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
1
Ministry of Health, Riyadh, Saudi Arabia.
2
College of Medicine, 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

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

ABSTRACT

Background: Cupping (Al-Hijamah) therapy is a traditional complementary and alternative

medicine practice used in diverse diseases with the variable outcome since ancient times. The
precise selection of cupping points is a core component of cupping therapy 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 skin 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.
_____________________________________________________________________________________________________

*Corresponding author: E-mail: qureshinaseem@live.com;

 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 medicine, 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; prophetic medicine; Chinese traditional
medicine; modern medicine; adverse events.

1. INTRODUCTION crusted lesions, lipoma, keloid scar (local

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

2
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
published literature on anatomical sites for
cupping points in Saudi Arabia after year 2013
[24]. The objective of this study is to overview
qualitatively the pertinent literature with a special
focus on cupping therapy (Al-Hijamah) points
used in the management of many medical
conditions. The significance of this pilot research
calling for an universal acceptable system of
cupping points is that cupping practitioners within
and outside Saudi Arabia may have knowledge
concerning cupping point locations derived from
different traditional medical systems, which need
to be used accurately in various diseases
resulting in further standardization of cupping
techniques associated with better outcome and
good quality of life.
2. METHODS
2.1 Search
Boolean operators were used to search specific
data on cupping therapy points. Electronic
searches of three databases and three open
access scientific publishing houses (Google
Scholar, PubMed, OvidSP and Dovepress.com,
Hindawi.com and Sciencdomain.org) using
keywords such as cupping therapy points OR
Cupping points OR Hijamah points OR Chinese
Cupping points OR Acupoints OR Traditional
cupping points OR Islamic Cupping points OR
Sunnah Cupping points OR Modern Cupping
points AND Cupping procedures OR Cupping
case reports OR Cupping observational studies
OR Cupping RCTs OR Cupping systematic
reviews were conducted for retrieving articles
published in English literature. A large number of
articles (n=5759) were retrieved. Two authors
(NAQ and SMS) independently reviewed the
available data for extracting pertinent articles.
Consequently, unrelated articles (n=2075),
inaccessible papers (n=1102), no abstract
available (n=142), and duplications (n=2375)
were excluded. The remaining were 65, which
were screened further, and those full English
articles (n=40) which mainly focused on cupping
(Hijamah) therapy points along with scientific
relevance of the last five years (2013-2017) were
selected by two independent reviewers.
3. RESULTS
3.1 Cupping Points
There are a large number of cupping points
reported in the pertinent literature. Most cupping
3
points used in cupping therapy are located at
head and neck region, back, front chest,
abdomen, anterior, posterior and sides of trunk,
front of upper arms, front, back and sides of both
legs, and feet but overall cupping points most
frequently used are located on dorsal side of the
body [3,24]. There is converging evidence that
cupping therapy is used in a variety of diseases
with variable outcomes [3,24-27], and
inconsistent recovery could be attributable to a
number of factors including an improper selection
of cupping points. Therefore selection of cupping
point locations concerning a medical condition by
a trained experienced professional is highly
important for reducing adverse events and
increasing efficacy of cupping therapy. Besides
precise selection of cupping point, quality of
cupping sets and aseptic procedures are equally
important tools to achieve good results in a
disease. To be concise but unambiguous,
cupping point locations on the body surface
(hence cupping is a skin surface therapy) mainly
connected to TCM meridian acupoint system,
and assimilated over decades and corresponding
important medical conditions especially
presenting with pains are given in order of
importance in the adapted Table 1[24, 28].
However, the cupping points with numbers
localized on the body surface (back and front)
regarding a particular disease needs scientific
research to provide evidence-based data to
support its comprehensiveness and
standardization because this system from Arab
traditional practitioners and healers is outdated
as impressed by modern cupping therapists,
though these points may be derived or copied
from TCM or Traditional Korean or another
system. The moot idea is if a cupping point
number from traditional healers matches with
Chinese meridian acupoint number with a
Chinese prefix is not the reliable point for
Chinese or Arabic cupping (Al-Hijamah) therapy?
Most researchers will agree on this point
positively if traditional healers point matches with
acupoints. This is our pure presumption but we
lack the evidence, and researchers should bridge
this important knowledge gap by conducting
pertinent studies. However, some anatomical
cupping point sites without numbering
concerning a number of diseases are described
elsewhere [3]. In this review 20 case reports and
case series reported cupping points in the
following way; back (n=12), back combined with
other areas such as abdomen, chest, shoulder,
forearm, sternum, (n=5), posterior cervical area
(n=3), no report of cupping points (n=3) and
other areas [3] without specifying any points or
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
following any system including TCM acupoints,
Prophetic medicine, modern anatomical system
and traditional points. There are several
nomenclatures of cupping points without any
substantial evidence and hence cupping points
system remains a challenging grey area. In a
randomized controlled trial (RCT) dry cupping
was reported to apply on P6 acupoint on the
wrist for managing postoperative nausea and
vomiting with success in patients who underwent
laparoscopic cholecystectomy [29]. In another
RCT, patients were relieved of shoulder and
neck pain when cupping therapy used SI 15, GB
21, and LI 15 acupuncture points [30]. There is
probably no clear universal classification of
cupping points and their origin concerning
cupping therapy, and Chinese researchers
especially use different meridian acupoints with
specific names and numbers in Chinese cupping
[30]. It is beyond this paper to include a full
spectrum of diseases, adverse effects, efficacy
and outcome studies and all cupping points
system in the given Table 1 and for more details
see these sources [3,24,26,28,31]. Notably
cupping therapy has evident role in promotion of
health and prevention of diseases [1, 24, 32] and
notably cups are applied on healthy skin surface.
With special reference to interscapular region
points including Kahel (Fig. 2) which are used
frequently in most systemic diseases but not all,
this area is characterized by five features; brown
adipose tissue, direct proximity to sympathetic
ganglia, passage of the thoracic duct, two
important acupuncture meridians, and closeness
to the main vessel divisions carrying blood from
the heart and the brain. The interscapular
application of wet cupping (Hijamah) therapy
discharges waste products, stimulates the body's
metabolism, increases immunity, and regulates
blood biochemistry reflecting its therapeutic
effects [24,28,33]. The Kahel area covers the
largest skin surface on the back between the two
scapulars and may include these points (# 1, 55,
45, 46, 48 and others with different Chinese
cupping points).
3.2 Tentative Criteria for Selecting CPs
Arguably, there is no need to select and use all
cupping points especially taken from Chinese
meridian system (acupoints) which are
thousands in numbers (maybe the key points on
the main meridians =365, extra-meridian points
more than =1000); however, according to
traditional healers most frequently used CPs are
55(1-55) on the back and 43 on the front (141-
143) [28]. Notably cupping therapy points differ
4
from disease to disease and certain methods or
rules need to define the precise selection of
cupping points and current overview attempted to
do so. The first criterion is that cupping points
may be one or more but select the least number
of points, may range from 1 to five from the
above mentioned CPs. Furthermore select the
most frequently used points in most diseases,
which are beneficial to many patients concerning
cupping practice. Another important criterion for
selecting cupping points is the most painful
locations on body surface concerning a disease
under consideration, matching with
recommended cupping points. The head region
must be the last option for selecting cupping
point. Notably the site of cupping (front or back of
the body) will decide about the types of cupping,
and use of two respiratory windows (back)
located in the interscapular region in most
systemic diseases. Notably, opposite points to
the selected cupping points on the skin for a
disease should be given equal importance for
cupping therapy but this is more fitting to
acupoints often selected in acupuncture therapy.
Furthermore, cups should not be placed on any
skin disease/or lesion, i.e., eczema or psoriasis
and directly over varicose veins which are not
only the contraindications of cupping therapy but
posit a potential risk of rupturing veins and
consequently bleeding. There are other areas
where cupping points also should not be selected
and cupping is not done on those locations
mentioned in the subsequent section.
Conversely, cupping points include pathological
sites based on more than a dozen mechanisms
from which a high degree of clearance of blood
and interstitial spaces is required [24].
Furthermore, the third important criterion for
selecting cupping points is related to the
mechanism of cupping actions and effects and
therapeutic value, which are comprehensively
described elsewhere [3,6,24,]. Briefly, the
proposed mechanisms underlying Hijamah
include pain-gate theory, diffuse noxious
inhibitory controls (DNIC) and reflex zone theory,
and accordingly pain is reduced through
competitive inhibition either at peripheral (pain
gait theory) or central (DNIC) levels,
biomechanical properties of the skin
(neovascularization and microtrauma) are
favorably changed and transformed, and fresh
blood circulation (with oxygenation) is increased
considerably to the diseased area by cupping
(Hijamah) therapy [6,24,34]. In other words,
Hijamah tends to increase pain threshold and
consequently pain is reduced and not perceived
by the patient. From TCM perspective, illnesses
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
are triggered when the life force of body in terms
of “chi” or “qi” is disturbed or stagnated
attributable to medical disease or trauma,
infections, stress, anxiety and other factors.
According to Chinese theory, cupping therapy
(and also acupuncture modality) that impact
energy channels brings back equilibrium, and
thus patient condition including pain improves.
Another hypothesis- nitric oxide theory- explains
cupping effects in terms of muscle relaxation,
changes in local tissue structures (microtrauma
and inflammation) and increase in oxygenated
blood circulation, anticoagulation effect and anti-
inflammatory responses. Activation of immune
system theory by cupping explains
physiologically its immunological effects,
hormonal adjustments and clearance of
proinflammatory cytokines especially in those
health conditions linked with immunological
disturbances [6,7]. According to blood
detoxification theory, cupping (Hijamah) helps to
release toxins and removes wastes and heavy
metals from the body [6,35] attributed to
enhanced excretory functions of the dermis,
removal of congestion, tissue adhesions being
broken and restoration of homeostasis [26].
Assumingly these theories mostly work in
tandem in producing cupping effects in the body.
In context to cupping points, reflex zone theory is
important but other theories too because it
guides practitioners to put cups on distant points
which are painful but may be away from the
diseased organs [36]. Overall selection of
cupping points in a particular medical condition is
governed by a number of criteria linked with
disease type, its severity and nature, most
painful sites, areas surrounding disease site,
disease site itself, most safe sites, most
frequently used points linked with good efficacy
such as Kahel, critical anatomical sites, and
underlying mechanisms of action and effects of
cupping [3,6,24]. It is advisable not to apply cups
to critical anatomical sites such as skin overlying
carpal tunnel (a potential possibility to injure
nerves and veins), axilla skin (may injure brachial
plexus), over nasal sinuses (dangerous area may
transfer infection to intracranial structures), skin
th
in front of ears (may injure 7 cranial nerve), skin
overlying thyroid gland (may injure underlying
great vessels and veins), and potentially
dangerous triangle of face (may transmit
infection to dural sinuses to intracranial
structures causing thrombosis and death) and
skin overlying superficial neck veins and arteries
(may rupture them and cause hemorrhage) [24].
5
The overall selection of cupping points may
include local and adjacent points, distal and
proximal points, clustering points and their
combinations. However, when it is necessary
extreme precautions should be taken in applying
cups on anatomical critical sites.
3.3 Other Salient Features of Cupping
Therapy Points
Dry cupping (without puncturing/scarification),
wet-cupping (with scarification) and other forms
of cupping including combined with other
therapies like acupuncture are used in various
ailments across different parts of the world
[2,8,24]. These conditions typically include many
chronic diseases which are associated with
moderate to severe pain. In specific terms,
variable numbers of cups but often not more than
five in a given session are used on precisely
selected points on ill or surrounding body surface
at a time for a variable time, usually 5 to 20
minutes. Conversely cups are applied often on
the back involving healthy skin surface in the
prevention of diseases and promotion of health
such as in athletes for enhancing their
performance. There is no fixed number of
sessions, fixed number of cups, and fixed time
schedule for a session. Notably cupping therapy
might be given lifelong in chronic diseases with
monthly interval or so. Later on, these cupping
points might be changed depending on the
outcome of disease or recovery rate, for
example, if the outcome is poor or recovery is
very slow. Accordingly number of cupping
sessions and the interval between them may also
vary for a particular disease as there are no
scientific rules concerning these items of cupping
therapy. Cupping sessions can be repeated in
case of relapse of the disease. Overall aforesaid
cupping technique components may vary based
on clinical condition of an individual patient.
Notably, wet cupping (Al-Hijamah) is preferred
compared to other forms of cupping therapy,
based on severity and nature of disease such as
infections or non-communicable disease and
painless or painful condition [2,8, 24, 25, 37]. It is
wise to know that dry cupping has been used
successfully in many conditions including
musculoskeletal conditions associated with pain
and plantar fasciitis [38,39] and this mode of
cupping is going to survive in future. Wet cupping
therapy is widely used in Arabic and Islamic
countries whereas dry cupping is the commonest
type of therapy in the Western landscape.
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269

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
Low back pain 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

6
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269

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
Liver 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.

7
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269

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

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 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
4. DISCUSSION
Cupping (Al-Hijamah) therapy is an integral part
of traditional complementary and alternative
medicine practice since ancient times. Since then
there have been continuous technical
developments in several aspects of cupping
therapy including identification of cupping points
[3,24] and currently this traditional modality is
used in various diseases including low back pain
with good outcome [3,30,40-42]. In a recent
study, Hijamah is reported to be cardioprotective
as it restored sympathovagal imbalances by
stimulating the peripheral nervous system [43].
However, more rigorous better quality studies are
required to provide level I and II evidence
[3,30,39]. Recently Huang and colleagues (2017)
summarized seven cupping (wet cupping,
moving cupping, balance-cupping, cupping with
retention) studies that reported level I and level II
evidence of cupping in chronic conditions
including low back pain and acute lumber sprain
[44]. Although precise mechanism of action and
effects underpinning cupping therapy and
cupping points is not precisely known, several
hypothesis and theories have been put forward
to explain how precise application of cupping
points helps cupping therapy in producing good
outcome in various illnesses [3,6,45-51].
Cupping points possibly part of meridian
acupoints system and other traditional system
are powerful tools to standardize and modernize
the cupping therapy (Al-Hijamah). There
are twelve main meridians which are invisible
channels and present throughout the body with
Qi or energy flow. Each limb is traversed by six
channels, three Yin channels on the inside, and
three Yang channels on the outside. Like in
Traditional Chinese medicine (TCM), cupping
points are also described in prophetic medicine
(Tibb Nabawi), modern medicine and traditional
healers cupping methods [24] and intrinsically
cupping points are overlapping each other. For
example, Prophetic medicine recommended nine
cupping points (also called Sunnah points of
Hijamah Fig. 1 and for other points see sources
[24, 28]) including Kahel and Akhdayin whereas
Traditional Chinese Medicine recommended
numerous similar cupping points with special
names-number [24]. The surprising idea is that
when a cup is placed on a specific cupping point
concerning a disease; does it not cover
acupoints or extra-meridian points positioned in
close proximity? If yes, does the therapeutic
outcome need to be attributed to exclusively
cupping point or combined cupping and
9
acupoints? This amazing hypothesis-cum-idea
needs scientific answers by conducting relevant
research studies. The Kahel region includes skin
overlying 7th cervical vertebral spine and
surrounding area (upper, lower, right and left
lateral) and interscapular region. The Kahel
region used most commonly in diseases but not
all for therapeutic and preventive purposes
(especially cupping during Sunnah days, i.e.,
17th, 19th and 21st of the Islamic, lunar month
which coincide with Monday, Tuesday or
Thursday), and very important area (but similarly
other points on the back) linked with safe and
suitable skin points on the back, flat area suitable
for applying cups easily, and away from critical
structures such as nerves, veins, and arteries.
This area and Sunnah days for cupping were
also recommended by Prophet Mohammad
(PBUH) for cupping (Al-Hijamah) therapy [24,
28]. This Kahel area together with other cupping
points on the back and dorsum of legs is also
used for promotion of health in sports medicine,
and for enhancing athletes’ performance [32]. It
is better to use the largest cup on Kahel
area/point because of multiple reasons such as
large area. The Akhdayin sites closer to jugular
veins are important because cupping therapy
may clear biochemical substances (and toxic
materials) found in high concentration in jugular
veins (and interstitial spaces) during episodes of
cluster and migraine headaches [26]. When
practitioners apply cups on Akhdayin sites (#43
&44), they must take extreme precaution not to
injure jugular veins or else never use these
critical points. However cupping on areas behind
ears (#22&23 and #/GB20&21) is without any
risk as these points are away from jugular veins,
and these cupping perspectives need research
evidence in future.
The selection of cupping points and their
numbers differs from disease to disease, and
further determined by other factors such as
nature and severity of disease, relative
contraindications, and cupping mechanisms in
terms of distal painful sites [3,6,7,24,26]. The
avenue of selecting cupping points in various
diseases is controversial and confusing because
thousands of cupping points are described
according to anatomical sites, numbers and
meridian-derived acupoints terminology. For
example, Kahel area (in Arabic, and surrounding
areas along with interscapular region) is referred
to as the Feishu (BL-13) and Dazhui (Du 14/GV-
14 and 13 in TCM used in pain conditions)
acupoint groups and used in the treatment of
hypertension [52] and other conditions with pain
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
like trigeminal neuralgia. Another example
includes of Akhdayin (in Arabic) which is known
as GB20 and GB12 (GV14 acupoint group in
Chinese medicine [52]. However, it is heuristic to
select those cupping points with a precise
location on the skin surface which are used most
frequently and at the same time most beneficial
and safe to the patients with specific diseases
but with no adverse events and complications.
Another invaluable point is that authors of
cupping therapy studies need to mention what
and why certain cupping points are used in
individual diseases.
5. CONCLUSION
Cupping therapy (Al-Hijamah) is a traditional
complementary and alternative medicine
practiced since ancient times, and evidently
continuing progress has been made in its several
aspects including a precise selection of cupping
points in specific diseases yet this area is grey
and puzzling. Presumably, the precise selection
of cupping points is a powerful tool in
standardization and modernization of cupping
therapy techniques and, hence, this study is
calling for further global research for defining and
classifying cupping (Hijamah) therapy points’ and
their accurate applications in individual diseases.
DISCLAIMER
The views, thoughts, and opinions expressed in
this manuscript belong solely to the authors, and
not necessarily to the authors’ employer,
organization, or committee.
CONSENT
It is not applicable.
ETHICAL APPROVAL
It is not applicable.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
REFERENCES
1. Qureshi NA, Shaban T, Elsubai IS, Alqaed
MA, Gazzaffi I, El-Olemy AT, Al-Bedah
AM. History of cupping (Hijama): A
10
narrative review of literature. J Integr Med.
2017;15(3):172–181.
2. Al-Bedah AM, Shaban T, Alqaed MA,
Qureshi NA, Suhaibani A, Gazzaffi I, Khalil
M. Classification of cupping therapy: A tool
for modernization and standardization.
Journal of Complementary and Alternative
Medical Research. 2016;1(1):1-10:Article
no.JOCAMR.27222.
3. Al-Bedah AM, Shaban T, Suhaibani A,
Gazzaffi I, Khalil M, Qureshi NA. Safety of
cupping therapy in studies conducted in
twenty one century: A review of literature.
British Journal of Medicine and Medical
Research. 2016;15(8):1-12.
4. Kim TH, Kang JW. A good policy for
guaranteed safe practice of
complementary and alternative medicine,
usage of disposable cupping cups. Evid
Based Complement Alternat Med. 2015;
2015:970327.
DOI: 10.1155/2015/970327
5. Nielsen A, Kligler B, Koll BS. Addendum:
Safety standards for Gua sha (press-
stroking) and Ba guan (cupping).
Complement Ther Med. 2014;22(3):446-
448.
DOI: 10.1016/j.ctim.2014.03.012
6. Abdullah M.N. Al-Bedah, Ibrahim S.
Elsubai, Naseem Akhtar Qureshi, Tamer
Shaban Aboushanab, Gazzaffi IM Ali,
Ahmed Tawfik El-Olemy, Asim AH Khalil,
Mohamed KM. Khalil, Meshari Saleh
Alqaed. The medical perspective of
cupping therapy: Effects and theoretical
mechanisms of action. Journal of
Traditional and Complementary Medicine;
2017 [in press].
7. Guo Y, Chen B, Wang DQ, Li MY,
Lim CH, Guo Y, Chen Z. Cupping
regulates local immunomodulation to
activate neural-endocrine-immune
worknet. Complement Ther Clin Pract.
2017;28:1-3.
DOI: 10.1016/ j.ctcp.2017.04.005
8. Cao H, Han M, Zhu X, Liu J. An overview
of systematic reviews of clinical evidence
for cupping therapy. Journal of Traditional
Chinese Medical Sciences. 2015;2(1):3-10.
9. Chen B, Li MY, Liu PD, Guo Y, Chen ZL.
Alternative medicine: An update on
cupping therapy.JM. 2015;108(7):523-525.
DOI: 10.1093/qjmed/hcu227
10. Qureshi NA, Al-Bedah AM, Aboushanab
TS. Cupping Hijama therapy skin marks:
What should we know about them? Journal
of Complementary Medicine and
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
Alternative Healthcare. 2017;3(3):555612.
DOI: 10.19080 /JCMAH.2017.03.555612
11. Vender R, Vender R. Paradoxical, Vender
R, Vender R. Cupping-induced localized
psoriasis: A koebner phenomenon. J
Cutan Med Surg. 2015;19(3):320-2.
DOI: 10.2310/7750.2014.14109
12. Turtay MG, Turgut K, Oguzturk H.
Unexpected lumbar abscess due to
scarification wet cupping: A case report.
Complement Ther Med. 2014;22:645–7.
13. Lee SJ, Chung WS, Lee JD, Kim HS. A
patient with cupping related post-
inflammatory hyperpigmentation
successfully treated with a 1,927 nm
thulium fiber fractional laser. J Cosmet
Laser Ther. 2014;16:66–8.
14. Kim TH, Kim KH, Choi JY, Lee MS.
Adverse events related to cupping therapy
in studies conducted in Korea: A
systematic review. European J Integrative
Medicine. 2013;6:434-440.
15. Park TH. Keloid on scapular area
secondary to therapeutic dry cupping. Int
Wound J; 2013.
DOI: 10.1111/iwj.12184
16. Schumann S, Lauche R, Hohmann C,
Zirbes T, Dobos G, Saha FJ. Development
of lipoma following a single cupping
massage - a case report. Forsch
Komplementmed. 2012;19(4):202-205.
DOI: 10.1159/000341869.
17. Lee JH, Cho JH, Jo DJ. Cervical epidural
abscess after cupping and acupuncture.
Complement Ther Med. 2012;20:228–231.
18. Chen B, Guo Y, Li M-Y, Chen Z-L, Guo Y.
Standardization of cupping therapy may
reduce adverse effects (correspondence).
QJM: An International Journal of Medicine.
2016;287.
DOI: 10.1093/qjmed/hcv220.
19. Lee MS, Kim J, Kong JC, Lee DH, Shin
BC. Developing and validating a sham
cupping device. Acupunct Med. 2010;
28(4):200-2004.
DOI: 10.1136/aim.2010.002329.
20. Al-Bedah AM, Shaban T, Alqaed MA,
Qureshi NA, Basahi JA, El-Olemy AT,
Khalil M. The use of medical simulation in
cupping therapy training: A novel idea from
the National Center for Complementary
and Alternative Medicine. Journal of
Complementary and Alternative Medical
Research. 2016;1(3):XX-XX:Article
no.JOCAMR.30027.
21. Abdullah M. Al-Bedah, Tamer S.
Aboushanab, Meshari S. Alqaed, Naseem
11
Akhtar Qureshi, Ibrahim Elsubai, Ahmed T.
El-Olemy, Mohamed Khalil. Assessing the
effectiveness of using simulation in
cupping therapy training course for
undergraduate medical students: A study
in Riyadh, KSA. Journal of Advances in
Medical and Pharmaceutical Sciences.
2394-1111;13(2).
22. Ahmed T. El-Olemy, Abdullah M. Al-
Bedah, Ahmed H. Almosilhi, Jawaher A.
Almusailhi, Asim A Hussein, Mohamed
Khalil, Tamer S. Aboushanab, Ibrahim M.
Elsubai, Meshari S. Alqaed, Ali GI,
Sulaiman Al-Eidi, Naseem A. Qureshi.
Cupping therapy (Al-Hijama): An
exploratory study of healthcare
Professionals controversial Beliefs and
conceptions, Kingdom of Saudi Arabia.
Journal of Complementary and Alternative
Medical Research. 2017;3:1-11.
23. Ahmed T. El-Olemy, Abdullah M. Al-
Bedah, Mohammed A. EL-Olemy, Asim A.
Hussein, Mohamed Khalil, Tamer S.
Aboushanab, Ibrahim S. Elsubai, Meshari
S. Alqaed, Mohammad Hamza, Dalal S.
Al-Dossari, Sara O. Salem, Naseem A.
Qureshi. Cupping therapy (Al-Hijamah):
Healthcare professionals' controversial
beliefs and conceptions before and after
training Program, Kingdom of Saudi
Arabia. Journal of Complementary and
Alternative Medical Research. 2017;3(4):
1-13.
24. Mahmoud HS, Abou-El-Naga M, Omar
NAA, El-Ghazzawy HA, Fathy YM, Nabo
MMH, El Sayed SM. Anatomical sites for
practicing wet cupping therapy (Al-
Hijamah): In light of modern medicine and
prophetic medicine. Altern Integr Med.
2013;2:138.
DOI: 10.4172/2327-5162.1000138
25. Mehta P, Vividha D. Cupping therapy: a
prudent remedy for a plethora of medical
illness. J Tradit Complement Med. 2015;
5(3):127-135.
Available:https://www.ncbi.nlm.nih.gov/pm
c/articles/PMC4488563/
26. El Sayed SM, Mahmoud HS, Nabo MMH.
Medical and scientific bases of wet
cupping therapy (Al-Hijamah): In light of
modern medicine and prophetic medicine.
Altern Integ Med. 2013;2:1-16.
27. Cao H, Li X, Yan X, Wang NS,
Bensoussan A, Liu J. Cupping therapy for
acute and chronic pain management: A
systematic review of randomized clinical
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269
trials. Journal Traditional Chinese Medical
Sciences. 2014;1 (1):49-61.
28. Cupping resources.
Available:https://cuppingresource.com/cup
ping-hijama-points/
(Accessed on October 10, 2017)
29. Farhadi K, Choubsaz M, Setayeshi K,
Kameli M, Bazargan-Hejazi S, Heidari
Zadie Z, Ahmadi A. The effectiveness of
dry-cupping in preventing post-operative
nausea and vomiting by P6 acupoint
stimulation: A randomized controlled trial.
Medicine (Baltimore). 2016;95(38):e4770.
DOI: 10.1097/MD.0000000000004770
30. Chi LM, Lin LM, Chen CL, Wang SF, Lai
HL, Peng TC. The effectiveness of cupping
therapy on relieving chronic neck and
shoulder pain: A randomized controlled
trial. Evid Based Complement Alternat
Med. 2016;2016:7358918.
DOI: 10.1155/2016/7358918
31. Saha FJ, Schumann S, Cramer H,
Hohmann C, Choi KE, Rolke R, Langhorst
J, Rampp T, Dobos G, Lauche R. The
effects of cupping massage in patients with
chronic neck pain - a randomized
controlled trial. Complement Med Res.
2017;24(1):26-32.
32. Musumeci G. Could cupping therapy be
used to improve sports performance?
(Editorial). Journal Functional Morphology
Kinesiology. 2016;1:373–377.
DOI: 10.3390/jfmk1040373.
33. Ghods R, Sayfouri N, Ayati MH.
Anatomical features of the interscapular
area where wet cupping therapy is done
and its possible relation to acupuncture
meridians. J Acupunct Meridian Stud.
2016;9(6):290-296.
DOI: 10.1016/j.jams. 2016.06.004
34. Emerich M, Braeunig M, Clement HW,
Ludtke R, Huber R. Mode of action of
cupping--local metabolism and pain
thresholds in neck pain patients and
healthy subjects. Complement Ther Med.
2014;22(1):148-158.
DOI: 10.1016/j.ctim.2013.12.013
35. Ahmed A, Khan RA, Ali AA,
Ahmed M, Mesaik MA. Effect of wet
cupping therapy on virulent cellulitis
secondary to honey bee sting-a case
report. J Basic Applied Sciences.
2011;7:123-125.
36. Ahmadi A, Schwebel DC, Rezaei M. The
efficacy of wet cupping in the treatment of
tension and migraine headache. Am J
Chinese Med. 2008;36:37-44.
12
37. Teut M, Kaiser S, Ortiz M, Roll S, Binting
S, Willich SN, Brinkhaus B. Pulsatile dry
cupping in patients with osteoarthritis of
the knee- a randomized controlled
exploratory trial. BMC Complementary
Alternative Medicine. 2012;12(1):184.
Available:https://ncbi.nlm.nih.gov/pubmed/
23057611
38. Rozenfeld E, Kalichman L. New is the well-
forgotten old: The use of dry cupping in
musculoskeletal medicine. J Body work
Movement Ther. 2016;20(1):173-178.
DOI: 10.1016/j.jbmt.2015.11.009
39. Ge W, Leson C, Vukovic C. Dry cupping
for plantar fasciitis: A randomized
controlled trial. Journal Physical Therapy
Science. 2017;29(5):859-862.
DOI: 10. 1589/jpts.29.859
40. Nimrouzi M, Mahbodi A, Jaladat AM,
Sadeghfard A, Zarshenas MM. Hijamat in
traditional Persian medicine: Risks and
benefits. J Evid Based Complementary
Altern Med. 2014;19(2):128-136.
DOI: 10.1177/2156587214524578
41. Markowski A, Sanford S, Pikowski J,
Fauvell D, Cimino D, Caplan S. A pilot
study analyzing the effects of Chinese
cupping as an adjunct treatment for
patients with subacute low back pain on
relieving pain, improving range of motion,
and improving function. The Journal of
Alternative and Complementary Medicine.
2014;20(2):113-117.
Available:https://doi.org/10.1089/acm.2012
.0769
42. Bridgett R, Klose P, Duffield R, Mydock S,
Lauche R. Effects of cupping therapy in
amateur and professional athletes:
Systematic review of randomized
controlled trials. The Journal Alternative
and Complementary Medicine; 2017.
Available:https://doi.org/10.1089/acm.2017
.01 91
43. Arslan M, Yeşilçam N, Aydin D, Yüksel R,
Dane S. Wet cupping therapy restores
sympathovagal imbalances in cardiac
rhythm. J Altern Complement Med. 2014;
20(4):318-21.
DOI: 10.1089/acm.2013.0291
44. Huang C-Y, Choong M-Y, Li T-S.
Effectiveness of cupping therapy for low
back pain: A systematic review.
Acupuncture Med. 2013;31:336-337.
DOI: 10.1136/acupmed-2013-010385
45. Kim JI, Kim TH, Lee MS, Kang JW, Kim
KH, Choi JY, Kang KW, Kim AR, Shin MS,
Jung SY, Choi SM. Evaluation of wet-
 Qureshi et al.; JOCAMR, 4(3): 1-13, 2017; Article no.JOCAMR.39269

cupping therapy for persistent non-specific 49. Lo XX, Ma LS. Therapeutic effect of
low back pain: A randomised, waiting-list balance cupping therapy on acute
controlled, open-label, parallel-group pilot lumbar sprain. Chin J Infor TCM.
trial. Trials. 2011;12:146. 2010;17:75–76.
46. Liu BX, Xu M, Huang CG. Therapeutic 50. Ma LS, Lo XX. Therapeutic effect and
effect of balance cupping therapy on non- differentiation nursing on acute lumbar
specific low back pain. Chin J Rehabil sprain. Mod J Integr Tradit Chin West Med.
Theory Pract. 2008;14:572–573. 2010;19:1394–1395.
47. Xuan B. The effect of moving cupping 51. Chen CM, Pan HH. Therapeutic effect of
therapy and dexibuprofen on nonspecific moving cupping on 60 cases of acute
low back pain: Clinically randomized lumbar sprain. Clin J Anhui Tradit Chin
controlled study. J Anhui Health Vocational Med. 2000;12:531.
Tech Coll. 2010;9:19–21. 52. Aleyeidi NA, Aseri KS, Matbouli SM,
48. Hong YF, Wu JX, Wang B, Li H, He YC. Sulaiamani AA, Kobeisy SA. Effects of
The effect of moving cupping therapy on wet-cupping on blood pressure in
non-specific low back pain. Chinese hypertensive patients: A randomized
Journal Rehabilitation Medicine. 2006; controlled trial. J Integr Med. 2015;13(6):
21(4):340-343. 391–399.
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