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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 217-223  

Management of knee osteoarthritis with cupping therapy


1 Department of Moalejat (Medicine), Faculty of Medicine, ), Jamia Hamdard, New Delhi, India
2 Literary Research Institute of Unani Medicine(LRIUM), Jamia Hamdard, New Delhi, India

Date of Web Publication15-Nov-2013

Correspondence Address:
Umar Jahangir
Majeedia Hospital, Jamia Hamdard, New Delhi - 110 062
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-4040.121417

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  Abstract 

The study aimed to evaluate the effect of cupping therapy at a clinical setting for knee osteoarthritis. A randomized, controlled clinical trial was conducted. Cupping was performed on 0-6 th day; 9-11 th day and 14 th day, i.e., 11 sittings follow-up to determine longer term carryover of treatment effects utilizing both objective and subjective assessment. The assessment was performed before and after treatment spreading over a period of 15 days. The results of this study shows significant and better results in the overall management of knee osteoarthritis, particularly in relieving pain, edema, stiffness and disability. The efficacy of treatment with cupping therapy in relieving signs and symptoms of knee osteoarthritis is comparable to that of acetaminophen 650 mg thrice a day orally, in terms of analgesia, anti-inflammatory and resolution of edema with minimal and temporary side-effects like echymosis and blister formation while as control drug has greater side-effects particularly on upper gastrointestinal tract. It is recommended that further studies are conducted with a larger study samples and of longer duration.

Keywords: Cupping therapy, knee osteoarthritis, regimenal therapy


How to cite this article:
Khan AA, Jahangir U, Urooj S. Management of knee osteoarthritis with cupping therapy. J Adv Pharm Technol Res 2013;4:217-23

How to cite this URL:
Khan AA, Jahangir U, Urooj S. Management of knee osteoarthritis with cupping therapy. J Adv Pharm Technol Res [serial online] 2013 [cited 2020 Sep 29];4:217-23. Available from: http://www.japtr.org/text.asp?2013/4/4/217/121417


  Introduction Top


Regimenal therapy is a category of treatment modality that utilizes various mechanisms like massage, exercise and leeching etc., to change local and thereafter systemic hemodynamic. Cupping a component of regimenal therapy is utilized for local bloodletting and for local hemo dynamic changes. It ensures enhancement of tissue metabolism by increasing the blood circulation of that site. [1],[2],[3],[4],[5]

These chemical changes through physical procedures and subsequent diversion resulting in excretion from the site or body are known as Imala. [6],[7]

Cupping is of three types; dry cupping is caused by creating a vacuum through mechanical means. Wet cupping utilizes a scarifier to cause bloodletting before or together with dry cupping, whereas, the third type uses fire to create the desired vacuum. [2],[3],[4],[5]

In osteoarthritis, the proteoglycans synthesis rate is brought down from a half-life of weeks to a more rapid one whereas, that of collagen from a half-life of several years to a shorter period leading to chondriocystic loss. This loss is a result of disturbance in the three dimensional framework that holds the proteoglycans in collagen. Hence, there is a failure in repair of both proteoglycans and collagen. [8],[9],[10] Imala has the potential to change the chemical form of the compounds by breaking them into simpler ones and to change their chemical structure for example uric acid accumulated in tissues is changed to ureates or into uric acid excretable through urine. [7],[6]

Osteoarthritis is the most common of all joint disorders and the most expensive in terms of productivity, both in terms of days lost from work and in terms of cost of treatment. Another disadvantage of the disease is the absence of treatment to prevent or ameliorate the basic process. Keeping the effects of cupping in mind the present study was conducted to evaluate the efficacy of cupping in osteoarthritis from a clinical point of view.


  Materials and Methods Top


Diagnosed cases of knee osteoarthritis attending the Pain Clinic at New Delhi were selected for the study after obtaining their written consent. Patients were randomly allocated either to test Group A or control Group B, The duration of the study was 8 months, whereas the duration of the treatment was 15 days.

A 15-day follow-up was conducted to determine longer term carryover of treatment effects utilizing both objective and subjective assessment. Measurements of subjects were taken pre-and post-test.

Inclusion Criteria

  • Subjects with osteoarthritis aged between 30 and 60 years old.
  • Subjects who did not receive cupping to the knee region before or to any other region of the body 6 months prior to the study.


Exclusion Criteria

  • Subjects with gross deformity.
  • Osteoarthritis of joints other than the knee.


The subjects fulfilling the criteria were randomly allotted Group A or B. Group A patients received cupping therapy whereas Group B was given Acetaminophen 650 mg thrice a day orally with water.

Basic Cupping therapy equipment was utilized including a hand suction pump, plastic cups of the same size and anti-septic tools.

The Procedure

The following procedure was adopted while performing cupping:

Prior to commencing application of treatment, we ensured that:

  • The subjects had complied with the pre-cupping requirements (inclusion criteria).
  • Contra-indications were eliminated
  • Equipment was sterilized
  • Subjects were explained and subsequently reassured regarding the temporary and minor side-effects such as echymosis and blister formation.
  • As per surface anatomy dry cupping was done on vastus lateralis, vastus intermedius, tibialis anterior and biceps femoris insertion laterally, medially it was done on tendons of Sartorious, gracilis and semitendinosus inferiorly and superiorly on vastus medialis [11] for 15 min.
  • Cupping was done on 0-6 th day; 9-11 th day and 14 th day, i.e., 11 sittings in all.


Assessment Scales

Pain scale


  • G1 - No pain
  • G2 - Aching intermittent pain
  • G3 - Constant severe pain
  • G4 - Pain with restricted movement
  • G5 - Movement difficult without assistance


Stiffness scale

  • G1 - No stiffness
  • G2 - Occasional stiffness
  • G3 - Stiffness during flexion
  • G4 - Stiffness while climbing
  • G5 - Stiffness while walking


Tenderness scale

  • G1 - No tenderness
  • G2 - Occasional tenderness
  • G3 - Tenderness on flexion
  • G4 - Tenderness while climbing
  • G5 - Tenderness while walking


Movement disability scale

  • G1 - No movement disability
  • G2 - Occasional movement disability
  • G3 - Disability in flexion
  • G4 - Disability while climbing
  • G5 - Disability while walking


Edema scale

  • G1 - No edema
  • G2 - edema occasionally present
  • G3 - Moderate edema
  • G4 - Severe edema


Crepitation scale

  • G1 - No Crepitations
  • G2 - Crepitations occasionally present
  • G3 - Crepitations present all the time


Nocturnal pain scale

  • G1 - No Nocturnal Pain
  • G2 - Presence of Nocturnal Pain


Statistical Analysis

Results were assessed based on symptoms, signs which were graded accordingly. Calculations were done with Biostatistics software Graphpad instat 3.10 version by using Paired t-test. Percentage change was calculated by: (y2-y1)/y1 × 100 formula.


  Results Top


Group A

A total of 30 volunteers consented to take part in the study. Three volunteers dropped out because they were afraid of the echymosis. A total of 27 volunteers began the study; five volunteers dropped because of excessive pain and two volunteers were unable to attend the final three appointments and the remaining 20 volunteers completed the trial (n = 20).

Group B

A total of 32 patients were booked for the trial. Two volunteers dropped out as they found the treatment expensive. Thirty volunteers started the study of which two dropped because they felt the results were not satisfactory, whereas eight developed gastrointestinal symptoms and had to stop the study therefore 20 volunteers completed the trial (n = 20).

Epidemiological Data

Group A


The constitution of the twenty volunteers in the study was as follows: Male (n = 6, 30%), female (n = 14, 70%) as shown in [Table 1] and Graph 1 [Additional file 1]
Table 1: Distribution of patients according to gender

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The patients belonging to age group 30-40 (n = 1, 5%) the patients of 40-50 years is n = 8.40%. 50-60 years n = 11, 55% as shown in [Table 2] and Graph 2 [Additional file 2].
Table 2: Distribution of patients according to age

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Of the 20 patients, 13 (65%) patients reported joint stiffness and tenderness and whereas 10 (50%) patients reported movement disability. Majority of the patients gave a negative family history (n = 12 60%). As shown in [Table 3] and Graph 3 [Additional file 3], 9 (45%) patients had edema and crepitations, while 3 (15%) had nocturnal aches at night, 2 (10%) had muscle wasting [Table 4],[Table 5] and Graph 4 [Additional file 4] .
Table 3: Distribution of patients according to family history

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Table 4: Distribution of patients according to muscle wasting

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Table 5: Distribution of patients according to adverse effects

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Group B

The constitution of the twenty volunteers in the study was as follows: male (n = 8, 40%), female (n = 12, 60%) as shown in [Table 1] and Graph 1.

The patients belonging to age group 30-40 (n = 2, 10%) the patients of 40-50 years is n = 7, 35%. 50-60 years n = 11, 55% as shown in [Table 2] and Graph 2.

Of the 20 patients, 14 (70%) patients reported joint stiffness and tenderness and whereas; 11 (55%) patients reported movement disability. Majority of the patients gave a negative family history (n = 15 75%). 10 (50%) patients had edema and crepitations while. 6 (30%) had nocturnal aches at night. 2 (10%) had muscle wasting [Table 4] and Graph 4.

Assessment of Efficacy

Effect on pain


The effect of both the cupping and acetaminophen was statistically extremely significant in relieving pain with P value in both the cases being <0.0001. The percentage change in pain after treatment for cupping group was observed as 46.37% while Group B had 43.055%. The comparable percentage change was 3.32% higher with Group A [Table 6], Graph 6] [Additional file 5].
Table 6: Effect on pain

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Effect on morning stiffness

The effect of both the cupping and acetaminophen was extremely significant with P value in both the cases being <0.0001. The percentage change for cupping group was observed as 49.09% while Group B had 42.30%. The comparable percentage change was 6.79% higher with Test Group A [Table 7], Graph 7] [Additional file 6].
Table 7: Effect on morning stiffness

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Effect on tenderness

The effect of both the cupping and acetaminophen was extremely significant with P value in test Group A as <0.0009 whereas in the control Group B as <0.0001. The percentage change for cupping group was observed as 39.62% while Group B had 38%. The comparable percentage change was 1.62% higher with Group A [Table 8], Graph 8] [Additional file 7].
Table 8: Effect on tenderness

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Effect on crepitations

The effect of both the cupping and acetaminophen was extremely significant with P value in Group A < 0.0018, whereas in Group B was <0.0009. The percentage change for cupping group was observed as 36.84% while Group B had 25%. The comparable percentage change was 11.84% higher with Group A [Table 9], Graph- 9] [Additional file 8].
Table 9: Effect on crepitations

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Effect on edema

The effect of both the cupping and acetaminophen was extremely significant with P value in Group A <0.0016, whereas in Group B was <0.0010. The percentage change for cupping group was observed as 38.46% while Group B had 32.5%. The comparable percentage change was 5.96% higher with Group A [Table 10], Graph-10] [Additional file 9].
Table 10: Effect on edema

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Effect on disability

The effect of both the cupping and acetaminophen was extremely significant with P value in Group A <0.0010, whereas in Group B was = 0.0248. The percentage change for cupping group was observed as 40.42% while Group B had 21.42%. The comparable percentage change was 19% higher with Group A [Table 11], Graph-11] [Additional file 10].
Table 11: Effect on disability

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Effect on nocturnal pain

The effect of both the cupping and acetaminophen was extremely significant with P value in Group A =0.1625 whereas in Group B was =0.0828. The percentage change for cupping group was observed as 8.69% while Group B had 11.53%. The comparable percentage change was 2.84% higher with Group B [Table 12], Graph 12] [Additional file 11].
Table 12: Effect on nocturnal pain

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  Discussion Top


Cupping on the said sites ensured erythema, ecchymosis, release of sebum, water vapor and even blister formations. The erythema and ecchymosis were circular in shape and were directly proportional with symptomatic improvement. Blisters too appeared on the anterio medial aspect of the knee. The blisters gave the characteristic burning sensation and appearance of pressure blister. These varied in number from two to three to plentiful, i.e., 15 with straw colored fluid. The blisters were ruptured under aseptic conditions with a sterile needle. No further treatment was necessary for the blisters. The fluid from such blisters varied from 0.05 ml to 0.2 ml per sitting. The blistered site was given rest for a day or two for healing. The knee improved dramatically after blister formation especially in terms of edema, crepitations and stiffness. Blisters usually formed after 4 to 5 days of cupping. The blisters formed easily and larger in numbers during summers and under increased room temperature. Individuals reacted differently to the same amount of pressure, time of application and room temperature. Some gave severe ecchymosis where as others had blisters [Table 5] and Graph 5 [Additional file 12] while some other had no changes at all. This difference in reaction can be attributed to:

  1. Personal temperament
  2. Temperament of the Ma-adda ghair mehmooda or metabolites.
  3. Fat deposition in the area. The fats deposited are inversely proportionate to the ecchymosis, blisters, etc.
  4. The severity of disease - the amount of metabolites accumulated or the pathological changes since cupping ensures imala, the more the metabolites the more time is spend in diversifying them.
  5. History of prior cupping - if the patient had been undergoing cupping for some time his metabolites are already in a state of movement.
  6. Bathing or perspiration - if the patient has had a bath prior to cupping session. The water absorbed by the skin during bathing or post perspiration is excreted in the form of blisters during cupping sessions.
  7. Local use of anti-inflammatory drugs - the anti-inflammatory drugs too cause a change in the metabolitic status of the joint.


The hemodynamic changes brought about through dry cupping are evident from ecchymosis and blister. These biochemical changes that resulted from vacuum are signs of imala. The vacuum pulls the muscle beyond its normal elastic limits and causes breeches in microvasculature of that area ensuring local hyperemia. Thus increasing the blood supply in the capillary system of that specific site. The metabolites that are diversified from the bony tissue towards muscle are taken up by the phagocytes from these capillary beds.

The patients on cupping therapy showed better results terms of pain, morning stiffness, tenderness, edema, crepitations and movement disability when compared with those on acetaminophen. However, patients of acetaminophen responded well to nocturnal pain when compared to those on cupping therapy.

The ecchymosis and blister formation are directly related to the duration and volume of negative pressure created by cupping and are usually the only undesired effects of cupping therapy for the patient besides causing a mild pain during the cupping session due to indrawing of tissues because of suction effect. But when the patient is taken into confidence and informed in advance of such effects and ensured about their transient nature than the patients are not bothered by their occurrence.


  Conclusion Top


The study proved cupping to be a good analgesic and anti-inflammatory with efficacy better than acetaminophen. Thus, cupping can be recommended for other painful conditions besides being a line of treatment for osteoarthritis.

Cupping superimposes acute inflammation on chronic inflammation. The chronic inflammation of cartilage that is deep seated has acute inflammation on the skin and muscles. A study conducted by Pete et al. in Poland states that degenerative changes occurs as a result of decreased blood supply. Acute inflammation at a site 1-3 mm from the affected joint does improve the blood circulation of the site for a sustained period of 11 days shows the desired changes.

The effect of this at proteoglycans and collagen level needs evaluation to understand the pharmokinetics of vacuum of healthy and ailing tissue another aspect that needs further attention is the concept of healing by causing acute inflammation in tissue superior to chronic inflammation.

The initial increase in pain in Grade 3 and Grade 4 must be because the pain of osteoarthritis had restricted the use of these muscles and thereby causing a loss in their elasticity hence the additional burden on the elasticity caused pain.

Cupping also proved to be a good exercise to specific muscles besides improving their blood supply.

 
  References Top

1.Arzani MA. Mufarreh Quloob. Lucknow: Matba Nami Grami Munshi Nawal Kishore; 1915. p. 583-8.  Back to cited text no. 1
    
2.Baghdadi IH. Kitab ul Mukhtaraat fit Tibb. Hyderabad: Matbaul Jamia Dairaul Maroof Ul Usmaniya; 1914. p. 297-9. [1326 H].  Back to cited text no. 2
    
3.Masihi IA. Kitab ul Umda fil Jarrah. 1 st ed., Vol. 1. New Delhi: CCRUM; 1986. p. 194-200.  Back to cited text no. 3
    
4.Razi Z. Kitab ul Mansoori. 1 st ed. New Delhi: CCRUM; 1991. p. 283-4.  Back to cited text no. 4
    
5.Sinna I. Al Qanoon fit Tibb. Vols. 2, Book I. Jamia Hamdard, New Delhi: Department of Islamic Studies; 1993. p. 364-7.  Back to cited text no. 5
    
6.Arzani MA. Mufarreh Quloob. Lucknow: Matba Nami Grami Munshi Nawal Kishore; 1915. p. 543-5.  Back to cited text no. 6
    
7.Rushd I. Kitab ul Kulliyat. 2 nd ed. New Delhi: CCRUM; 1987. p. 106-10.  Back to cited text no. 7
    
8.Thomas O, Schnitzer J. Cecil's Text Book of Medicine. Vol. 2. Philadelphia: Harcourt Asia Pte. Ltd.; 2000. p. 1550-2.  Back to cited text no. 8
    
9.Nuki G. Davidson's Principles and Practice of Medicine. 17 th ed. London: Churchil Livingstone; 1995. p. 877-80.  Back to cited text no. 9
    
10.Brandt KD. Harrisons Principles of Internal Medicine. 14 th ed., Vol. 2. New York: Philadelphia; 1998. p. 1692-7.  Back to cited text no. 10
    
11.John S. Surface Anatomy. 3 rd ed. New York: Churchill Livingstone; 2003. p. 103.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]


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