Wet cupping therapy ameliorates pain in patients with hyperlipidemia, hypertension, and diabetes: A controlled clinical study

Background: Cupping therapy has long been practiced in several cultures for the treatment of ailments and improvement of general well-being. Thus, the aim of this current study is to observe the clinical ef ﬁ cacy and safety of wet cupping treatments in relieving headache, chest pain and muscle ache in patients recently have diagnosed with hyperlipidemia, diabetes and high blood pressure. Materials and methods: This study determines the effects of wet cupping on some blood parameters and pressure in 50 males and 50 female patients aged between 35 and 55 years undergoing wet cupping therapy at the Sheefa Cupping and Acupuncture Private Center after they have been diagnosed clinically to have hyperglycemia, diabetes and high blood pressure by a specialist at Department of Chronic Diseases, Sulaimani Teaching Hospital. Venous blood was obtained, and blood pressure taken from patients immediately before and 72 h after cupping therapy. The hematological parameters and serum lipid pro ﬁ le, fasting blood sugar, ferritin, urea, and creatinine concentrations were determined. Results: Wet cupping signi ﬁ cantly reduced the cholesterol, triglyceride, low-density lipoprotein, fasting blood sugar, ferritin, urea, and creatinine, lowered blood pressure but did not signi ﬁ cantly affect the erythrocyte parameters, leukocyte or platelet counts in the patients. The normal hematological parameters in patients after wet cupping therapy showed that the treatment is not detrimental to health. The treated patients showed signi ﬁ cantly reduced headache, chest pain and muscle ache verbally. Conclusion: Wet cupping therapy is bene ﬁ cial as a prophylactic and/or complementary treatment for hyperlipidemia, hyperglycemia, and hypertension and in prevention and control of diabetes mellitus and kidney disease, hence reducing the headache, chest pain and muscle ache. © 2020 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).


Introduction
Cupping is an ancient therapy practiced by several cultures for improvement of health and general well-being [1].The technique involves the use of either a plastic, bamboo, earthen or glass cups placed on the desired acupoints on the skin to create suction.Currently, the mechanism of effect of cupping therapy remains unclear, although proper cupping causes skin hyperemia or hemostasis that facilitates healing [2].
In Kurdish culture, cupping therapy is known as Kalla-Shax.Cupping in Arabic name is Al-Hejamah, which means to reduce size in order to return the body to its natural state [3].Al-Hejamah has been part of the Middle-Eastern culture for thousands of years [4,5] with records of the practice in an Egyptian medical textbook, Ebers Papyrus, dating as early as 1550 BC [6].The earliest records of cupping in China were in an ancient book, Bo Shu, which was discovered in an ancient tomb of the Han Dynasty (206 BC e 220 AD) in 1973 [2].Cupping therapy is now formally and widely practiced in hospitals throughout China [7].
Cupping therapy can be either dry or wet.Dry cupping therapy is more popular in the Far-East whereas wet cupping is favored in the Middle East and Eastern Europe regions [7,8].Cupping is either used alone or in combination with acupuncture [9] to symptomatic treat a wide range of conditions such as pain, hypertension, stroke, cardiovascular diseases, hemophilia, inflammation, varicose veins, rheumatic arthritis, sciatica, back pain, chest pain, muscle ache, severe headache and migraine [4,7].The therapy is also recommended as a form of deep tissue massage, and for mental and physical relaxation and infertility [10e12].According to Islamic prophetic medicine, cupping therapy is best performed on the 17th, 19th, and 21st of the Islamic calendar and it is recommended that patient should not eat at least 2e4 h before cupping [13].
Although cupping therapy is a relatively safe form of complementary and alternative medicine, excessive cupping therapies, especially within short intervals, may cause weakness, drowsiness, and lighten head [14,15].Bruising and skin discoloration are among the adverse effects of cupping while excessive cupping may also cause, ecchymosis, bleeding, anemia, blisters, skin pigmentation, abscesses, and wound infections if performed by unqualified therapist [6].
Although some clinicians remain skeptical about the effectiveness of cupping, growing evidence shows that the therapy has beneficial health benefits.Among the benefits of cupping are in the treatment of herpes zoster, cough, asthma, pain, high blood pressure [16e20] and primary infertility in male [9].As well as, it might remove oxidants and heavy metals from the body, and increases sleep quality [19e22].Thus, this study investigated the effect of wet cupping therapy on pathophysiological, hematological, and serum biochemical parameters in human patients with severe headache, chest pain and muscle ache with history of metabolic diseases.

Materials
Disposable premium quality sterilized plastic cupping sets fitted with hand suction pumps were purchased from (Kangzhu 6-Cup Biomagnetic Chinese Cupping Therapy Set, Model B1, Kangzhu, Beijing, China).

Methods
The study was conducted from April to August 2017 on 50 male and 50 female patients aged between 35 and 55 years who consulted the Sheefa Cupping and Acupuncture Private Center, Kawa Street, Sulaimaniyah City, Northern Iraq after they have been enrolled to Department of Chronic Diseases, Sulaimaniyah Teaching Hospital and diagnosed clinically to have diabetes, hypertension and hyperlipidemia by a specialist clinician.All patients received based on their verbally complaints of a severe headache, breathing difficulties, muscle ache (especially shoulder, arm, and leg), chest pain, and depression.All patients were asked to sign informed consents forms, thereby agreeing to receive wet cupping therapy and to allow blood collection from them.Venous blood was obtained from patients immediately before and 72 h after cupping therapy.We followed the Consolidated Standards of Reporting Trials and Standards for Reporting Interventions in Clinical Trials of Wet Cupping guidelines for designing and reporting controlled trials.Our team strictly defended the patients' legitimate rights and interests, and we were totally responsible for the whole therapeutic process.Detailed questionnaires (Supplementary I) were obtained from all patients, including questions about sociodemographic characteristics, history of pain appearance and diseases, detailed symptoms and duration of symptoms, as well as anthropometric measures (Table 1).The research proposal was approved by the ethical committee of College of Medicine, University of XXXXX, Northern Iraq with approval number of COM-UNIVSUL-2016-1010.

Exclusion criteria
Pregnant or lactating subjects and patients with severe heart, liver and kidney disorders or diseases, coagulation abnormalities, anemia, cancer, and severe bone fracture were excluded from the study.Additionally, patients who failed to complete the questionnaires and were not able to follow medical orders were also excluded.

Patient allocation
Patients who were interested in participating in this trial were interviewed first to confirm the availability of severe headache, chest pain and muscle ache.After recruiting the participants, they were invited by the medical laboratory scientist to assign the participants to the treatment and decided to conduct the wet cupping to them.The patients were included in the study respective of whether or not they were undergoing any form of treatment for the pain.

Anatomical sites for cupping therapy
Generally, it is guided to put the sucking cups near anatomically as possible to the painful area to facilitate excretion of pain.Thus, we chose the following points during the wet cupping therapy (Fig. 1A) [11]: 1: At skin overlying the spinous process of 7th cervical vertebra.It is the most prominent vertebral spine at the lower aspect of back of the neck.
4 and 5: Between the upper part of the medial borders of the 2 scapulae i.e. about 3 cm lateral to the spinous process of 3rd thoracic vertebra.20 and 21: At midpoints of skin covering trapezii.These points are beneficial in treating neck pain, shoulder pain and tingling of upper limbs.

Cupping therapy technique
The shoulder and the spine region were examined for abnormalities to ensure the correct application of cupping therapy.Each patient was separately treated in the therapeutic room and the chosen points on the back of the patients were thoroughly sterilized with alcohol.Designated skin acupoints on the shoulder and at both sides of the spine, using sterilized surgical blades, were nicked to a predetermined depth (0.1 cm) and width (2.0 cm) to cause bleeding.Vacuums were created in the cups with a pump, the cups firmly placed at the acupoints, and blood allowed to drain out for 3 to 5 times using multiple cups (Fig. 1B).Upon removal of the cups, the wounds were aseptically cleaned and covered with gauze and secured.Following the termination of the process, each participant was offered a 200 mL of freshly prepared natural fruit juice.

Pathophysiological and blood parameters
The blood pressure of subjects, before and after cupping therapy was determined using a conventional mercury-based sphygmomanometer and a stethoscope (Equmed, Sdn.Bhd.Malaysia).The temperature of the therapeutic room was never below than 25 C. Fasting blood sugar, serum cholesterol, triglyceride, low density lipoprotein, ferritin, urea, and creatinine concentrations were determined using Cobas c 311 (Roche Diagnostics, Germany).Additionally, total erythrocyte (RBC), leukocyte (WBC), platelet (Plt) count, hemoglobin (Hb), and hematocrit (PCV) were determined using a Coulter Counter (Beckman, USA).

Statistical analysis
The results of all experiments expressed as mean ± SD and analyzed statistically using SPSS version 20.0 (SPSS Inc., Chicago, USA).Paired t-test were done to compare the pre and post treatment results.Probability values of P < 0.05 were considered statistically significant.

Results
There is no significant difference (P > 0.05) in the levels of hematological parameters in the patients between before and after cupping therapy.The blood total cholesterol, triglyceride, LDL, blood sugar, urea, and creatinine concentrations and blood pressure were significantly (P < 0.05) lower in both male and female patients at 72 post-cupping compared to the pre-cupping period (Table 2).
The questionnaire showed that 80% of male and 4% of female volunteer patients was smokers.The patients, particularly males, had diets high in protein and red meat.Most patients do not regularly exercise.

Discussion
Cupping therapy is an ancient traditional medical practice that has now become a treatment modality in many hospitals and local clinics throughout Asian countries including Iraq.The treatment method is primarily employed for the alleviation of pain and depression [23].The results of the study showed that the high lipid profile (Fig. 2) is more pronounced in males than females.
Based on the history of the patients, this phenomenon is suggested to be due to high intake of fat diet from consumption of mutton cooked in ghee for cooking.This is compounded by lack of exercise among the male patients [24].High cholesterol diet is one of the leading causes of atherosclerosis that results in hypertension, especially among middle-aged to old patients [6].In our study, the high blood pressure is significantly (P < 0.05) improved in both sexes after wet cupping therapy which is similar to the findings of another study that reported clear relationship between wet cupping therapy and the reduction and control of systolic blood pressure in patients with hypertension [25].
Cupping therapy did not cause the significant decrease in RBC count, indicating the blood loss due to the technique is marginal and not a health hazard.Similarly, no significant changes were seen in hematological data (Complete blood count) before and after cupping therapy for both sexes which is in the same line with the results of another study conducted in Iran [26].Values are mean ± SD that have been analyzed using post hoc comparison test one way ANOVA.Data revealed.LDL: low-density lipoprotein, WBC: white blood cells, RBC: red blood cells, Hb: hemoglobin, PCV: packed cell volume, PLC: platelet count.a Indicating a significant increase in the level of tests in patients before cupping therapy in comparing to the normal standard level.b Indicating a significant lowering in the level of tests in treated subjects in comparing to the subjects before cupping therapy.c Indicating a significant decreasing in the level of tests in patients before cupping therapy in comparing to the normal standard level.d Indicating a non-significant lowering in the level of tests in treated subjects in comparing to the subjects before cupping therapy.Male patients that volunteered for cupping therapy had higher serum ferritin concentrations than female patients.This is associated with males generally having higher total erythrocytes count than females.Additionally, there is an association between high serum ferritin and smoking [27].Kurdish men are generally heavy smokers, thus, the higher serum ferritin in male than in female patients in the study is partially attributable to smoking habits.
In Kurdish culture, sugar is heavy consumed in the diet through drinking of tea, coffee, and soft drinks, sweets, and other confections [28].There is no accurate report on the prevalence of diabetes mellitus in Iraq.However, one study suggested that in the Basrah city/Iraq, one in five adults is affected by the disease [29].There is no known cure for type 2 diabetes, but the disease may be prevented with regular wet cupping therapy and adopting the healthy lifestyle.Our study on patients in the Kurdish region showed that wet cupping therapy might reduce blood glucose both in males and females which is in agreement with another study that suggested wet cupping can be introduced as the complementary treatment for diabetes [30].
Iron stores may predict the development of diabetes [31].Iron overload (Fig. 3) is associated with insulin resistance and increased risk of development of type 2 diabetes mellitus [32].We showed that cupping might decrease the ferritin levels, suggesting the procedure might decrease iron stores in male patients.The study indicates that wet cupping treatment may be an effective adjuvant therapy for patients with familial history of diabetes to adapt to prevent the development of the disease [33].
One abnormality in diabetes mellitus is dyslipidemia [34].In diabetics, restoration of the lipid profile to normality may suggest disease remission.In our study, wet cupping therapy decreased total cholesterol, triglyceride, and LDL concentrations both in males and females which is in agreement with another study conducted by Ranaei-siadat et al. [26].Thus, wet cupping may be one of the means to improve the lipid profile in diabetic patients while serving as an effective method to improve lipid metabolism and subsequently prevent the development of atherosclerosis.
However, Farahmand et al. indicated that wet cupping did not have a significant (p > 0.05) effect on lipid profile in a randomized controlled trial study on 63 patients [35] while Mahdavi et al. showed a significant (p > 0.05) improvement in lipid profile of a randomly selected group of healthy volunteers underwent wet cupping [36].
Dyslipidemia is a common manifestation of the patient with anxiety and depressive disorders [37,38].The lowering of serum lipid parameters in patients in our study suggests that wet cupping may be used to alleviate symptoms of depression.This result is in agreement with the outcomes of another study which mentioned that cupping has been shown to benefit psychological well-being by alleviating anger, hostility, depression and anxiety in a group of patients with metabolic syndrome [39].
Serum creatinine and urea are indicators renal function that is used in the assessment, diagnosis, and monitoring treatment efficacy in kidney diseases.In this study, the levels of both creatinine and urea are relatively higher in patients before treatment, which may be directly related to the high protein and red meat consumption.After treatment, both analytes decrease in level, which is suggested improvement of renal function that might be associated with wet cupping [40].

Conclusion
In conclusion, wet cupping therapy is not detrimental to health, instead, it might be beneficial as a prophylactic and/or complementary for the treatment of hyperlipidemia, hyperglycemia, and hypertension and in prevention and control of diabetes mellitus and kidney disease, and consequently effective to alleviate headache, chest pain and muscle ache in treated patients.

Ethical approval
Blood sample from patients were used.

Fig. 1 .
Fig.1.Photographs showing various anatomical points for wet cupping therapy (A) and a hijamatologist performs a wet cupping at chosen points (1, 4, 5, 20, and 21) using a sterilized disposable premium quality plastic cupping set along with hand suction pumps.Cups were applied to the treatment region and the blood was carefully drained for 3e5 times.

Fig. 2 .Fig. 3 .
Fig. 2. Photographs showing a lipidemic blood indicating high lipid profile including either cholesterol or triglyceride or both in a male patient during cupping therapy.

Table 1
Socio-demographic features and anthropometric measures of the studied participants.