Introduction

Cupping is an ancient method of treatment that has been used in the treatment and cure of a broad range of conditions; blood diseases such as haemophilia and hypertension, rheumatic conditions ranging from arthritis, sciatica, back pain, migraine, anxiety and general physical and mental well-being. The aim of Cupping is to extract blood that is believed to be harmful from the body which in turn rids the body of potential harm from symptoms leading to a reduction in well-being.

History and origins of Cupping Therapy

Traditionally, Cupping Therapy has been practiced in most cultures in one form or another. In the UK the practice of Cupping Therapy also dates back a long way with one of the leading medical journals ‘The Lancet' being named after this practice. A lancet is a piece of surgical equipment that was traditionally utilised to release excess blood i.e. venesection and to prick boils. The Arabic name for Cupping Therapy is Al-Hejamah which means to reduce in size i.e. to return the body back to its natural state. The practice of Al-Hejamah has been part of Middle-Eastern cultural practice for thousands of years with citations dating back to the time of Hippocrates (400 BC). Of the western world, the first to embrace Cupping Therapy were the ancient Egyptians, and the oldest recorded medical textbook, Ebers Papyrus, written in approximately 1550 BC in Egypt mentions cupping (Curtis, 2005). Cupping Therapy can be divided into two broad categories: Dry Cupping and Wet Cupping. Dry Cupping Therapy tends to be practiced more commonly in the Far-East whereas Wet Cupping is favoured in the Middle East and Eastern Europe. For the purpose of this research Wet Cupping Therapy will be investigated and the referred to as Cupping Therapy.

Current use of Cupping Therapy

Complementary and Alternative Medicine (CAM) is becoming more popular with the public and gaining credibility within biomedical health care (Hill, 2003). Surveys show that approximately one third of the UK's population (Ernst, 1996) and slightly higher in the USA (Wootton and Sparber, 2001) have used CAM. Additionally, mainstream healthcare, whilst requesting further evidence for CAM, are increasingly interested in some forms of CAM (Hoffman, 2001).

Medical effects of Cupping Therapy

According to Hennawy (2004), Cupping Therapy is indicated for blood disorders, pain relief, inflammatory conditions, mental and physical relaxation, varicose veins and deep tissue massage and quotes up to 50% improvement in fertility levels.

The principles of Acupuncture and Acupressure are very similar to that of Wet Cupping Therapy, except for the fact that Wet Cupping involves the letting of blood whereas Acupuncture and Acupressure utilise suction and stimulation of points to attain the desired results. Letting out blood is in fact among the oldest of acupuncture techniques (Dharmananda, 2004). It is speculated that acupuncture started as a method of pricking boils of the skin, then expanded to letting out “bad blood” that was generated by injuries or fevers and finally allowing invisible evil spirits and perverse atmospheric qi (most notably “wind”) escape from the body (Unschuld, 1985).

Focussing attention back to the research into Chinese healing traditions, the discovery of Acupressure and Acupuncture analgesia has proved that they can elicit the release of morphine like substances (Endorphins), Serotonin or Cortisol which can ultimately lead to pain relief and alter the physiological status of the individual (Schulte, 1996). Acupressure and Acupuncture in fact are being utilised and proven useful in pain and addictive management (Schulte, 1996; Hinze, 1988; Cadwell, 1998). At a biological level; Acupressure and Acupuncture work by stimulating or activating (1) the immune system; (2) Enkephalin secretion; (3) neurotransmitter release (4) vasoconstriction and dilatation and (5) the gates for pain in the CNS which interpret pain sensation (NIH Consensus Development Panel, 1998; Schulte, 1996). Finally, it is believed that stimulation of Acupoints can lead to the pain gates to be overwhelmed by increasing frequency of impulses, therefore ultimately leading to closure of the gates and hence pain reduction (Oumeish, 1998; Cadwell, 1998).

According to the National Institute of Health (NIH) Consensus Development Panel (1997), acupuncture is also effective against chemotherapy nausea and vomiting, nausea in pregnancy, dental pain, adjunct therapy, addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, low back pain, carpal tunnel syndrome, asthma and so forth (Lee, 2001). Given the relative low cost of CAM in general, integration of therapies into mainstream healthcare delivery will no doubt lighten the financial and time burden on our healthcare system.

As Cupping Therapy has been proposed as an effective treatment for pain and given the similarities with Acupuncture and Acupressure theory, it is possible to therefore accept the above mechanism of biological action for Cupping Therapy for pain reduction as well.

Anterior Knee Pain and Cupping Therapy

It is well established that knee injuries are the most common serious injury during sporting activities (Johnson, 2005). The potential for Cupping Therapy to treat anterior knee pain and its associated morbidity should be researched as mentioned earlier as the health and cost implications are indeed promising. It is proposed that Cupping Therapy alongside sound medical and physiotherapy advice for conditions such as Anterior Knee Pain will work well as research has shown that conventional treatment of Anterior Knee Pain (AKP) with sound physiotherapy advice are effective tools in reducing levels of AKP as well as having benefits on individual well-being (Clark et al., 2000).

Cupping Therapy and the ethnic minority population

Britain's population is very diverse; the number of people classed as ethnic minorities is on the increase, (Commission for Racial Equality 1999). It is well established that the use of health care services by ethnic populations is disproportionate to that of the Caucasian population in the UK (Crespo et al., 2000) and also that physical inactivity is more prevalent among ethnic minorities than among Caucasians, (King et al 2000). Therefore an intervention such as Cupping Therapy may help to bridge the gap as did Acupuncture with Far-Eastern communities.

Contra-indications and Precautions to treatment

Cupping Therapy has no major side effects aside from minimal discomfort due to the method of application of skin cuts to the patient. In cases where the patient's pain threshold is low, a local anaesthetic can be administered. Also other possible minor side effects that may occur is the feeling of slight light headedness post Cupping Therapy, this again is similar to the sensation one feels after having had blood taken from the doctor, as Cupping Therapy encourages blood flow to the cupped region (hyperaemia), one may therefore feel warmer and hotter as a result of vasodilation taking place and slight sweating may occur. Again this can be attributed to sound scientific rationale and there is no cause for concern.

Pregnant women or menstruating women, cancer (metastatic) patients and patients with bone fractures or muscle spasms are also believed to be contra-indicated. Also, Cupping Therapy cannot be applied to a site of DVT, where there are ulcers, arteries or places where a pulse can be felt (Chirali, 1999,).

Aims of the research

The aim of the research:

• Evaluate the effect of Cupping Therapy on Anterior Knee Pain (AKP), Range of movement and its impact on quality of life and well-being.

Testable hypothesis

Methodology and research design

The method of this study was an experimental survey utilising clinical trial and a questionnaire methodology. A three week follow-up was conducted to determine longer term carry over of treatment effects utilising both objective and subjective assessment. Measurements of subjects were taken pre- and post-test.

The research was designed after extensive literature review, discussion with cupping practitioners, observation of the application techniques, and discussion and communication with practitioners and centres involved in performing cupping (mainly in the Middle East). After that, the procedure for the application of cupping for this research was established(see cupping application procedure).

An assessment sheet (see appendix 1) was designed to include patient information, past and present medical history, vital signs measurements (pulse rate, blood pressure and O ² saturation rate for monitoring purposes only). All measurements and questions were performed by the same researcher before and after cupping to enhance validity and reliability.

Outcome measures that were used were the Pain Visual Analogue Scale (Pain VAS), Well Being Visual Analogue Scale (Well Being VAS) and joint range of motion, both Active Range of Motion (AROM) and Passive Range of Motion (PROM). The independent variable in this study was the treatment of Cupping Therapy, which all participants received. The independent variables measured were Pain and Well-being VAS scales and Active and Passive Knee Ranges of Movement. The participants were also asked about their perception of cupping and general health and quality of life through a questionnaire. The questionnaire was designed carefully through integrating an array of generic qualitative approaches such as the World Health Organisation Quality of Life questionnaire (WHOQOL-100), EuroQol-5D (EQ-5D) and the 15D Health Related Quality of Life (15D); with the aim to develop a questionnaire specific to Cupping Therapy. Prior to the main study, the questionnaire was tested successfully in two pilot studies.

Population and Sampling

The target population for this investigation was the general public predominantly in the Greater London region and currently unaffiliated with any health trust using convenience sampling technique. Subjects were recruited utilising a range of advertising techniques including advertising on; a national radio station (Spectrum Radio 558 AM), university email system, a medical documentary TV show on ANN satellite channel (Arab News Network).

Inclusion Criteria

Exclusion Criteria

Instrumentation

Ethical consideration of the study

The procedure

Data Analysis

Results

Response Rate

The difference between Passive and Active Ranges of Movement, Pain and Well Being scores before and after Cupping Therapy

The table below illustrates there was an increase in the mean both Active and Passive ranges of movement, as a reduction in pain scores and an increase in well-being. The Std. Deviation pre-Cupping for PROM was (M±SD) (142.64 ± 11.168), and three weeks post-cupping the Std. Deviation was (151.67 ± 5.96). Likewise for AROM the Std. Deviation pre-Cupping for AROM was (134.14 ± 16.53) and three weeks post-cupping the Std. Deviation was (147.24 ± 7.04). A similar trend can be seen for the pain and well being scores. The Std. Deviation pre-Cupping for Pain was (5.38 ± 2.8), and three weeks post-cupping the Std. Deviation was (1.29 ± 2.02). The Std. Deviation pre-Cupping for well-being was (7.21 ± 1.65), and three weeks post-cupping the Std. Deviation was (8.29 ± 1.20).

Figure 1

Table 1: Showing the difference between Passive and Active Ranges of Movement, Pain and Well Being scores before and after Cupping Therapy

The significance of differences in subject scores before and after cupping

As we have seen from the above table there are noticeable differences in each outcome measure scores pre-Cupping and the follow-up sessions. The paired sample t-test was performed to ascertain the statistical significance difference between the pain scores, range of motion and well being: immediately after Cupping, 1 week after Cupping, 2 weeks after cupping and 3 weeks after Cupping.

Figure 2

Table 2: showing the significance of differences in subject scores before and after cupping

The table above shows that there is a statistically significance difference in Passive Ranger of Motion, Active Ranger of Motion, Pain Visual Analogue Scale and Well Being Visual Analogue Scale before and after Cupping Therapy; p ≤ 0.05 in all outcome measures.

Discussion

Effect of Cupping Therapy on Ranges of Motion and Pain level reduction (Tables 1 and 2)

The impact of Cupping Therapy Well-Being (Tables 1 and 2)

Conclusion

It is not for the purpose of an exploratory piece of work like this to implement changes in healthcare practice. Rather the aim being to investigate and raise awareness of a procedure and to address issues of importance associated with it. The efficacy of the treatment of Cupping for Anterior Knee Pain, Range of Movement and well being has been researched and results reveal statistically significant differences in support of Cupping Therapy. It is also suggested that as an intervention, Cupping Therapy needs to be regulated and a register of practitioners developed. Longer term studies related to the effects of Cupping Therapy need to be conducted for other musculo-skeletal conditions.

Appendices

Figure 3

Appendix 1

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