular veins, channels, three Yin channels on the inside, and and these cupping perspectives need research three Yang channels on the outside. Like in evidence in future. Traditional Chinese medicine (TCM), cupping points are also described in prophetic medicine The selection of cupping points and their (Tibb Nabawi), modern medicine and traditional numbers differs from disease to disease, and healers cupping methods [24] and intrinsically further determined by other factors such as cupping points are overlapping each other. For nature and severity of disease, relative example, Prophetic medicine recommended nine contraindications, and cupping mechanisms in cupping points (also called Sunnah points of terms of distal painful sites [3,6,7,24,26]. The Hijamah Fig. 1 and for other points see sources avenue of selecting cupping points in various [24, 28]) including Kahel and Akhdayin whereas diseases is controversial and confusing because Traditional Chinese Medicine recommended thousands of cupping points are described numerous similar cupping points with special according to anatomical sites, numbers and names-number [24]. The surprising idea is that meridian-derived acupoints terminology. For when a cup is placed on a specific cupping point example, Kahel area (in Arabic, and surrounding concerning a disease; does it not cover areas along with interscapular region) is referred acupoints or extra-meridian points positioned in to as the Feishu (BL-13) and Dazhui (Du 14/GV- close proximity? If yes, does the therapeutic 14 and 13 in TCM used in pain conditions) outcome need to be attributed to exclusively acupoint groups and used in the treatment of cupping point or combined cupping and [52] and other conditions with pain

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like trigeminal neuralgia. Another example narrative review of literature. J Integr Med. includes of Akhdayin (in Arabic) which is known 2017;15(3):172–181. as GB20 and GB12 (GV14 acupoint group in 2. Al-Bedah AM, Shaban T, Alqaed MA, Chinese medicine [52]. However, it is heuristic to Qureshi NA, Suhaibani A, Gazzaffi I, Khalil select those cupping points with a precise M. Classification of cupping therapy: A tool location on the skin surface which are used most for modernization and standardization. frequently and at the same time most beneficial Journal of Complementary and Alternative and safe to the patients with specific diseases Medical Research. 2016;1(1):1-10:Article but with no adverse events and complications. no.JOCAMR.27222. Another invaluable point is that authors of 3. Al-Bedah AM, Shaban T, Suhaibani A, cupping therapy studies need to mention what Gazzaffi I, Khalil M, Qureshi NA. Safety of and why certain cupping points are used in cupping therapy in studies conducted in individual diseases. twenty one century: A review of literature. British Journal of Medicine and Medical 5. CONCLUSION Research. 2016;15(8):1-12. 4. Kim TH, Kang JW. A good policy for Cupping therapy (Al-Hijamah) is a traditional guaranteed safe practice of complementary and alternative medicine complementary and alternative medicine, practiced since ancient times, and evidently usage of disposable cupping cups. Evid continuing progress has been made in its several Based Complement Alternat Med. 2015; aspects including a precise selection of cupping 2015:970327. points in specific diseases yet this area is grey DOI: 10.1155/2015/970327 and puzzling. Presumably, the precise selection 5. Nielsen A, Kligler B, Koll BS. Addendum: of cupping points is a powerful tool in Safety standards for (press- standardization and modernization of cupping stroking) and Ba guan (cupping). therapy techniques and, hence, this study is Complement Ther Med. 2014;22(3):446- calling for further global research for defining and 448. classifying cupping (Hijamah) therapy points’ and DOI: 10.1016/j.ctim.2014.03.012 their accurate applications in individual diseases. 6. Abdullah M.N. Al-Bedah, Ibrahim S. Elsubai, Naseem Akhtar Qureshi, Tamer DISCLAIMER Shaban Aboushanab, Gazzaffi IM Ali, Ahmed Tawfik El-Olemy, Asim AH Khalil, Mohamed KM. Khalil, Meshari Saleh The views, thoughts, and opinions expressed in Alqaed. The medical perspective of this manuscript belong solely to the authors, and cupping therapy: Effects and theoretical not necessarily to the authors’ employer, mechanisms of action. Journal of organization, or committee. Traditional and Complementary Medicine; 2017 [in press]. CONSENT 7. Guo Y, Chen B, Wang DQ, Li MY, Lim CH, Guo Y, Chen Z. Cupping It is not applicable. regulates local immunomodulation to activate neural-endocrine-immune ETHICAL APPROVAL worknet. Complement Ther Clin Pract. 2017;28:1-3. It is not applicable. DOI: 10.1016/ j.ctcp.2017.04.005 8. Cao H, Han M, Zhu X, Liu J. An overview COMPETING INTERESTS of systematic reviews of clinical evidence for cupping therapy. Journal of Traditional Chinese Medical Sciences. 2015;2(1):3-10. Authors have declared that no competing 9. Chen B, Li MY, Liu PD, Guo Y, Chen ZL. interests exist. Alternative medicine: An update on cupping therapy.JM. 2015;108(7):523-525. REFERENCES DOI: 10.1093/qjmed/hcu227 10. Qureshi NA, Al-Bedah AM, Aboushanab 1. Qureshi NA, Shaban T, Elsubai IS, Alqaed TS. Cupping Hijama therapy skin marks: MA, Gazzaffi I, El-Olemy AT, Al-Bedah What should we know about them? Journal AM. History of cupping (Hijama): A of Complementary Medicine and

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