Cupping therapy in Saudi Arabia: from control to integration

Abstract

Cupping therapy or Hijamah is a leading traditional practice after spiritual healings and herbal medicine in Saudi Arabia. Wet cupping is by far the most common type of cupping therapy. Hijamah in Saudi Arabia and other Muslim countries is a model of religious influences, interconnectivity, and cross-cultural influences between different civilizations. Accordingly, differentiating the cupping practiced in Saudi Arabia, and other Muslims societies from that practiced in other countries like China, by Korea only by the technique or cupping sites is an underestimation of the differences. In Saudi Arabia, the profile or characteristics of cupping therapy user is distinct from the profile of other traditional medicine users by being more educated, with higher job rank and not affected by nationality or gender. After an era of unregulated practice, cupping therapy is currently regulated and monitored by the National Center for Complementary and Alternative Medicine in the Ministry of Health (NCCAM/MOH) of Saudi Arabia. Regulations and licensing include practitioners, practice place, and cupping equipment. After regulation, cupping is mainly offered by the private sector and paid directly by the client as insurance does not cover it. In the private sector, licensed cupping service is usually provided as a parallel and not an integrated service. However, there are few models of integrated cupping clinic in universities, academic institutions, and governmental hospitals. Further health system research is needed to develop more models of integrated cupping service pending for the healthcare transformation which is going on in Saudi Arabia.

1. Introduction

Traditional medicine (TM) is widely used in Saudi Arabia. Interest in traditional and complementary medicine (T&CM) has grown considerably in recent years not only among the public, but also among medical professions, decision makers, and researchers in Saudi Arabia.1, 2, 3, 4 In the absence of a national survey, multiple regional surveys showed that TM use is ranging from 60 to 75%.5, 6, 7 Religious healings, herbal medicine, cupping therapy, and the healing with honey are the leading four therapies respectively in TM in Saudi Arabia.1, 6 There is no Traditional Healing System similar to China, Korea, Japan, or India. However, the term “Traditional Arabic and Islamic Medicine” (TAIM) is used in Saudi Arabia like other regional and Arab countries to refer to a group of healing therapies practiced in the Arab and Islamic world within the context of religious influences of Islam.⁸ TAIM represents the interconnectivity between the Islamic medical influences and the regional healing practices emerging from different geographical and cultural origin including the Traditional Chinese Medicine, Ayurvedic, Unani and Persian therapies.⁹ The influences of Islamic religion or Prophetic traditions may promote or discourage the use of specific traditional practices imported from other cultures.10, 11 Cupping therapy or Hijamah in Saudi Arabia and other Muslim countries is a model for this interconnectivity and cross-cultural influence.

2. Review on cupping therapy (Hijamah)

2.1. The influence of religion and prophetic traditions on cupping therapy (Hijamah)

In traditional Arabian medicine, Hijamah means sucking (cupping), and it includes wet and dry cupping, but in Arabian culture, Hijamah usually refers to wet cupping.¹² Hijamah is performed by Muslims as it is a form of medicine specifically mentioned and encouraged by the prophet of Islam “Muhammad.” Among other narratives “hadith”, the prophet said that “Hijamah is the best of your remedies”.¹²

Although there is a confusion between the term “Islamic medicine “and Prophetic Medicine”, Muslim historians and scholars draw a line between Islamic medicine and “prophetic” medicine. Prophetic Medicine is related only to the collection of “hadiths” or accounts of the sayings and actions of the prophet of Islam “Muhammad” that are related to sickness, diet, hygiene, and other aspects or determinants of health.13, 14 Prophetic medicine is distinct from Islamic medicine by the fact that according to the majority of Muslims, there is no need to search for scientific explanation or evidence on the effectiveness or the mechanism of action because they are considered credible solely on the basis that they originated from the prophet of Islam.¹¹ This explains the importance and the widespread use of cupping therapy (Hijamah) in Saudi Arabia and other Muslims societies,1, 15 and the priority given to cupping therapy for regulation in Saudi Arabia. Influences of religion, highlights the controversy of searching for scientific evidence for a practice that has been promoted by the prophet of Islam. In addition, it reflects the complexity of evaluating the compound effect of Hijamah, if accompanied by prayer as a part of religious belief.

2.2. Cupping technique used in practice

Wet-cupping (AlHijamah) is by far the most common type of cupping used in Saudi Arabia. However, the wet-cupping technique used in Saudi Arabia and the Middle East is different from the one used in China or Korea. In the Middle East technique, they usually use a three or triple steps procedure (cupping – puncture – cupping) order of steps,¹⁶ with the use of a sharp surgical blade for the scarification. Cupping sites nomenclature is also different although it can be related to the corresponding Ashi points in Chinese acupuncture. The common cupping sites used are mainly at the back and the neck. Other sites can be included according to the condition.17, 18, 19 The wet cupping technique used in China, Korea, and Germany, usually uses two-step procedures.¹⁶ They apply the cups only after puncture (puncture – cupping) with the use of auto-lancet needles rather than surgical blades. In certain countries or protocols, they are guided by the acupuncture points as the sites of cupping.²⁰ Auto-lancet is currently encouraged in Saudi Arabia as it is easier to use especially for the beginners and it was used in the clinical trials conducted by the Saudi NCCAM using a modified Korean protocol.20, 21 However, traditional healers in Muslims countries favor our local technique (three-steps) as it was used during the life of the Prophet of Islam.²² The method reported in Saudi Arabia and the Middle East (cupping – puncture – cupping) is claimed to give a more extended opportunity for the filtration process to achieve better results and better excretory outcomes. Also, the presence of suctioning step as the first step may help in protecting the dermal capillaries from being damaged by this intervention. Also, the superficial scarifications/puncturing after initial cupping is considered to give a chance for the suction pressure to help in excretion the local intercellular fluids and assist in the capillary filtration process.²² Traditional practitioners believe that when they do not start with the suctioning first, this approach will lead to increase in the possibility of pain compared to the anesthetic effect that resulted from suctioning first.22, 23 Both techniques (the local traditional three-steps versus two-steps Asian) were compared in a clinical trial for the management of chronic low back pain.²⁴ The interim results of the trial did not show any significant differences between the two techniques regarding the pain outcome measures.²⁵

2.3. The profile of cupping therapy (Hijamah) user

The profile of Hijamah user in Saudi Arabia differs significantly in some characteristics compared to the general characteristics of the overall TM user. Regional studies conducted in Saudi Arabia showed that TM user is more likely to be Saudi national, older, female with a lower rank job and education.6, 26 The characteristics or profile of the T&CM user in Saudi Arabia is similar to the Eastern countries²⁷ but not the western societies specifically The United States except for gender.28, 29 However, Hijamah user in Saudi Arabia is not affected by gender, education, and job in the same manner. Hijamah user can be a male or female with a broader range of age, with higher education level and job rank.6, 30 In addition, Hijamah user is significantly more likely to accept cupping therapy from experienced non-medical providers, accept cupping therapy as traditional and complementary approaches without substantial scientific evidence and is more willing to participate in cupping research.³¹

Female gender is the most significant predictor of T&CM use in western and eastern countries as it is more prevalent among females compared to males.27, 32 However, it does not predict cupping Hijamah use in Saudi Arabia. Being part of Prophetic Medicine and traditions, Hijamah may be prevalent equally and not affected by gender.1, 6, 26 This may also explain the broader range of age, education, and job rank, in Hijamah user compared to the usual TM user in Saudi Arabia which is similar to other Eastern countries.

2.4. Regulating cupping practice in Saudi Arabia

The Ministry of Municipal Affairs was previously responsible for licensing Hijamah (cupping therapy) practitioners and practice places. Muslims who are visiting the two holy cities, commonly perform Hijamah as a part of the Prophetic traditions (Sunna) where you can easily locate cupping shops beside the Holy Mosques. But in general Hijamah until recently was unregulated in Saudi Arabia and was mainly practiced by unlicensed traditional healers at the home of the providers or the clients.³³ The main risks arising from the practice of unregulated complementary and traditional therapies including cupping therapy are not those directly related to the therapies themselves, but the indirect risks due to limitations in the therapists’ diagnostic and clinical knowledge, skills and the lack of infection control measures. After the establishment of the National Center for Complementary and Alternative Medicine (NCCAM, MOH) in Saudi Arabia, it was decided to regulate the cupping therapy including practitioners, practice place or centers, and cupping equipment. The regulation also included the practices which were previously licensed by the Ministry of Municipal Affairs.³⁴ A community survey was initiated through the National Center for Complementary Alternative Medicine in Saudi Arabia before issuing the regulations. The survey included 481 participants using multistage sampling technique targeting the attendance of the healthcare facilities in four regions in Saudi Arabia. The questionnaire included four modules to address the practitioner, practice, safety, and evidence of effectiveness. Participants agreed that cupping practitioners should be licensed; preferably qualified health practitioners and that cupping should be performed in licensed places. Safety was a primary concern to the public. Participants believed that that effectiveness by experience and not only by medical research should be taken into consideration. Participants who used cupping before gave more weight to the value of experience in evaluating the effectiveness of cupping therapy than naïve participants.³¹

According to the new regulations, in the first phase (the current phase), license to practice cupping is being given only to medical professions (physicians, physiotherapists, and nurses) and practitioner with a degree in T&CM, as the risks around the practice are less likely to occur with medically qualified practitioners. Also, medically qualified practitioners have the capacities of working within the conventional health care system in an integrated healthcare approach.35, 36 After evaluating the first phase, subsequent phases supposed to include other medical professions, then traditional healers. Including traditional cupping providers in the licensing and regulatory process will be a challenge. It depends mainly on the success of the current phase and on developing a creative program to adopt them in the healthcare system.

Licensing requirements of the cupping practitioners include attending a training course on Hijamah practicing, followed by written, oral, and clinical exams by the NCCAM. The training course is five days for non-physicians and four days for the physicians irrespective of previous experience in cupping therapy.

Applicant should be free of infectious diseases, including the Acquired Immune Deficiency Syndrome “AIDS”, and Viral Hepatitis (B and C).

Cupping regulations also include workplace specifications to guarantee the license.

Cupping providers should be licensed and practicing in a licensed working place (Hijamah centers) and using equipment approved by The Saudi Food and Drug Authority (SFDA). Currently, there are more than 600 trainees and 160 licensed practitioners. Passing the training course is not a guarantee for licensing as a provider should be linked and working in a licensed cupping clinic. Of the 64 currently licensed Hijamah centers, 33% are located in Riyadh region, 22% in the two holy cities (Mecca and Madinah), and the remaining centers are distributed all over Saudi Arabia.

According to the recommendation of NCCAM/MOH, cupping is currently mainly used for musculoskeletal pain which was studied and evaluated by the NCCAM21, 37 and other institutions and showed a growing evidence.³⁸ Preventive Hijamah according to the Prophetic medicine and traditions is also allowed.³⁹ Preventive Hijamah is usually done on healthy persons. Clinical guidelines are still under development. However, cupping practitioners in Saudi Arabia, are using cupping for a wider range of illnesses and conditions even without proven evidence.

2.5. Integration of cupping clinics in healthcare services

There is a growing demand for complementary & traditional medicine (C&TM) in Saudi Arabia. A recent study in Saudi Arabia showed that a person spends out of his pocket on the average 560$ per year on C&TM visits and products.⁶ The spending is increasing in case of chronic illnesses where patients are seeking the help of traditional healers even if they were treated in the highest Saudi modern medical institutions.40, 41, 42 The private sector is the primary provider for C&TM in Saudi Arabia. In general, the private sector is known to give greater opportunities for autonomous C&TM practice⁴³ and more tolerant to patient choice as a consumer of healthcare.⁴⁴ Nevertheless, a study conducted by the Saudi NCCAM showed that current private investment in C&TM is limited due to the absence of regulations and insurance coverage. However, they have a plan for expansion as the Saudi government is planning to expand insurance coverage.⁴⁵ According to investors cupping therapy is a promising area of investment and is a leading area of investment. Encouraging private sector investment is an important step to cope with the unmet demands for integrative medicine in the governmental institutions.⁴⁶

Currently licensed wet cupping (AlHijamah) is mainly practiced in licensed private sector clinics. The practice is still parallel to and not integrated into the conventional medical care due to technical regulatory issues between different regulatory authorities. The service is paid directly by the client and not covered by insurance.⁴⁷ According to The Unified Insurance Document issued by The Saudi Council of Cooperative Health Insurance (CCHI), clients cannot reimburse the cost of any T&CM therapies including cupping therapy.⁴⁸

Few cupping clinics are currently available in academic and research institutions for providing service and for research purposes.⁴⁹ As a model of cupping integration in the governmental health care, cupping clinics were established by NCCAM/MOH in three governmental secondary care hospitals in three different city. The aim was to build and evaluate a model of integrated service and to evaluate the interdisciplinary approach and relation between the modern medicine physicians and the cupping providers.21, 50 Patient satisfaction and outcome measure showed an encouraging rate to support the model.⁵¹ Further health system research is needed to include integrated models in the healthcare systems which is currently going a transformation stage toward more privatization.52, 53

3. Conclusion

Regulating and licensing cupping therapy (Hijamah) in Saudi Arabia was an important step. Religion influences has been a crucial factor in taking Hijamah as a priority. Cupping is still offered as a parallel, not an integrated service due to operational reasons and resistant from modern medicine decision makers. Healthcare decision makers are always in favor of the western integrative medicine model which strictly requires its complementary methods to be supported by scientific evidence.⁵⁴ Developing the current cupping therapy guidelines into clinical evidenced-based guidelines will support integration. Integrating the service is a complex pathway and needs more efforts on the cross-cutting policy objectives among the related authorities and stakeholders.⁵⁵ Transforming the current cupping practice into sustainable integrated model needs further research and evaluation during the current stage of transformation of healthcare.

Conflicts of interest

Authors have nothing to declare.